Probe Finds Both Structural, Building-Level Problems Contributed to COVID-19 Outbreaks in Nursing Homes

A third-party analysis of the government and industry response to COVID-19 in nursing homes has found a host of intertwined issues on both the micro and macro levels, with reform recommendations that range from greater emergency collaboration to increased infection-control penalties.

A wide range of problems endemic to both the industry and government oversight led to the substantial death toll in New Jersey’s nursing facilities, a new report from legal and consulting firm Manatt Health determined.

“Despite efforts to manage spread of coronavirus in N.J. and elsewhere, COVID-19 fed on and exposed weaknesses in our health care system, perhaps most notably in our nursing homes,” Manatt concluded in its report.


The Garden State commissioned the firm to perform a post-mortem on the long-term care sector’s preparedness for COVID-19; Manatt completed the work in about three weeks, with Politico initially reporting the results this week.

The analysis confirmed a claim that nursing home leaders across the country have repeatedly emphasized during the crisis: New Jersey officials prioritized the acute-care setting during the earliest push to establish an emergency plan and distribute supplies. Nursing homes, meanwhile, were out on an island.

“Nursing homes generally were not adequately tied into the larger system of care and typically do not have strong communications and consult relationships and protocols with emergency departments,” Manatt found. “Further, there is often poor communication between nursing homes and hospitals at the point of hospital admissions and discharges. In addition, there is a lack of interoperability between nursing home and hospital electronic health records.”


To remedy that situation in the future, Manatt recommended the development of a long-term care emergency operations center that can serve as a central authority for deploying resources, collecting data, and keeping families and the public informed.

Simply put, state authorities in New Jersey — as elsewhere in the country — were caught flat-footed without an emergency infrastructure for the facilities that were being hit hardest by the virus.

“You cannot invent a system that works when a crisis hits; the system must already be in place,” Manatt observed.

But those structural issues also trickle down to the building level, where Manatt called for a series of fundamental changes. For instance, the report pointed to widespread issues with infection control in nursing homes, as well as concerns about ownership transfers without proper vetting from the government.

To fix those problems, Manatt recommended that New Jersey implement change-of-ownership rules similar to those implemented in Kansas in the wake of Skyline Healthcare’s collapse, which would require potential buyers to fully disclose their ownership interests and submit a detailed budget explaining how they intend to provide quality care.

In addition, Manatt called on the state to more narrowly tailor its surveys to focus on top issues such as infection control, while increasing the penalties for the most serious violations.

And while the Manatt report acknowledged that operators require more funding to meet the demands of a COVID and post-COVID world, the firm recommended that Medicaid payment increases be tied to quality improvements — a plan that’s already been implemented in states such as Texas — and directly support staff salaries.

“Require a portion of any rate increase be passed through to nursing home workers, similar to state legislation passed for personal care services, and tie increases to quality and safety improvements,” the firm noted.

Increasing staff pay and prestige will serve as a vital strategy to help operators navigate the current crisis and prevent future outbreaks. Simply put, if you pay workers more and give them a path toward career advancement, Manatt argues, they will help to improve care quality — while also creating a landscape where workers do not have to hold jobs across multiple buildings, a key factor in the spread of COVID-19 in nursing homes.

“Nursing home staff earn close to minimum wage, have inconsistent access to health coverage and sick leave, and are often not recognized or valued as part of the health care workforce, factors that contribute to chronic staffing shortages and turnover, and training gaps,” Manatt observed.

The report was not without political wrangling in the Garden State. As in New York, some lawmakers have harshly criticized Gov. Phil Murphy’s response to the coronavirus pandemic in nursing homes, particularly a controversial order requiring facilities to accept COVID-19 cases early on during the crisis.

A trio of Republican officials claimed that the Manatt report — which the Democratic Murphy administration commissioned at a price of $500,000, according to reports — unfairly absolves the governor’s office of blame.

“It’s undeniable that our long-term care facilities warned that they didn’t have sufficient supplies of PPE or the ability to manage the highly infectious patients that the Department of Health was forcing them to accept from hospitals,” Republican state senator Declan O’Scanlon said in a statement. “By failing to address these simple truths, this rushed report was irrelevant the second it was released.”