They must demonstrate COVID-19 readiness but lack essential supplies.


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As federal and state governments issue guidelines for the phased reopening of nursing homes, the facilities find themselves in a bind. To reopen, they must demonstrate that they have adequate supplies of personal protective equipment (PPE) and diagnostic tests as well as no new COVID-19 cases. But their pleas for government assistance to acquire these supplies have been largely ignored, leaving some nursing homes unable to qualify for reopening.

Figure. Patients are... - Click to enlarge in new windowFigure. Patients are removed from Magnolia Rehabilitation and Nursing Center in Riverside, California, after dozens tested positive for COVID-19 and staffers, afraid for their safety, stopped showing up for shifts. Photo by Gina Ferazzi / Los Angeles Times.

Nursing homes in the United States have been hard hit by the pandemic, both in the volume of cases and in economic impact. By May, nursing home residents had accounted for 25% of documented COVID-19 deaths nationwide, yet they represented only 0.5% of the U.S. population. There have been more than 133,000 confirmed cases of COVID-19 in nursing homes, and close to 38,000 deaths.


Nursing home residents are particularly vulnerable to the virus because they are mostly older adults with comorbidities who live in close contact with one another. Staff is also at risk as many residents require intimate, hands-on care. Moreover, the nature of certain comorbidities, such as dementia, makes it difficult to achieve compliance with mask wearing and social distancing, thereby increasing infection risk to residents and staff. Compounding these challenges are growing staff shortages due to illness, lack of childcare, and fear of working without sufficient PPE.


The pandemic has revealed the precarious financial situation of nursing homes, which historically have relied on higher Medicare payments for short-term post-acute patients in order to stay in the black. Long-term residents are generally covered by Medicaid, which pays less. With fewer post-acute patients because of pandemic-related limits on elective surgical and other procedures, facilities have lost this offsetting Medicare revenue. Some face bankruptcy.


Why have nursing homes lagged hospitals in obtaining adequate supplies of PPE and diagnostic tests? "Initially, nursing homes were not prioritized. Hospitals came first," said Christopher Laxton, executive director of the Society for Post-Acute and Long-Term Care Medicine, in an article in the July 14 JAMA. Only in May did the Federal Emergency Management Agency begin shipping PPE to nursing homes, but both quantity and quality were inadequate. Some boxes contained loose and seemingly unsterile gloves packed in sandwich bags, masks with broken elastic, and protective gowns that resembled garbage bags with no arm or hand openings, according to a July 24 report in the New York Times. For many facilities, the shipments came too late to mitigate the spread of infection.


The Centers for Medicare and Medicaid Services (CMS) issued the nursing home reopening guidelines in June to shore up infection control and prevention practices for COVID-19 and other pathogens. The agency has noted that nursing homes with poor quality scores on federal and state inspection reports appear to have had worse outbreaks of COVID-19. Other pandemic-related actions by the CMS include stiffer fines for homes with persistent infection problems. The guidelines specifically address infection monitoring and prevention, testing, staff PPE requirements, and social interaction among residents. Visitors should be permitted only if a facility has had no new COVID-19 cases for 28 days. Many nursing homes have already been closed to visitors for months because of the pandemic.


Nearly $5 billion in aid for skilled nursing facilities from the U.S. Department of Health and Human Services was announced shortly after the CMS guidelines were released. Nursing home industry representatives hold, however, that that funding isn't nearly enough for their needs as the pandemic continues.-Joan Zolot, PA