The first major outbreak of the COVID-19 pandemic in the U.S. struck a skilled nursing facility in the state of Washington, but it was the East Coast that took a tremendous beating in the initial surge of the disease.
SNFs on the Atlantic side of the U.S. were not spared, and had to grapple how to keep their residents safe with a much smaller knowledge base about the behavior of the virus and far fewer testing resources than operators have now.
Sidney Greenberger, the CEO of the Cranford, N.J.-based AristaCare Health Services, saw first-hand the damage COVID-19 could do to SNFs. With six SNFs in New Jersey and eight in Pennsylvania, Greenberger watched COVID-19 move down from the original U.S. epicenter of New York City to New Jersey and beyond, starting from late March
And based on his experiences, he has some advice for SNFS as COVID-19 cases rise across the country, particularly in the Sun Belt states in the South.
Skilled Nursing News caught up with Greenberger on July 29 to talk about what he learned from the first COVID-19 surge, what providers in hotspots should do to prepare — and why operators have to start taking steps now to make indoor visitation safe.
Where did AristaCare get hardest-hit for COVID-19, geographically, and how did those outbreaks start?
Geographically, we got hit in New Jersey the toughest, and from that perspective, I would say New York City was the epicenter, so the closer we were to New York City, those were the first facilities that had the outbreaks. So it was really the proximity to New York City.
The further away we were — we have some facilities in southern New Jersey — they were hit several weeks later than our three facilities that we have in central New Jersey. North Jersey got hit, and then it started moving down south, toward the center of the state, and then further south.
The first indication that we had something going on was with one of our employees that tested positive. But I have to say that once we had one positive in a building back then and during the beginning, it spreads like wildfire — to use Governor Cuomo’s phrase, like fire through dry grass.
That’s what happened. It started with one staff member, and then it just spread. We don’t know whether or not we had patients coming in from the hospitals that were COVID-positive at that time, because there was no testing at that time. Even with our staff member, we found out that one of our staff members had tested positive because they were having some symptoms and they went to their own personal physician and tested positive. They reported it to us, and when we were made aware and we started doing tracing — this was actually an individual who was in the administrative offices, so it wasn’t even a hands-on staff member.
But when we started doing the tracing, we found out that this individual had been in a meeting where there were 22 people at the meeting. We had 22 people on quarantine; we didn’t allow them into the facility. At that time, we had wanted to do 22 tests, to rule out that anybody had it, but our request was 22, and we got eight — so kind of negotiating with the laboratories, saying, “Okay, you need 20, but we’ll give you eight.”
When it spreads, it spreads very, very, very quickly. This was towards the end of March, I believe the last week of March. The state labs were not distributing COVID tests, period. We didn’t get anything from the state labs, we didn’t get at that time anything from state or federal. We worked with our laboratory provider, who’s been our laboratory provider for the last 20 years. And we’re a good customer, so we had hoped we’d be able to get as many as we needed. But they really had to ration it among all of their clients.
And when I say negotiating, I don’t mean it was really a negotiation. It was: Listen, we need to test 22 people — and this was before we tested the first resident — we need to test 22 people at that meeting. Can we get 22 swabs? And the answer was: I can get you eight swabs, because I have other clients as well, and there’s not enough testing sites to go around, not enough tests to go around.
So when that’s the reality, what do you do at that point? What’s the decision-making process?
The decision was: We started doing screening, and this was even before CMS mandated the screening to come into the nursing home, whether for staff members or visitors, where we started doing the temperature screening, the symptom screening. We saw: Okay, this thing is here, there is community spread.
Again, this was before there was testing widely available, so this was just symptoms-based that we were looking at. That’s how we attempted, without having the luxury that we have today of widely available testing, to be able to keep COVID out of the nursing homes.
What does “widely available” look like now in terms of testing, especially compared to the state it was in at the beginning?
There was very little testing to be found, very little swabs to be found. We found out afterwards this was a CDC [Centers for Disease Control and Prevention] issue, where they had some problems with their reagents, and that the tests didn’t become widely available until later on.
There is no problem with the availability of the tests right now; the only question is how long it takes to process the test. But back in the beginning, and this was based on CDC guidelines of who should be tested and who should not be tested: Only symptomatic staff or residents should be tested. Anybody else should not be tested. So things have changed, not by us particularly but by the CDC and through the states. In the beginning, it was actually on a daily basis with changing their recommendations at that point. There was also a lot of confusion that was going on right then.
The labs, whoever their providers were, they were also being rationed as to how many swabs they would get; it was also the ability of how many test machines that they had to run the testing. Even when we did have the testing initially, I remember the first test for the administrative employee that came back positive, I think it took us about 11 days to get back.
We had our entire administrative staff out of the building during that time. Had it been a 24-hour, 48-hour turnaround, we would have had them back in the building; it turned out there was one other individual that turned out to be positive in that meeting.
So for facilities in areas of ongoing community spread, what steps should they take now on the testing front to ensure access to testing?
They should be reaching out to everybody and anybody. The first people they should be reaching out to are their laboratory providers, because that’s their first line of defense. Again, some states — Pennsylvania gave out the first two rounds of testing when we started with universal testing, when testing became widely available. But check with your laboratory provider. That’s key initially: Check with your laboratory provider and see what their capacity is, what their ability is and have an honest and open conversation with them.
In the event that there is an outbreak, if your laboratory or provider is not able to handle the influx of tests coming in, or provide enough testing swabs, then look at all any and all other alternatives. No. 1: Calling your local and state departments of the health, but also reaching out to different laboratories. You may have a relationship — in my case, we have a relationship for 20 years with the same lab and they’re a fantastic lab, and I have only amazing things to say about them — but perhaps look for a smaller lab that’s not servicing so many facilities. They actually may have more swabs than they need because they’re not doing as as much testing.
Also I think that it’s important to note that, as always, money talks. When you’re dealing with your typical lab and your payment terms are 30 to 60 days and so on and so forth, okay, everybody’s in the same boat. When you start looking at outside laboratory providers that are accredited by the state — we’re not talking about fly-by-nights, we’re talking about accredited laboratories — be prepared to have an agreement in which you pay net 10 days or the net 15 days, because that’s going to put you on the front of the line.
One of the things that we have found when we went to alternate labs, who perhaps are not as big as the big lab providers within the state, where we would guarantee them net payment within a very small window of time, they would have to guarantee us a turnaround of 48 hours max. Guaranteed.
Personal protective equipment (PPE) is the other big component of the response. Again, I want to go back to how it was at the beginning of this whole situation. What was your typical PPE stockpile like? And then when that first positive came in, how did what you had compare to what you ended up actually needing?
I can’t say the exact days of the burn rate. But as far as CDC, the way they described it is: conventional capacity, contingency capacity, and crisis capacity, meaning as far as how much PPE you have in the building.
We went from conventional capacity, meaning having whatever we needed to take care of the residents that we had pre-COVID, straight to crisis capacity, which was again, something that the CDC said under crisis capacity, they ease the restrictions — I would say somewhat but really considerably with regard to how long and reusing PPE. I mean, they said put scarves over your face if you need to, if you can’t get the masks.
There was a mad rush in the Northeast, particularly in New York and New Jersey, once it hit, to acquire and be able to get pandemic-capacity PPE, which hadn’t existed before. We have flu outbreaks that are, I would say, normal during to any particular year, and you order enough PPE so that you have that in that stock. But what happened was — and we realized this very early on — is that when we called our providers, our medical supplies providers for PPE, we were being rationed.
We had two main providers: One is a local provider, one is a national provider. We had a local provider who maxed us at 100% of what our historical orders were for PPE. So historically, how many goggles did we have to use? Or how many shields did we have to use? Very few. How many booties — I don’t know what they’re called, but the things that go over the shoes — how many of those did we have to use in the past? Very, very little.
So our stockpile and our monthly orders were very little, and all they did was limit it to 100%. With our national medical supplier, they limited us to 75% of what our historical utilization was.
With regard to facilities that are in states that are going to have hotspots at this point, how to be able to get around that—– that’s a tough one. Because I would say to the next pandemic, not this second wave, but if there is another pandemic, post a second wave, we should always be prepared and continue to order more than your weekly allotment so that you can take some of that and put it in reserve.
Like when you pay a mortgage, the bank requires you to put a reserve also, a capital expenditures reserved. You should always be able to have enough that you can put some of them in reserve, and I would say that that’s kind of like an insurance policy, like a life insurance policy. It’s something that you want to pay for, but never want to use.
What we had to do under those circumstances was come up with some very unconventional ways to be able to get PPE into our buildings. We couldn’t get them from our medical suppliers. It was a 24-hour effort to try to figure out how can we get medical supplies or PPE into our buildings when our medical suppliers weren’t giving them out, and probably also had a difficult time getting them when you had the federal government bidding against the state governments to get the PPE from wherever they came.
We threw our hat into that same lot, and we went directly to the manufacturers. We did so by putting together a group of operators who together, through a lot of a lot of digging and a lot of research, were able to get ahold of distributors in China, manufacturers in China. And we brought PPE in by the container loads; we split them between several operating facilities, meaning several operators within the state of New Jersey, Pennsylvania. We worked together to bring to bring PPE in, and that itself wasn’t an easy task.
How many operators did you get together for that?
We actually had three operators that were, together between our facilities and their facilities, we were probably close to about 75 facilities. It was just three operators that we put together. When there’s nothing to be had, there’s nothing available, it becomes a dog-eat-dog world, quite frankly. You want to protect your residents. So what do I do to get PPE for my residents?
Again, going back to the federal and the state levels, you know, that’s what they’re concerned with, is: “How can I get ventilators for my state? I’m not worrying about the other state, I have to worry about my state.” I have to worry about my residents, the safety of my residents and the ability to contain the virus.
We had to come on to some unconventional sources, and also take a lot of risks in doing that, because anything that we were buying directly from the source, this wasn’t net-10 or net-15 or net-30. This was: You wire the money up front. And you get the product in three weeks.
So what I would just say is open your eyes to different avenues. You’re going to get a lot of calls from a lot of people that will say that they have PPE. Screen them. Some of them are downright hoaxes or frauds. But some of them are legitimate. You can get PPE from those direct sources. And that’s not to say that we have not been burned, because we actually have been burned in wiring money up front to get PPE and then it not coming through at the end of the day.
Do you have any tips for that, like what you learned from that, that you wouldn’t do again?
Honestly, I don’t know that we wouldn’t do it again — because you’re almost taking your chances. Yeah, we lost money. But I would say that as a small percentage of what? The PPE itself was running about five-plus times the dollar amount as it would be during normal times for a case of masks or a case of gloves.
I would say the percentage of times that we got burned by a fraudulent seller or expediter to be able to bring in supplies from China is a very small percentage of the amount that we actually did receive. I think that’s just the price of doing business in a time of a pandemic: If you want to protect your residents, you have to be prepared to take some risks.
On the supply front, is it still the same kind of intense situation when the first wave of sorts was happening in the Northeast? Or has there been any kind of easing in the supply lines that might make things different for operators in hotspot areas now?
There has been an easing of the supply line. It takes a couple of weeks for PPE to arrive, whether it’s China or India or other countries where it may be manufactured, so there was always a lag time at that point. It has become easier for almost all products.
I would say the most difficult product right now is gloves. The reason for that is because, up until now, there was a certain market for gloves. There was hospitals, nursing homes, health care facilities. Today: everybody, any business that’s open is using gloves. Walmart’s using gloves, Target’s using gloves. Everybody’s using gloves. So the demand for gloves — while the supply has been able to remain steady, the demand has increased exponentially.
Jumping back a little bit to the testing questions, the government is going to be sending out point-of-care tests to all skilled nursing facilities in the U.S. For providers that are getting those those point-of-care testing devices, what are your thoughts on using them in a COVID-19 hotspot? If you had had one of those devices back when this was first happening for AristaCare, how would you have deployed them and what do you think the best use of them would be?
Those devices would have been a game changer. I’m not a statistician, but I do believe that testing is and has always been the the No. 1 key to identifying the virus. Because as we know now, some of the time, or even most of the time, patients — whether they’re in nursing homes or they’re in the community — are asymptomatic. So as far as the screening that the states required us to do and that we did on our own, it was symptoms-based screening. All of them were symptoms-based: Do you have fever, do you have any shortness of breath, and other symptoms?
But how many times did people have none of the above, and were positive and coming into the facility? Had we had the ability to deploy point-of-care testing, that would have been our screener. It wouldn’t be a manual screen, or perhaps it would have been a manual screen, but it would be followed up by a point-of-care machine in which staff would have to wait 15 minutes until they get into the building to see they were, at that point in time, negative.
Like I said, I’m not a statistician, but I think that testing in general — forgetting about the point-of-care, had we had the availability to test entire facilities at a time, which A) was not recommended, B) was not possible — those directives came out at the end in [May and] June, even for the early states like New Jersey and Pennsylvania, to have universal testing. And the reason they couldn’t come out with that earlier is because it would have been impossible to get those tests.
Testing in particular, I think, is the single most important aspect in being able to keep the virus out of out of your building and identifying it as soon as possible. CMS is starting to give out those point-of-care tests. What I would say is: My company was in talks with Abbott Labs before CMS announced that they would be giving out these point-of-care tests. And I’m not sure if you were on the call last week with with the CMS with Seema Verma and with Admiral [Brett] Giroir. But the phrase that stuck with me most was — I’m paraphrasing, but: “You can’t wait to put makeup and lipstick on this. We have to build this plane as we’re flying it.”
That was kind of an eye-opener. And that’s great because, you know, without any other opportunity, that’s what we have to do. But in the rollout, they said they started sending out some of them to hotspots; they said it would be approximately a 14-week process. Again, not knocking government in any way, it’s just [the] reality that a 14-week process is probably going to be, let’s just say, a 28-week process getting those point-of-care machines out there.
Facilities that have gone through their hotspots, they’re going to be the last ones on the totem pole. New Jersey, New York, Pennsylvania, I believe that we’re going to be the last ones to receive those, so we’re not relying on those. We’ve had talks with Abbott Labs, and we are deploying the Abbott ID NOW machines within all of our facilities, because we can get them within four weeks — probably now even less than four weeks, because so many people are now going to be getting the free ones from CMS.
What I would say is if that you have the ability, if you have the wherewithal, try to do things on your own. This is not a plug for Abbott, because I don’t know how many other companies make these machines. But I would say: Take control of your own destiny, and not just your destiny. Take control of the lives and health of your patients and your residents. In the short term, it may cost you more money to buy these machines; I think they’re about $5,000 apiece. But in the long term, bottom line, you’re saving lives and that’s what we’re here for. To protect and save the lives of our residents and patients.
I think it’s great. I think it’s fantastic that the federal government is doing this. [It was] the first time that we had a call directly with CMS and all the providers that we feel that they’re taking long-term care seriously. It’s laudable that they’re now doing this and a lot of credit goes to the federal government. However, you’re still looking at it a significant lead time in order to get those machines if you’re not in the current hotspot area.
So my recommendation would be if you have the ability — and I think that most facilities in the country, aside from PPP [Paycheck Protection Program] loans for payroll, have also gotten through the CARES Act [funding] that has to be spent for COVID-related expenses. I think this is one of the first things that any facility should should get, is point-of-care testing as soon as possible.
What are some of the steps you’re taking now, whether for staff or supplies, to be prepared for either the next wave or another pandemic?
The No. 1 thing is that we’re doing, and that I would advise every facility owner, operator, administrator, to do is have communication. When I say communication, I’m talking about having communication and preparedness, but communication with your staff, No. 1. I’ll get back to why that’s No. 1.
But of course, communication and transparency with all the regulatory authorities, with families. I don’t believe that’s a problem anymore, only in the beginning before there was required reporting — not all facilities were communicating as as well as they should have been.
But that’s to the families and that’s to the state. I’m talking about communication with the staff. What we learned is we need to prepare the staff for when something like this hits. Everybody is scared. One of the toughest things during this outbreak was being able to get staff to come into the building. Let the staff know what you’re going to do when you have an outbreak — not if you have an outbreak, but when you have an outbreak.
For example, what we did is something called the Warrior program, before our second facility’s outbreak. What we realized is that staff need to know that you have the PPE, that they’re available. Because for some reason, there have been times — and I’m not saying about my facilities — but what I’ve read is that staff will say, “Well, we have to wear something for a week or whatnot,” but that’s not the case. Just administration has not put it out there that we have appropriate PPE. We’re following the CDC contingency plan or the CDC crisis plan.
More than that, what we did was we had volunteers of staff — of course, they would get paid more — but we would have staff [that we called] “Nurse Warriors.” From the onset, before there was a single case, they would say: If there is an outbreak in the building, and we have to have a COVID unit, they’re going to be the ones that are going to work on that COVID unit.
Again, that was something that we paid for. It’s something that staff signed up for readily because there was a significant upside for them, so long as we had the PPE to protect them, they were safe. But it also calms the nerves of the rest of the staff, because the rest of the staff knew that as far as our positive residents, they won’t have direct exposure. We already have in place who will be exposed to those residents and what steps we’re taking to protect those that will be exposed. You want to be able to, beforehand, come up with a plan with who’s going to take care of your COVID patients, so the other nurses are not going to be calling out.
In all facilities in New York, New Jersey, the staff was one of the major issues — was probably the biggest issue. I know that personally, there was a certain period of time that we were considering closing down one of our facilities, and evacuate residents to our other facilities in New Jersey, because up until the last moment, we didn’t know that we’d have enough staff to to come to take care of the residents that were there. It was really nail-biting experience.
But again, once we put together that staff warrior program, it made it a lot easier and gave a lot of comfort to the staff that knew that they’re not going to be directly exposed to those patients. Others will, with the appropriate PPE, but not them. So that made a big difference.
Is there anything else you’re thinking about for the long haul?
Without giving away trade secrets, but for the sake of the entire industry because this is not me, this is about the residents — the state of New Jersey several weeks ago has started to allow outdoor visitation for residents and families. It’s key. It’s instrumental to the mental, emotional well-being of our residents and family members.
And, frankly, from a business perspective, from an admission standpoint. We have sub-acute patients who used to come to nursing homes for rehab. Now they’re saying: Well, why would I go to a sub-acute rehab facility and not be able to have my family visit me when I can stay home and do outpatient therapy?
But let’s put that aside, that business stance. Let’s look at it from a resident standpoint. Summer comes and goes. Before we turn around, it’s going to be winter, and we don’t know when the state is going to start allowing indoor visitations. We know in New Jersey, they’ve allowed it only for the developmentally disabled and intellectually disabled within the nursing home. There’s a small carve-out that they’ve allowed.
But it’s going to have to break; there’s going to have to be a time. And there’s going to be a lobby for it from the nursing homes, from the residents, from the staff members, that: Hey, it’s gone on long enough, we have to be able to figure out a way how we can visit our loved ones.
Now, at this point, yes, it’s outdoors, that works. But what happens when it starts getting cold outside? What happens when it’s 50 degrees or 40 degrees or 30 degrees outside? How are you going to visit your loved ones outside?
I think that everybody needs to take a look at ways that they can safely — working with your local departments of health, working with engineering and architectural firms. We are working with one firm to put together for us what we call “protected visitor suites” so that visitors can actually come into the facility without going through any patient areas and have a glass wall in between, with negative pressure on both sides.
It has to be done really, really well — and, again, in accordance with local departments of health and state departments of health. Today they haven’t given really clear guidelines, but I believe with this concept that we have, we’re working with the local departments of health to show that to them and say: Hey, look, we know the inside visitation is not allowed but if we have A, B, C, and D, can we do that under these circumstances? Because winter’s coming.
The country’s residents have suffered long enough without being able to see family members, and we all collectively need to come up with a solution of what happens after the summer if COVID remains a reality, because it’s not sustainable to say: You come into a nursing home, you can never see your family again. It’s just not something that is sustainable for the long term.
No visitation — it’s not right. It’s right from a infection-control standpoint, but it’s not right for the residents. We have to find a way for residents and for families. We have to find a way that we can make it safe, so that those visitations can happen, and they can happen quickly.