Testing a weak link in nursing homes

After a nursing aide tested positive for COVID-19 on May 19, Presbyterian SeniorCare moved quickly to test all staff and residents at its Elmwood Gardens facilities in Erie for the highly contagious respiratory disease.

The Memorial Day weekend was fast approaching, and leadership, worried about the testing capacity in rural Erie County, chose a Monroeville lab to do the work, PSC Executive Vice President Susan Dachille said.

By then, supply shortages had forced labs across the country to limit the number of COVID-19 test kits as demand for testing spiked and turnaround times for results slowed.

To get the testing done, nonprofit PSC put together a relay that took four days and eight employees shuttling 200 test swabs between the Monroeville lab and the Erie facilities, a twohour drive away. Presbyterian SeniorCare employees — and sometimes even their family members who were recruited to help — handed off swabs at an Eat’n Park restaurant off Interstate 79 in Grove City.

The gymnastics exposed a weak link — testing — in containing the spread of coronavirus through a group of people who live and work in long-term care facilities and account for 70% of COVID-19 deaths in Pennsylvania. Now, the state Department of Health has ordered every resident and staff at group living facilities to get tested before July 24.

There are 77,000 people living in Pennsylvania’s nursing homes, so administrators are scrambling to meet the deadline.

As of Monday, just 75 of the 700 nursing homes in Pennsylvania had met the health department’s new directive. Facility administrators say testing capacity is sorely lacking, but state Secretary of Health Dr. Rachel Levine felt the timing was right.

“We are very confident of doing this testing now,” she said at a Monday media briefing, adding that the department will provide test kits to nursing homes, if needed. “We will ensure that it happens by July 24.”

Some Western Pennsylvania’s long-term providers were less sure of that.

“It’s a bald-faced lie,” said James Cox, Paramount Health Resources chairman and CEO. “I can’t get testing equipment. What they’re saying is just do it and you all just figure it the hell out. Everybody is just covering their butts.”

Canonsburg-based Paramount operates long-term care facilities in six states including Pennsylvania.

‘Not a clear road map’

Few industries were blindsided by the COVID-19 outbreak like long-term residential care facilities — where shortages of tests and protective gear and a fire hose blast of sometimes conflicting guidance came as virus-related deaths mounted at nursing home hot spots in the Pittsburgh area and elsewhere around the country.

“Everything happened so quickly, there wasn’t time for the preparation, the guidance,” Paul Winkler, president and CEO of the Oakmont-based Presbyterian SeniorCare, said about the spread of the pandemic in Western Pennsylvania.

“There was not a clear road map. We just had to figure it out in real time.”

The closest thing to the spread of COVID-19 was the great flu pandemic, which happened 100 years ago. Today, the long-term care industry encompasses 2.9 million units and revenue ranging between $250 billion and $270 billion, according to the Annapolis, Md.-based nonprofit National Investment Center for Seniors Housing and Care.

When COVID-19 struck, nursing homes had little or no stock of protective gear for staff, such as face shields or masks, nursing home administrators said. It wasn’t required. And virtually no skilled care facility had an infectious disease doctor on staff for advice on the best way to stop the virus.

In the early days of the pandemic, it wasn’t clear how the new coronavirus was spread — aerosolized droplets, touching contaminated surfaces, both, neither — but airborne transmission was an early suspect. At the point when Gov. Tom Wolf announced the first two cases of COVID-19 in the state on March 6, doctors were discouraging wearing homemade masks, saying the polyester-blend N95 masks were far better.

When stocks of N95 masks quickly dried up, health officials said surgical masks would do. And when those masks became scarce, nursing home staff turned to homemade masks donated by church groups.

In the meantime, nursing homes were closing communal dining rooms, restricting visitors — sometimes angering families — while canceling social activities for seniors and preparing for the kind of surge in the region’s COVID-19 patients that hard-hit parts of the country like New York City had experienced. The worst of the surge never arrived in Western Pennsylvania.

“We were getting daily and hourly directions and re-directions,” said John Dickson, president and CEO of Redstone Highlands, a nonprofit that operates senior living facilities in Greensburg, Murrysville and North Huntingdon. “What really came to light was how unprepared we were for this.”

Mask prices soared

Still, Redstone was ahead of the health department mandate — testing all of its 1,000 staff and residents over three days ending June 8 in collaboration with Greensburg-based hospital system Excela Health. But getting test results took three days, longer than the 12- to 24-hour ideal, Mr. Dickson said.

Delayed testing turnaround times can make it harder to track down everyone who came in contact with an infected person, Mr. Dickson said.

Meanwhile, supplies of face masks, shields and disposable gowns evaporated.

At the for-profit Paramount Health Resources’ nursing home in Peters, the staff at one point taped rubber bands to coffee filters for use as masks when supplies of the real thing ran out, Paramount’s CEO Mr. Cox said.

Finding enough personal protective equipment is a continuing struggle.

“You get it, you don’t get it, it’s lost,” Mr. Cox said. “It’s just been one trial after the next.”

The sudden demand for available equipment drove prices sharply higher. Cabotbased senior services nonprofit Concordia Lutheran Ministries, which operates 14 senior care facilities, watched as supplies of N95 masks dried up — with prices soaring from 75 cents to $8 each, President and CEO Keith Frndak said.

All together, Concordia’s expenditures for disinfectants and staff protective equipment climbed to $700,000 even as the number of patients seeking highmargin rehabilitation therapy services at its facilities shrank by half due to the state ban on nonemergency procedures such as joint replacement surgery.

And it wasn’t just equipment costs that were rising.

David Fenoglietto, president and CEO of Cranberrybased nonprofit Lutheran SeniorLife, said the electronic accommodations necessary to allow its administrative staff to work from home jumped to $18,000 to $20,000 a month from $2,000 a month for additional conference lines. For aides, nurses and other attendants who had to report to work, the senior care provider relied on thousands of homemade masks donated by churches.

Failing the test

As mitigation efforts start to ease, Mr. Fenoglietto worries about increased travel by employees and contact with others who might carry the infection, even though they may not feel sick.

“That one test on that one day at that one hour may change tomorrow,” he said.

Of all the challenges that nursing home administrators faced as the COVID-19 pandemic roared, peaking in April in the western part of the state, none has been more crucial than testing for the disease. Easing shutdown restrictions without knowing the prevalence of the disease is little more than a public health experiment, experts say.

“Without testing, the response will continue to fall short,” Dr. Eric C. Schneider wrote in a May 15 New England Journal of Medicine editorial. “That the United States is failing such a simple test of its capacity to protect public health is shocking.”

Operators of senior care facilities say testing capacity lagged from the start, and the problem is now being made worse by the health department’s July 24 deadline.

“Frankly, we don’t have them yet,” Concordia’s Mr. Frndak said about the 2,400 to 2,500 COVID-19 tests he needs. “We intend to fully comply, but right now we can’t find enough tests.”

The local hospital said it can only do 50 tests a week, he said.

Prices up, carriers leaving

Other costs are rising, too. In early May, Mr. Wolf granted doctors and front-line health care workers malpractice immunity for treatment of COVID-19 patients, but he didn’t extend the protection to nursing home operators.

The result will be higher professional insurance liability premiums in an already tight market, said Tom Philbin, director, commercial lines at Henderson Brothers Inc., a Downtown insurance broker.

“In the long-term care industry, prices are going up, carriers are leaving,” he said.

Some nursing home operators could see liability insurance premiums jump 30% to 70% in the coming year, Redstone Highlands’ Mr. Dickson said.

It’s unknown how higher overhead costs will affect consumer prices at senior living facilities.

The COVID-19 pandemic may speed changes in the model that has been used for at least a century — the shared living arrangements for the aged and infirm that create economies of scale in providing health care and other services.

Those may be the very thing that helped turn some nursing homes into COVID19 petri dishes.

The disease will accelerate the move away from large senior complexes with two or more patients per room to houses with a dozen or fewer patients, said J. David Hoglund, principal at Downtown-based design firm Perkins Eastman, which specializes in longterm care facilities.

“This is a model that has been outdated for a long time before COVID-19 came along,” he said.

“This is a huge wake-up call. There will be other airborne illnesses.”