COVID-19 leaking into Florida nursing homes; cases soaring
Florida regulators take credit for saving lives in nursing homes, but with a late testing strategy and rules that allow thousands of untested vendors and staff to enter, cases keep rising.
More than 6,700 staff and residents at nursing homes and assisted living facilities have been infected with COVID-19 in the month of July, a 129% rise that regulators blame on vendors and staff who unwittingly bring in the virus.
But the state also played a role. Gov. Ron DeSantis and Secretary of the Agency for Health Care Administration Mary Mayhew say they have tried to keep coronavirus out by putting eldercare homes on lockdown since March. In June, they announced a plan to test nearly 200,000 staff for evidence of the virus every two weeks, and the gover
nor has boasted that the efforts have “saved lives.”
But for many in the industry who have been scrambling to halt the spread of the virus as it surged in their communities, there are two problems with the state’s approach to COVID-19: Testing has been too late and incomplete, and every day, thousands of vendors, staff and even state workers are allowed to enter long-term care facilities without proof they are free of the virus.
Leaders of nonprofit nursing homes called it a “category five emergency” and the situation has become so alarming that the federal Centers for Medicaid and Medicare Services on Wednesday announced it would send “strike teams” into 18 nursing homes in six states with the highest case rate among residents, including an undisclosed number in Florida.
The governor also previewed the initiative in a tweet, saying he would be sending infection control teams to inspect and monitor homes, as he did in
April when the virus was first attacking elders. The infection rate was so high in some places, such as Fair Havens Nursing Center in Miami Springs — where 51 residents have died — state health officials issued more emergency orders in May than in any month since April 2011.
CMS Administrator Seema Verma announced that federal regulators will soon be requiring states like Florida, where the positivity rate is above 5%, to test nursing home staff weekly and it is “ratcheting up financial penalties” for homes that violate basic protocols such as handwashing and mask-wearing. CMS currently only “recommends” that testing occur regularly.
And CMS will spend $5 billion for technology so residents can connect with their families if they are not able to visit and to buy 15,000 testing machines for all nursing homes to test staff and visitors who enter their facilities.
The reason for the stepped-up attention: Current policies don’t seem to be working.
When the governor announced the state would reopen to Phase 1, elders living in long-term care facilities accounted for 7 in 10 Florida COVID-19 deaths. Now, of the 5,518 deaths in Florida, 2,557 had been residents or staff at long-term care facilities, according to the latest data from the Florida Agency for Health Care Administration.
New infections among residents at long-term care facilities in Florida rose by 142% or 2,819 cases between July 1 and July 21, while the increase among staff rose 121% or 3,882 cases.
And last week was the deadliest week for residents and staff at long-term care facilities since the state first started releasing data on deaths in early May, with more than 250 additional deaths reported between July 17 and July 23.
‘WORN DOWN’
“The reason the virus went rampant was because of nursing home staff, and two-thirds of nursing home staff are hourly employees working in multiple facilities trying to make ends meet,’’ said Jay Solomon, CEO of Aviva Campus for Senior Life in Sarasota. As the virus spread in Florida’s communities, the staff went home and brought it back to their workplace, he said.
“What we’re finding is staff is coming in contact, without even knowing it,’’ he said. “Our communities are truly a microcosm of the larger community.”
Positive staff tests have, in some cases, been a harbinger of resident deaths to come. At the Hialeah Nursing and Rehabilitation Center, for example, the number of positive staff cases went from 20 cases on May 20 to 52 cases June 2 to 78 cases on June 16, according to a Miami Herald analysis.
In the same time period, the number of resident deaths at that facility increased from 2 reported as of May 22 to 18 deaths roughly a month later on June 18. Since then, the number of deaths has increased from 18 to 52 in the most recent data released July 17.
When virus numbers began to spike in June, Solomon identified employees who were working at more than one facility, and “the moment we heard those facilities had a positive case, we offered them an opportunity to pick up more hours in our facility — part-time to full-time,’’ he said. “We created our own pool of employees that we knew were under our protective bubble.”
He also required everyone on his campus to wear a mask indoors and, when he saw the numbers of positive coronavirus tests surge in his community, he also mandated masks outdoors. None of the 300 residents on Solomon’s campus have become infected with the coronavirus.
It was just one of the workarounds Solomon and many other long-term care administrators have employed that go beyond the rules imposed by the state to keep their residents COVID-free.
“The virus has literally worn the workforce down and the level of support for these facilities is not there,’’ said Doug Adkins, CEO of Dayspring Village, a mental health ALF just south of the Georgia-Florida state line.
He tested all staff and residents regularly before the state required it, and required all contract help who came into the building to also prove they are tested and COVID-19 free. When his staff has come in contact with a family member who tests positive for COVID-19, even though they show no symptoms, he has paid them to stay home.
It’s expensive, he said, but has helped to keep his facility free from COVID. “I need to see the infection rates go down before I can get to a comfort level,’’ he said.
UNREGULATED VENDORS
AHCA has two standards when it comes to vendors. The agency requires “all staff entering the facility to be tested,’’ said Katie Strickland, AHCA spokesperson. “This includes clinical, housekeeping, nutrition and food service, maintenance, administration, and contract staff.”
But AHCA guidelines say vendors and contractors entering buildings for necessary repairs, like plumbers, electricians, pest control workers, are not required to be tested for COVID-19. However, they should be “appropriately screened” for fever and required to wear “appropriate” personal protective equipment, she said.
Vendors are not supposed to come in close contact with residents while they’re in the facility. But there’s no provision urging against close contact with the nursing home workers who could then potentially pass the virus on to their patients. Additionally, many residents employ their own private duty aides, sitters and companions, and the state imposes no requirements that they be tested.
In a Q and A on the agency website, AHCA asks if these outside staff must be tested “and can the facility restrict them from entry if they are not tested?”
The answer is that it’s up to each facility administrator and there appears to be no enforcement if they ignore it.
“The nursing home or ALF administrator must ensure that all staff are tested prior to entry into the facility,’’ the AHCA document states. “Staff who are not employed by the facility may obtain testing through other resources as long as they can provide documentation to the facility of the date tested and results.”
Kristen Knapp, spokesperson for the Florida Health Care Association, which represents nursing homes and ALFs, said many vendors are conducting their own tests or having their staff get tested at state-run sites.
“Many of them are telling me that facilities are not letting them in unless they are testing and show proof of that,” she said.
But she couldn’t say whether every administrator is imposing this requirement and what happens if a vendor doesn’t test its staff.
“Those kind of confusing policies [have] led to the surge across the state and in facilities,’’ said Brian Lee, director of Families for Better Care, which advocates for nursing home residents and families. ”The nursing home is at the heart of the economic engine of that community. As the community spread occurs, it’s just going to seep into these facilities. And once it gets in there, you just can’t flush it out.”
STATE STAFF EXEMPTED FROM TESTS
While AHCA demands that every nursing home and ALF test all staff and vendors, it exempts its surveyors, the state inspectors who enter homes daily to monitor safety, code and infection violations.
“Surveyors are not at this point required to be tested,” Kimberly Smoak, AHCA chief of field operations, said in a conference call with industry representatives last Thursday. Industry executives had asked why state employees didn’t have to prove they were virus-free, even if they have visited homes with active COVID cases.
“They do not provide or perform any direct patient or resident contact care,’’ Smoak answered. She said the state is following federal guidelines and noted that inspectors must wear protective gear. But, she reminded them: “You have to let them in.”
Failure to cooperate with surveyors could result in fines and penalties.
For weeks, DeSantis and AHCA Secretary Mary Mayhew have touted the fact that they kept the virus from spreading by preventing hospitals from transferring patients to long-term care facilities unless they have tested negative.
But as hospitals across the state starting filling up, the agency reversed that position and imposed a new rule last week that allows hospitals to transfer COVID-positive patients to nursing homes and ALFs as long as the receiving facility has a dedicated isolation wing with a dedicated staff to care for the residents. As an alternative, the state has also established an estimated 21 COVID-only hospitals to accept patients when they can’t be otherwise isolated.
Mayhew told long-term care administrators in a teleconference call Thursday that the change is because “nobody should be in a hospital bed longer than necessary” and some people don’t test negative but are no longer contagious.
DeSantis said Thursday that Florida had fewer outbreaks than other states because they have adhered to the state guidelines. He also noted that within longterm care facilities the positivity rate has been “about 3%,” which is lower than the 11% statewide.
DEMAND FOR RAPID TESTS
The industry has concluded the only way to stop the COVID leaks into nursing homes is more frequent testing with rapid results. For months, long-term care officials in Florida pleaded with the state to make regular and rapid testing available so they could prevent the spread of the virus in their facilities.
After the governor initially rejected the idea of regular testing of staff and residents put forth by the White House Coronavirus Task Force in May, AHCA issued a rule on June 15, requiring that all 700 nursing homes and 3,800 ALFs test their staff by July 7, and every two weeks after that. The state would pay for the tests until September.
The state contracted with Curative Labs and is distributing COVID tests that may be self-administered by staff through an oral or nasal swab and then shipped immediately to the lab. The expected turnaround time on results is within three days. The initiative has been widely welcomed and praised.
“We have just sent off our second round of testing,’’ said Martin Goetz, CEO of River Gardens Hebrew Homes in Jacksonville, who had been a vocal critic of the administration for waiting so long to require staff testing at long-term care centers and is now much happier.
“Curative Labs has been excellent,” said Goetz, whose campus is COVIDfree. “They are timely and efficient. The software for reporting results is outstanding. I am deeply grateful to the state of Florida for creating this important mechanism for testing personnel coming and going into our facilities.”
However, another confusing guideline is a provision that allows COVIDpositive staff to return to work before producing a negative test result, a policy advanced by the federal Centers for Disease Control and Prevention. Questions remain about whether staff who test positive are staying away long enough and whether it is contributing to the leakage into facilities.
Blanche Norwood, a certified nursing assistant at Treasure Isle Care Center, a nursing home in North Bay Village, said asymptomatic staffers who have tested positive for the virus are allowed to come back to work after quarantining for a certain number of days without testing negative first.
“I don’t like it because I think that if you’re asymptomatic and you haven’t tested negative yet, you could still be transmitting the disease to other people,” she said.
She said she’s raised the issue with administration, and their response was that the CDC guidelines, updated last week, say they don’t have to wait.
The CDC rule adopts a “symptom-based strategy” that allows staff to return to work without testing after 10 days if at least 24 hours have passed since the last fever, and they haven’t used fever-reducing drugs and there has been an improvement in symptoms. The previous guideline said they had to wait 72 hours since their last fever. Workers with severe to critical illnesses must wait at least 20 days since symptom onset.
“A test-based strategy is no longer recommended
[...] because, in the majority of cases, it results in excluding from work HCP who continue to shed detectable SARS-CoV-2 RNA but are no longer infectious,” the CDC guidelines state. (HCP stands for healthcare personnel.)
Lucreta Brown, Treasure Isle’s director of nursing, would not comment other than to say the facility follows all CDC guidelines. Treasure Isle has had six patient deaths and no staff deaths to date, according to data from Florida’s Department of Health.
But requiring staff to stay home while they await test results is not practical, said Margarette Nerette, vice president of long-term care for 1199SEIU United Health Care Workers East, which represents more than
8,000 Florida elder-care workers. Staff can’t afford to take multiple days off until their test results come back and the nursing home wouldn’t be able to function if they did, she said.
“If they say they have to stay home until it’s resolved, they’re not going to have workers to work,” she said.
Some administrators, like Solomon and Adkins, are taking extra precautions just in case.
Solomon said he placed 25 staff members on quarantine because, although they were not positive, they had been exposed to others that had been. “Twenty-five staff members out for 10 to 14 days, that affects quality of care that hurts the delivery,” he said.
Meanwhile, the frontline workers are wearing out.
“The stress and fear that providers are feeling, residents and families are feeling in the places that have had COVID outbreaks is horrific,’’ Solomon said. “Without the rapid testing our nursing home residents are still going to be the most vulnerable in our population, and our staff is going to be right with them.”