Coronavirus Commission Report Released; Administration Responds
Regulation | September 18, 2020 | by Jodi Eyigor
The Coronavirus Commission on Safety and Quality in Nursing Homes final report was released on September 16, promptly followed by a response from the Trump Administration.
The highly-anticipated Coronavirus Commission on Safety and Quality in Nursing Homes final report was released on September 16. The Commission, formed in June 2020 and including 25 individuals with diverse expertise and viewpoints, convened 9 times through August to address safety and quality in nursing homes in relation to the public health emergency. The final report includes 27 recommendations covering 10 themes: testing and screening; equipment and personal protective equipment (PPE); cohorting; visitation; communication; workforce ecosystem – stopgaps for resident safety; workforce ecosystem – strategic reinforcement; technical assistance and quality improvement; facilities; and nursing home data.
Concurrently, in response to the report, CMS pushed out a press release and the Trump Administration released a document comparing the Commission’s recommendations with Administration actions to date. While the comparison document demonstrates a number of steps the Administration has taken to address COVID-19 in nursing homes, a few central themes emerged throughout the Commission’s report that have yet to be addressed. Some stakeholders have suggested that this independent commission was formed to spend more than 2 months finding ways to commend government agencies on a job well-done. Much remains to be done to address the gaps and shortfalls identified by the hard-working and extremely knowledgeable experts of the Commission.
What follows is an analysis of several Commission recommendations by theme, the Administration’s response, and potential areas for action.
Testing and Screening
The Commission calls for a national strategy for rapid-results testing that takes into account local community prevalence and CDC-recommended screening protocols.
We are well aware of the guidance (and requirements) CMS has put in place related to testing. CMS has also released staff and resident screening guidance, supplemented by more detailed guidance by Centers for Disease Control & Prevention (CDC). HHS has provided antigen testing devices to nursing homes to allow for point-of-care testing by 2 different methods. While these helpful distributions were greatly appreciated by nursing home providers across the country, they were short-term fixes for a long-term problem. Testing supplies covered nursing homes’ needs for a few weeks at best. A comprehensive, national strategy involves ensuring adequate supplies are available at reasonable costs, and that funding is available to support nursing homes as they meet the requirements that will ensure the safety of residents and staff in the nursing home.
Equipment and Personal Protective Equipment (PPE)
The Commission recommends that the Administration assume responsibility for a process that ensures that nursing homes can procure and maintain a 3-months supply of high-quality PPE; provide specific guidance on the use, decontamination, and reuse of PPE; and provide guidance on training to all staff on proper PPE use.
Federal Emergency Management Administration (FEMA) shipped two weeks’ of PPE supplies to nursing homes and in August 2020, more than 5 months after declaring the pandemic a public health emergency. However, as with the testing supplies, the PPE shipments were a temporary fix that barely scratched the surface of nursing homes’ needs. While CDC has provided strategies to optimize PPE supplies, contingency- and crisis-level strategies would not be necessary if nursing homes and other healthcare providers had access to the PPE needed to keep staff safe and limit transmission risk.
The Commission recommends that the Administration update cohorting guidance to better balance infection control concerns with residents’ psychological well-being, while improving reimbursement policy to address nursing home differences.
While guidance on cohorting is available, we note that reimbursement policy continues to inadequately address cohorting strategies. Guidance recommends that residents who are COVID-positive may be cohorted with other COVID-positive residents if a single room is unavailable; however, nursing homes continue to be reimbursed different rates based on whether a resident is isolated in a private room or cohorted in a shared room, despite requiring the same isolation precaution. As recommended by the Commission, nursing homes must be adequately and consistently reimbursed for the care provided.
The Commission recommends that CMS update visitation guidance, including both in-person visitation and virtual visitation, and take steps to address residents’ mental health and well-being as impacted by social isolation.
While the Administration has released visitation recommendations and guidance, and the Administration and nursing home providers alike recognize the devastating impact of visitation restrictions on residents’ well-being, one cannot lose sight of the primary issue. COVID-19 disproportionately impacts the vulnerable populations often served by nursing homes and research indicates that asymptomatic carriers account for more than 40% of COVID-19 cases. The only way to detect an asymptomatic carrier of this virus is through testing. Without a federally-funded national testing strategy that ensures adequate access to supplies for all residents, staff, and visitors, a nursing home cannot identify and appropriately restrict an asymptomatic individual from entering the nursing home and potentially transmitting the virus to residents.
The Commission calls for workforce support to address a fatigued workforce through a number of actions including minimum care standards, enhanced infection preventionist requirements, and increased staffing mandates. The Commission also recommends taking steps to improve workforce recruitment, specifically certified nursing assistants (CNAs), through processes that recognize on-the-job training, testing, and certification and a national CNA registry.
The Administration points to CDC guidelines to address staffing shortfalls and support from FEMA in select nursing homes impacted by surges; however, these actions do not address the actual problem of a workforce shortage that existed before and has only been exacerbated by this pandemic. The Commission’s recommendations for increased wages through Medicare/Medicaid reform, hazard pay, quarantine pay, and greater interstate reciprocity for licensure and certification to provide surge-staffing pools are a step in the right direction. We are concerned, however, that some recommendations around the infection preventionist might actually serve as a hinderance to the workforce ecosystem by creating barriers to recruiting individuals for this role.
Technical Assistance and Quality Improvement
The Commission recommends increased funding and reprioritization of activities to increase the availability of collaborative, on-site, data-driven, and outcomes-oriented support to nursing homes prior to, during, and after a public health emergency.
The Administration highlights the assistance provided by deploying the Quality Improvement Organizations (QIOs) to “over 1,500 nursing homes since March 2020” for technical assistance. We note that that accounts for fewer than 10% of all certified nursing homes nation-wide. The Administration also references federal strike team visits; however, to date, CMS has only disclosed providing assistance to a total of 18 nursing homes nation-wide under this initiative.
While this assistance, in addition to the QIOs’ weekly online learning offerings, have been invaluable, we concur with the Commission that greater expansion of this assistance is needed.
Nursing Home Data
The Commission calls for easy-to-use, intuitive, and interactive technical infrastructure to streamline reporting processes and support coordination of data among health organizations.
The Administration points to the creation of the National Healthcare Safety Network (NHSN) COVID-19 module, through which nursing homes are now required to report COVID-19 data. We note that this module added to reporting burden, rather than streamlined it, since the majority of states continue to require reporting at the state level separate from the federal NHSN reporting requirement. Additionally, we note that the Administration eliminated the NHSN COVID-19 module for hospitals months ago, effectively severing any potential bridges for data coordination that could have been developed. Additionally, nursing home providers are now required to provide additional reporting through yet a separate platform when conducting any point-of-care testing, including the point-of-care testing that has been supplied by the Administration.
We commend the months-long work of the Coronavirus Commission and the support provided by the various agencies thus far, including CMS and the QIOs, CDC, FEMA, and the Office of the Assistant Secretary for Health (OASH) among others, but urge the Administration to seriously consider how they might further deliver on the recommendations of the Commission. These recommendations, if funded and implemented, could help fortify a long-underfunded field and set it in a better stead to handle the months to come as our nation continues to battle this pandemic.