Carole Givens lost touch with her mother – a resident at Providence Assisted Living in Senatobia, Mississippi – in stages.

Lee touts state plan to increase testing in nursing homes

It started in early March when COVID-19 was fairly unknown.

“First it was sanitizers everywhere. And then they monitored where you were in the building. Then, it was just immediate family that could go. They did that for two to three weeks. And then,” she says, “we were told nobody could come.”

Givens has had a lot of time to think about what comes after the threat recedes for her mother, a 90-plus-year-old who used to model for Sears and the old John Gerber Department Store in Memphis.

She suspects group visits are gone for good, and doubts she’ll ever be able to take her mother out again.

“I would pick Mother up and we would go ride around Sardis Lake. It was so fun and she loved it. But I’m removing her, and then she’s coming back in,” Givens says of the likely fear that infection could come back with her.

Wholesale changes are in store for nursing homes, where at least 28,000 residents and staff — about a third of the total coronvavirus deaths in the U.S. — have contracted the virus and died.

The Village at Germantown has had five fatal cases, followed by four at Highlands of Memphis Health and Rehabilitation Center on Highland Avenue. That facility has had more transmission than any other nursing facility in the county. In Thursday’s briefing from the county Health Department, a total of 63 residents and 24 staff have tested positive since early April.

“Restaurants may have been more impacted financially, but I don’t think anyone is going to let this go for the nursing home industry,” says Derek Pierce, former CFO of Tennessee Health Management, which runs 27 skilled nursing care facilities in the state and 17 others across the South. 

He expects “clarity” as early as this summer in a list of orders from the Centers for Medicare and Medicaid Services, the government-funded safety net insurance that funds the lion’s share of skilled nursing care in the country.

“It may sound as routine as bleach, washing your hands and using PPE, but it will be measuring that and using that data in CMS’s reporting,” Pierce said. 

As the nursing-home industry regroups, it will have to consider facility redesign from an infection-control perspective, which many say will mean eliminating double-occupancy rooms and large, common areas.

With the states and federal government facing COVID-19 budget realities, it seems unlikely there will be more money for Medicare, said Cameron Jehl, a Memphis lawyer who specializes in nursing home neglect.

“If they have to have single rooms, it will impact the revenues, clearly. But maybe there are other things they can adapt, including better partitions in the rooms.”

State to test all nursing home residents, staff

Robert Kramer, former head of the National Investment Center for Seniors Housing & Care, says nursing homes would do well to break their populations into “small neighborhoods” of 10-12 residents and employ universal workers, a multi-skilled employees who could clean, do routine maintenance, cook and deliver meals, as a way to reduce exposure.

“In times of infection, you can close off those neighborhoods from each other to prevent against the spread of infection,” he said.

The other new reality, he said, is for nursing homes to be upfront about infection rates.

“When you do not have enough tests to test all of your residents and all of your staff, you can’t know. It’s absolutely impossible,” Kramer said.

“If you are not testing every resident, whether asymptomatic or not, and every staff member, you don’t know.” 

Minton Mayer, on the board of the Memphis Jewish Home & Rehab and co-managing partner of Prieto, Wood & Boyer, which specializes in nursing home law, says the new reality is that all visitors, including vendors, will have to be tested before they enter the facilities. And they will have to wear masks.

“That’s if and when visitation is permitted again,” he said. “I don’t know of another disease where you see as much transmission through asymptomatic carriers as we have with COVID-19.”

In early May, industry journal McKnight’s Long-Term Care News, reported that 70% of COVID-positive employees and half of the positive residents had no symptoms when they were diagnosed.

Mayer doubts the industry will be adequately reimbursed for the amount of PPE (personal protective equipment) it is going to need, or the hikes in pay that nursing and other staff are demanding.

“Thin margins make it difficult to pay those higher wages,” he said.

Last week, nursing home workers in 64 facilities in Illinois called off a strike when their pay demands were met at the last minute. They received a 24% hike, bringing their pay to more than $15 an hour, plus $2 per hour hazard pay for those working with sick residents.

Few people disagree change is needed, including Jehl.

His experience with nursing home neglect is that it’s tied to low staffing ratios and is worse for residents who don’t have regular visitors. He expects when families are allowed back in to visit, there will be pressure sores, unexplained broken bones and a raft of lawsuits.

He’s also annoyed that an industry that is supposed to be equipped to handle infections is now petitioning the U.S. government for immunity from wrongful death lawsuits. 

“How can you do a horrible job and then say, ‘We shouldn’t be responsible. We want immunity.’ They are still profiting during all this.”

Lawsuits are popping up now, but Jehl is not taking any because he doesn’t know how anyone will prove where an infection was contracted.

Nationally, nursing homes have an average occupancy of 85%. In Tennessee, it was 79%, pre-pandemic, partly because the state Legislature began allowing commercial insurers like BlueCross BlueShield to manage Medicaid members in need to long-term care services.

“The way they would save money is to find alternatives for members,” said Derek Pierce, a managing director with Healthcare Management Partners in Nashville. “They may deny admission to a nursing home, offering an alternative like home health care.

“It’s like there was a new sheriff in town and requiring a lot of additional documentation to admit those residents. In a year or two, you start to see occupancy rates drop,” he said.

When occupancy rates get below 80%, it’s difficult to make the numbers work.

Mayer says rates have dropped during the pandemic because families have moved their seniors out and new residents are not coming in.

“And some, to protect their existing population, are limiting the number of new admissions.”

The irony, he says, is that over the last two years, CMS completely upgraded infection-control standards in long-term care facilities, requiring each to have a full-time infection prevention officer on staff.

“The existing regulations were spot on,” he says. “They were anticipating something like this.”

His theory is that Medicare was preparing for outbreaks of antibiotic-resistant bugs, not a pandemic floating in the air from room to room. 

Most nursing care facilities rely on a mix of private pay and Medicare patients to offset the money they lose on Medicaid, which pays about $175 a day.

Medicare pays about $450 a day but only allows the patients, usually elderly people needing rehabilitation care, to stay 100 days. After that, they convert to Medicaid. Successful operators have to have a mix of private and public-pay patients, and they often sell additional services to Medicare patients, including physical therapy and occupational therapy – to offset the Medicaid losses.

The public, Kramer says, forced the operators to rely on the patient mix, “and now it is waking up shocked that people are dying in nursing homes.

“There will come a time when we will look at COVID-19 in the rearview mirror; there will not come a time when we return to the old normal for nursing homes and senior care,” he said.

Some predict increases in the number of people using Medicare Advantage plans, which pay health care providers to care for seniors living in their homes. Memphis has seen a proliferation of these companies in the last year, including Oak Street Health and ChenMed. Both are out-of-state firms setting up multiple clinics in under-served parts of Memphis where traditional fee-for-service medicine has not been as responsive.

And some home health care businesses are adapting technology quickly to link the elderly to nurses and physicians through telehealth.

“It’s cheaper for the government,” Jehl said, “because you are not paying for utilities and a physical facility. It’s the person’s own house. Even if the patient needs 24-hour care, it’s still cheaper because you’re not paying for all that overhead.”

He expects the models will grow, limiting the numbers of people who now end up in assisted living and long-term care facilities for lack of other options.

“There is no question folks can be safely cared for in assisted living and home health-care settings for a lot less money than in a skilled nursing setting,” Kramer said.

As people have opted for assisted living and home health care, nursing homes have been left with the frailest and the sickest, also the most difficult and expensive patients to care for at home.

States also play a role in how many nursing homes are built by the policies they adopt for how nursing homes are funded.

In Tennessee, the number of nursing homes is limited by certificates of need.

“There are only so many certificates of need out there. You can’t just open any facility you want,” Jehl said. “If you want to get in, you have to buy one.”

In Memphis, nursing homes, even blighted ones, sell over and over, he says, often to out-of-state investors.

“No one would be in the nursing home business if they were all losing money,” he says, noting complex ownership layers that can mean owners are making money while the care facility operates in the red.

“Part of the reason they are not performing better is because of the money that has been siphoned out,” Jehl said.

Health Department investigating clusters at two more long-term care facilities

The properties, he says, are visited about once a year by the state Health Department. Jehl says it’s easy for owners to be tipped off about visits by other properties in their ownership group.

“If they need to bump up the staffing, they bring them in from a different facility owned by the same company,” he said. “That is the testimony we have had.”

Part of the evaluation the nation needs to do, Kramer says, is to assess the skill it takes to work in a nursing home and pay accordingly.

“Skilled nursing and senior housing centers have been considered begrudgingly even part of the health care system. Now, we have come to realize they are the very front line. They are the places where the most vulnerable have to be protected, and if we are going to keep our hospitals and our ICUs from being overwhelmed, the key workers are the workers in skilled nursing and other senior housing communities.

“We’re asking you to run into the fire, but I’m sorry, we don’t have any protective gear to give you,” Kramer said. “You are not high enough priority for that.

“That will absolutely have to change,” he said.

In 45 days, CMS and the Centers for Disease Control issued a total of 85 regulation updates for the industry, Mayer said, including that they now must report the number of COVID patients, number of COVID deaths and the amount of PPE supplies on hand. More rules are coming.

“When you are in an emergency situation, and they keep changing what would be the proper protocol, it’s hard for providers to manage all those things,” he said.

Those reports will be made public, says Pierce, the industry consultant in Nashville.

“They can be used to the nursing home’s advantage or disadvantage,” he said, and they will be the “stick” the government uses to force compliance.

While the pandemic caught most industries off guard, Pierce says the nursing home industry is “grieving” because it did not know what was going on.

“Not realizing that (COVID) was moving from one room to the next on the sleeves or on the shoes or on the masks or gloves of caregivers, it is heartbreaking for both the caregivers and the residents.”

The industry will meet the new guidelines, he said, “but you are going to have to pay us for it.”

Givens, whose mother is in the long-term care facility in Senatobia, thanks her lucky stars every day that the unit across the hall from her mother is on an outside wall and empty. Every Friday, the staff move her mother across the hall so Givens can see her through the window.

“We can’t really talk, but at least we can see each other,” she said.

“We were so used to being able to hug. That is what is so hard for me. I can’t go out there and hug her.”

Givens still takes small gifts, flowers from her yard, or a newspaper, and leaves them at the front desk.

“Now, there’s a stop sign at the front entrance. A window has been cut through the wall so the office manager can take the things. It’s just so strange.”