Hospitals Should Discharge Patients with Coronavirus Only to Qualified Nursing Homes

As the coronavirus pandemic continues, nursing facilities are being asked, or told, to admit or readmit residents who had or may have COVID-19. Hospitals need beds for acutely ill residents and need to discharge patients that they determine can be safely discharged to other settings.  How do we keep as many people as safe as possible? Unfortunately, federal guidance is limited and state directives are contradictory.

Advocates for nursing home residents do not want states to order all nursing facilities to admit all patients, as New York State and California have directed.[1] Nor should facilities decide, on their own and by whatever criteria they choose, whether to admit any or all patients from acute care hospitals. The Center for Medicare Advocacy has heard of a facility with one- and two-star ratings in health surveys and staffing, as well as an abuse icon, arranging with local hospitals to admit patients with coronavirus. Such poor quality nursing facilities should not be permitted to admit COVID-19 patients.

Hospitals need to be able to discharge patients who no longer need an acute level of care. If such patients are going to post-acute settings, these settings need to be as safe as possible. We are fully aware that not all new or old post-acute facilities can meet all of the standards we recommend, but we believe that it is critical to think about what would be best and to accommodate as many good practices as possible. Our goal is to identify essential components of a good system that protects residents and to have as many of them put in place by as many facilities as possible.

If patients are discharged to post-acute settings, we set out our priority types of facilities below, in descending order (to the extent these alternatives are available, or can be created, in the community):

1. Long-term care hospitals or hospital-based SNFs;
2. Newly-identified or newly-created special COVID-19-only facilities;
3. Other nursing facilities meeting higher standards (discussed below) and with dedicated COVID-19 wings or units.

The second and third categories should be authorized to admit COVID-19 patients from hospitals only when:

• The hospital has first tested the patient for COVID-19 before discharging the patient to the nursing facility - patients without symptoms cannot be assumed not to have the disease because older people may have different symptoms than younger people with the virus;
• Each resident is given a private room;
• Registered nurses are on site, 24 hours per day;
• Facilities meet nurse staffing ratios of 1.25 hours per resident day of RN time and 4.5 hours per resident day of all nursing time;
• At least one qualified “infection preventionist” is on site full-time;
• Facilities have sufficient personal protective equipment (PPE) and necessary supplies.

We understand that not all facilities will be able to meet all of these requirements.

Some nursing facilities should be prohibited from admitting COVID-19 patients who are ready to be discharged from hospitals. Having certification for Medicare does not mean a facility is qualified to provide care to COVID-19 residents.

Facilities that should not be permitted to admit COVID-19 patients include:

• Facilities with low nurse staffing levels (one or two stars in either staffing category) or a nurse staffing waiver;
• Facilities providing poor quality care (Special Focus Facility (SFF) or SFF candidate or otherwise determined by CMS or the state to provide poor quality care);
• Facilities with currently imposed remedies of denial of payment for new admissions or civil money penalties exceeding $5000 for quality of care deficiencies; or
• Facilities that have an abuse icon.

Special Concerns about Creating COVID-19-Only Nursing Facilities

A number of states currently appear to have considerable interest in establishing COVID-19-only facilities, both through new transitional facilities and conversion of existing facilities. The Centers for Medicare & Medicaid Services (CMS) gave its approval March 28, 2020 to temporarily certifying non-SNF buildings, waiving requirements under 42 C.F.R. §483.90.[2] Advocates have concerns about both types of COVID-19-only facilities.

CMS currently provides no guidance on what new temporary transition facilities need to demonstrate before they receive patients with COVID-19. These facilities should be required to document that they can provide appropriate care to residents and meet the standards identified above (including sufficient staff, nursing and other, to provide care to residents, RNs 24 hours per day, a fully trained on-site infection preventionist, necessary equipment and supplies).

If COVID-19-only facilities are developed from existing facilities, advocates have additional concerns. We strongly oppose CMS’s authorizing facilities to move their residents without prior notice in order to separately cohort infected residents and non-infected residents when the discharges completely disregard and undermine longstanding protections of residents from involuntary discharge. CMS’s March 28 guidance waives “certain” but unspecified protections at 42 C.F.R. §§483.10, 483.15, and 483.21, to allow the involuntary moving of residents “solely for the purposes of cohorting and separating residents with and without COVID-19.”

The first nursing facility to convert itself into a COVID-19-only facility abruptly relocated residents to sister facilities and other nearby facilities. Families were notified only by a video on the facility’s website. Twenty-four hours later, many adult children did not know where their parents were.[3] The complete absence of preparation for the discharges endangered residents and is not an acceptable model.

A better approach appears in Connecticut. A joint letter to residents, families, and responsible parties from the Department of Public Health and the State Long-Term Care Ombudsman Program describes the need for more extreme, though temporary, precautions to protect residents and staff from coronavirus and the state’s necessary plan to move residents to create COVID-19-only facilities.[4]

The Connecticut letter promises:

If you or your loved one need to move to another room or nursing home, a team member from your nursing home will contact you directly. The rights, safety and well-being of the residents are always at the forefront of the State Official’s decision-making. This is an incredibly trying time and we are asking for your assistance keeping residents’ well-being as the priority.

The two agencies are setting up online meetings for residents and families when they will be able to ask questions of Department representatives. The letter also advises residents and families to contact the ombudsman with questions or concerns, and concludes with:

The Long-Term Care Ombudsman Program and the Department of Public Health are here to support you through this very challenging time. Please remember it is normal to have questions, feel uneasy or even scared due to this unprecedented situation. Our offices as well as the care team members at your nursing home are here for you. Reach out, talk about how you are feeling and what you think might help you cope with all of this. We need to do things differently right now and will continue to offer support so that we can get through this together.

According to the Connecticut Post, Connecticut has now announced plans to cohort residents, some to wings of existing facilities, some to separate facilities (including some previously closed and vacant facilities).[5] The article reports that the Department of Public Health will oversee “staffing, logistics and the moving of equipment” at the new facilities, which will get state licenses. Facilities will be required to report their staffing plans as well and equipment and food needs. Finally, the article identifies, by name, which Connecticut nursing facilities will be converted and which new sites will be opened.

Conclusion

In this pandemic, at least three actions are necessary:

• First, accurate and meaningful information about which nursing facilities have residents and staff with confirmed cases of coronavirus needs to be made public. The absence of clear, comprehensive, and truthful information creates more fear and anxiety for residents and families and the public in general.
• Second, tracking cases of the coronavirus in nursing facilities is important so that, to the extent possible, essential resources – staff, personal protective equipment – can be sent to those facilities with the greatest need.
• Finally, government needs to take responsibility to make sure that all facilities – newly created facilities and existing facilities – have the staff, supplies, food, and equipment that they need.

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[1] New York State Health Department, Advisory: Hospital Discharges and Admissions to Nursing Homes” (Mar. 25, 2020), https://skillednursingnews.com/wp-content/uploads/sites/4/2020/03/DOH_COVID19__NHAdmissionsReadmissions__032520_1585166684475_0.pdf;California Department of Public Health, “Preparing for Coronavirus Disease 2019 (COVID-19) in California Skilled Nursing Facilities,” AFL 20-25.1 (Mar. 20, 2020), https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/AFL-20-25-1.aspx.
[2] CMS, “Long Term Care Facilities (Skilled Nursing Facilities and/or Nursing Facilities): CMS Flexibilities to Fight COVID-19” (Mar. 28, 2020), https://www.cms.gov/files/document/covid-long-term-care-facilities.pdf.
[3] Robert Weisman and Tim Logan, “Officials are emptying nursing homes across Mass. to create coronavirus recovery centers,” Boston Globe (Mar. 28, 2020), https://www.bostonglobe.com/2020/03/28/metro/officials-emptying-nursing-homes-across-state-create-covid-19-recovery-centers/.
[4] Letter is embedded in  Rob Ryser, “State creating coronavirus-only nursing homes,” News Times (Mar. 31, 2020), https://www.newstimes.com/news/coronavirus/article/State-creating-coronavirus-only-nursing-homes-15168419.php.
[5] Ken Dixon, “Lamont plans shift of nursing homes to separate COVID-positive residents,” Connecticut Post (Apr. 2, 2020), https://www.ctpost.com/news/coronavirus/amp/Lamont-plans-shift-of-nursing-homes-to-separate-15173629.php?utm_campaign=CMS%20Sharing%20Tools%20(Desktop)&utm_source=t.co&utm_medium=referral&__twitter_impression=true.