Former CMS Consultant: Nursing Homes ‘Need to Know Exactly What We Expect of Them’

Until researchers come up with a COVID-19 vaccine, infection control will form a key pillar of nursing homes’ efforts to contain the virus’s spread — and nursing homes have historically struggled in that domain.

It’s a challenge that will only increase as case counts spike in certain regions, and facilities reopen their doors to visitors. But the Centers for Medicare & Medicaid Services (CMS) has made clear that infection control will be the top priority of surveyors during this time period, rolling out increased fines for facilities with a history of citations and beefing up enforcement for lower-level issues.

For the most recent episode of SNN’s “Rethink” podcast, we decided to call in an expert to help provide top-level guidance to operators looking to navigate the “new normal” of fighting an invisible, untreatable virus at every turn.

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As a CMS contractor specializing in infection control for a decade, Karen Hoffman was on the front lines of improving safety in nursing homes at the federal level. She also serves as a clinical instructor of infection control the University of North Carolina in Chapel Hill, and was the 2019 president of the Association for Professionals in Infection Control and Epidemiology (APIC).

Hoffman spoke about the need for clear, easy-to-understand federal benchmarks for nursing homes to meet around infection control — while also acknowledging the endemic challenges of keeping a virus from spreading among vulnerable elders in close quarters.

Excerpts from the discussion are presented below, but be sure to check out the full episode on SoundCloud, iTunes/Apple Podcasts, or Google Play — and subscribe if you like what you hear.

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Why is it so hard to prevent infections in nursing homes? And what are the biggest problems that kind of led us to where we are today?

We have, in nursing homes, the most fragile patients — patients that would have been in hospitalized care a decade or two ago. My background before infection prevention was actually in the ICU, and it’s really amazing how critically or seriously ill a lot of these residents in nursing homes are. They have central lines, they have ventilators; they just have a lot of things that require a really intensive amount of work, and just put them at serious risk of infection. 

Then the other thing that happens is, as these people come through the health care system over and over again — they go to hospitals, they go back to nursing homes — they often pick up multi-drug-resistant organisms. Before COVID, the problem that we were really looking at was the multi-drug-resistant organism problem. Recent studies have shown that as many as half of all nursing home residents have a multi-drug-resistant organism on their skin or in their mucous membranes, like their noses. When they get to a vulnerable stage, they might catch a cold or they might get a wound — that turns into a major infection.

It’s just very difficult for the staff, in terms of their staffing levels, to really be able to keep up with all the basic infection control practices that we know are most important. That is the time to take hand hygiene between residents, the time to wear appropriate PPE.

Then just the fact that people live in two-bed rooms for long periods of time just give it more opportunity — with shared dining and shared residential experiences — to share those multi-drug-resistant organisms between themselves.

It really takes a dedicated person looking at these issues, and then having the authority to do something about it, that can actually break the cycle that we see in long-term care.

As someone who’s worked with CMS, what’s the best strategy for improving this? Resident advocates say it’s just a matter of increasing fines, but we also know that funding — particularly for facilities that specialize long-term care — is extremely tight.

We’ve been trying to figure that out. We actually did a pilot study with CMS, initiating work with the quality improvement organization to look at how we could maybe make a change for improvement. With the nursing homes, we actually created an infection control worksheet, and that worksheet had about 40 pages of the key things that could prevent residents from getting an infection.

We piloted that in 40 nursing homes, along with 40 hospitals, to see if they could, with assistance, actually implement and improve the care measures — and in less than a year’s time, with just minimal interaction of some phone calls and assistance from the quality improvement organizations, which are funded by CMS, they were able to make significant improvements.

Sometimes we see that our APIC chapters, working in their own state, will try to have that assistance provided. There’s programs through the QIOs.

It takes additional outside expertise — and then working with someone in the facility, we find, is critical. [Someone] who is designated to do infection prevention that can answer these questions ongoing, and keep the focus on infection prevention and control because, like everything in health care, there’s just so many people pulling in so many directions, that sometimes infection control gets lost in that.

The media has certainly reported on the persistent infection-control challenges in nursing homes, but obviously COVID raises the stakes — with something like the flu, it can be dangerous, but you have weapons to fight it when it does break out. With COVID, testing and control are all you have.

No one is immune to COVID in the world’s population, so that’s the biggest issue — and it is a respiratory-spread organism. That makes it easy to move around from person to person, particularly in any congregate setting like a nursing home, or even schools and prisons and industry like the meat processing plants — anywhere we get people so close together, they can share those respiratory droplets.

We’re having problems, which really brings us back to basic infection control practices [that] we know work being instituted in each of these settings.

What are some of the top things that operators should be focusing on now that economies are reopening, and even the essential workers who may be entering and exiting buildings may not have the same kind of group protection they had during the lockdowns?

This is really where having an IP in the long-term care facility, that’s dedicated, is essential. It’s actually recommended by the CDC at this time, with the COVID outbreak, to have a designated infection preventionist if you don’t already have one in your facility, because they can really bring that high-level overview of what needs to be done.

For example, do you have an alcohol-based hand rub outside of each door and inside of each room available? That’s a basic work practice that we can institute that can help compliance with hand hygiene, which we know is one of the major things that prevents not only COVID but also every other kind of infection control issue we have — multi-drug-resistant organisms and food-borne pathogens and noroviruses. We’re coming into that season as well.

A simple thing like that — that is something that we’ve been encouraging nursing homes to implement for a long time, and it’s just been difficult for them to do.

Simple work practices, something than an on-site person can evaluate — the use of PPE being put on and taken off correctly is also problematic if you don’t have somebody there that can train and monitor for competency and compliance, doing audit for use and giving feedback when they see things go wrong.

That’s why that’s so important. Then you’ve got somebody who could actually work with the communicable disease or emergency preparedness or the resources that you have in your state to stay up-to-date because this is a very evolving outbreak we’re dealing with right now. Recommendations are changing. We’ve been seeing minor changes almost day to day, or week to week, that help us do a better job, and so you really need somebody to be totally focused on on that aspect.

Do you think that’s going to inform policy going forward? There’s been some attention on the fact that CMS moved to ease some of the new IP rules under the last round of the Requirements of Participation (RoP) updates.

I can’t really say how that decision is going to end up. But what’s happened up until now is that they did publish, in 2016, new regulations that required all skilled nursing facilities to have a trained IP in place by November 2019, and it could have been a full-time or a part-time position.

The change that occurred was that they changed the language a little bit to make it more nebulous — to say that they [must] have an IP for a sufficient amount of time, which I think would be difficult for surveyors and facilities to know exactly what that means.

What is the sufficient amount of time as opposed to requiring them to work part time? How much time do they really need to spend in their nursing homes to accomplish the best infection control practices that they should be doing?

What are some of the challenges around surveying for infection control, and how do you think the survey process should change as we go forward?

I think this outbreak has shown that we really need to make more proactive emphasis on infection control. We need to spend more time assessing it. The surveyors are challenged with having many, many things to look at when they come into a facility — of which infection control is just one of them.

I will say that it is the most frequently cited, or the second most frequently of all the different regulations that they look at, but it’s cited at a pretty low level. It gets the attention of administrators and nursing home operators when you tend to get the higher-level citations that can actually result in fines of substantial amounts.

I’m not saying they should be fining at substantial amounts across the board as they come in. But we need to figure out a better way of motivating nursing homes to implement things like putting up hand hygiene dispensers.

There actually needs to be more work together between the owners, operators, the associations representing them, and the recommendations from CMS and from CDC, so that we’re all on the same page — particularly around simple things like alcohol-based hand rub dispensers, where they can and can’t go.

Cleaning and disinfecting agents has also been a problem. We know that when you live in a house with family members, how easy it is to share colds. Well, it’s kind of the same thing in nursing homes, because they’ll share the same recreation, the same communal dining room. They go up and down the hallways, and use the handrail.

So the cleaning strategy with shared equipment that goes from room to room, they really need to make more emphasis on that, and get better agreement on what is and isn’t acceptable. Then across the country [it’s important] that we get accepted agreement on practices, because there are — from state to state agencies — differences in how they interpret the regulations and the interpretive guidance, which has also been difficult for facilities to know what to do.

With COVID-19, I think we’re seeing how a quote-unquote “low-level” citation can escalate quickly, just because of what we discussed before — the lack of any effective treatment once an outbreak occurs.

The mortality is very high, and that tends to get the attention of surveyors; they key in on anything that causes serious harm. That’s what they’re supposed to do. So COVID definitely causes serious harm and has a high mortality, morbidity, and they tend to focus their attention when they see those kinds of things reported.

You talked about the challenges around design, how shared rooms and spaces really accelerate the spread of diseases like COVID-19 — but we haven’t seen a ton of new investment in physical plants over the last few decades, really. What are some of the top things that you would want to see in terms of design based on lessons from this pandemic?

Well, that is a very big question. I can tell you the single most important thing I would do if I could design a nursing home — besides, obviously, making them single rooms — is the bathroom situation. Shared showers, shared bathroom facilities — a lot of the older facilities, there may be only one showering room, so everybody has to be brought to that one shower or bathing room.

You can imagine the risk of something warm and moist, continually, where people are being bathed — the risk of cross-transmission, and the importance of cleaning and disinfection in the shared, semi-private, or quad rooms where they have to share a bathroom in between. Now we’ve got four residents who have to share one bathroom, and so if one person is ill with something that’s communicable — particularly if it’s communicable through stool — the level of contamination and cleaning in between would be difficult to maintain.

That’s what I would primarily focus on if I could control the world.

If you controlled the world, and you could rewrite the regulatory strategy for CMS and nursing homes, how would you do it?

Well, I think that they need to know exactly what we expect of them in a consistent way. I think the infection control worksheets, which are now available on our website, have been recently updated. And by our website, I mean the CMS website … has an infection control worksheet that was updated to the current regulations. That is a great start.

We’ve seen this with dialysis. We’ve seen this with hospitals and ambulatory care centers. In 2009, the first infection control worksheets [were] put out by CMS, with the help of CDC, after they had some major outbreaks, and that really was helpful that we did it for hospitals. They have been able to be within 85%, 90%-plus compliance with these key measures really from the CDC guidelines.

Then dialysis — we were able to see improvements, significant improvements there. I think that we need to focus on what we’ve seen be successful in other settings, and work towards using that moving forward.

This interview has been condensed and edited for clarity.

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