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Lawmakers Push Blame For COVID-19 Toll At Nursing Homes

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    Members of a House subcommittee quarreled over who to blame for the failure to protect nursing home residents from COVID-19 during a virtual hearing on Thursday.

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    Democrats faulted the administration for its sluggish response to testing challenges and the difficulties that nursing homes faced in accessing personal protective equipment (PPE), while Republican members pointed fingers at certain governors for issuing policies they argue led to the deaths of thousands of residents.

    Witnesses speaking before the subcommittee for the House Committee on Ways and Means sought to cast blame as well, but also offered recommendations to prevent further harm to residents and staff.

    More than 50,000 people in the U.S. have died in connection with long-term care facilities since the start of the pandemic, according to the Wall Street Journal.

    "It didn't have to be this way," David Grabowski, PhD, of Harvard Medical School in Boston, told the subcommittee.

    Sluggish Response

    Grabowski argued that by failing to invest in testing, PPE, and the workforce, the federal government allowed a problem that could have been contained to grow out of control.

    Chairman Lloyd Doggett (D-Texas) agreed that "effective federal leadership" could have prevented the crisis.

    It took 97 days from the time an outbreak at Life Care Center in Kirkland, Washington was first identified before the Centers for Medicare & Medicaid Services (CMS) published data related to preparedness and infections at nursing homes across the country, said Doggett. As of Thursday, 800 of the nation's 15,400 facilities still had not reported their data, making it difficult to fully know which have been most affected by the pandemic, he added.

    Another 80 days passed between the Kirkland outbreak and CMS's decision to call for "baseline tests" of nursing home residents and staff, he said.

    While Congress appropriated $25 billion broadly for testing, CMS issued the requirement for facilities to test without providing the resources needed to implement it, Doggett said.

    Finally, it took 61 days from the time of the Kirkland outbreak, until the Federal Emergency Management Agency (FEMA) issued a directive around PPE for nursing homes.

    FEMA provided a 2-week supply of PPE, but "much of it was junk," said Doggett, and included "glorified trash bags" for gowns and cloth masks instead of N95 respirators.

    Doggett said he repeatedly invited CMS Administrator Seema Verma, who is responsible for nursing home oversight, to testify before the subcommittee, but said his requests were ignored.

    The 'Most Dangerous Job ... in America'

    Roughly 500 staff members at nursing homes have died from COVID-19, Grabowski said, making being a nursing home caregiver "the most dangerous job right now in America."

    Nicole Howell, executive director for the Ombudsman Services of Contra Costa, based in Pleasant Hill, California, called poor staffing in long-term care facilities "the gasoline to COVID's match."

    She pointed out that because many long-term care workers earn only a dollar or two more than minimum wage, many will take jobs at multiple locations in order to pay rent. This can result in caregivers bringing the virus from a facility with active infections to a previously unexposed facility.

    Melinda Haschak, LPN, a nursing home worker in Stamford, Connecticut, said she believes she contracted the virus after unknowingly working with an infected resident. Administrators knew which residents had COVID-19, but that information wasn't shared with staff, she said.

    Her facility also failed to provide staff with adequate PPE, Haschak said. She was given only a surgical mask and gown, and ultimately purchased her own PPE with the help of donations from friends and family.

    Even now, weeks after she and several of her colleagues contracted the virus, her facility still lacks sufficient PPE and workers still don't know which residents are infected, Haschak said.

    Grabowski argued that instead of leaving it to states to allocate funds for testing and PPE to facilities, the federal government should have nationalized the PPE supply chain from the beginning. Buying the supplies and sending them directly to the facilities that need them. Failing to do so placed nursing homes in competition with large hospitals.

    He also recommended instituting a rigorous testing surveillance program.

    "Until we get accurate and rapid testing for all staff and residents, we won't be able to contain COVID," he said.

    Weakened Protections

    Toby Edelman, JD, senior policy attorney for the Center for Medicare Advocacy argued that for the past several years the Trump administration weakened nursing home regulations and, more recently, relaxed both formal and informal oversight.

    "There has been nobody in nursing homes for 3 months. Not families, not the ombudsman ... and not the state or federal surveyor," she said. "And now we see the results ... of rolling back or not enforcing standards of care that we've had in place for decades."

    In 2017, the administration rescinded and replaced two Obama-era guidances that reduced nursing home penalties from on average $60,000 to less than $10,000. In July 2019, the administration proposed eliminating the requirement that facilities' infection prevention specialists be on site at least part-time.

    Then during the pandemic, the administration "unilaterally decimated longstanding statutory protections" for residents and suspended enforcement of all violations except those classified as "immediate jeopardy," which account for less than 1% of violations.

    CMS also waived requirements that facilities submit staffing-level data.

    Howell, in her written testimony, noted that California facilities with one or more cases of COVID-19 had on average 25% fewer nurses per resident in the last 3 months of 2019.

    To prevent more harm to residents, Edelman recommended that the survey and enforcement system be strengthened and that states and CMS enforce meaningful standards regarding who be allowed to operate a facility.

    On worker compensation and training, Edelman stressed that facilities must have well-trained and well-compensated nursing staff, and proposed implementing a type of "medical loss ratio" that would require facilities to spend a certain percentage of funding on residents' care.

    Governors' Costly Decisions

    Ranking member Devin Nunes (R-Calif.) defended the "aggressive steps" taken by the administration to protect nursing home residents and staff, including improving infection control and mandating that nursing homes report cases directly to the CDC.

    He and other Republican members on the subcommittee called out state governors, including Andrew Cuomo (D-N.Y.), who forced facilities to accept hospitalized COVID-19 patients.

    On March 25, Cuomo issued an executive order, explained Rep. Tom Reed (R-N.Y.), which mandated that nursing homes had to accept COVID-19-positive seniors. Reed said the order has since been "scrubbed" from Cuomo's website.

    When questioned about this particular decision, Grabowski agreed that it was "a mistake," but also noted that the governor's action was in line with CMS guidance that directed nursing homes to accept their usual patients, "including individuals from hospitals where COVID-19 was/is present."

    Reed claimed Grabowski was trying to "sugarcoat" the deaths of 6,300 seniors in New York.

    On questioning, Rebecca Gould, president and CEO of Schuyler Hospital, said that her hospital decided to keep COVID-19 patients out of her facility, in order to prevent the virus from spreading to its nursing home patients.

    She agreed it was "definitely risky" to have a patient recovering from COVID-19 in the facility.

    Gould suggested that developing regional networks to allow COVID-19 patients to be taken care of in the proper setting could help resolve the dilemma.

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