LEXINGTON, Ky. — With 46% of Kentucky’s COVID-19 deaths occurring in long-term-care facilities, up from 32% just a week ago, nursing homes continue to be a tinderbox for the coronavirus. That has prompted state officials to ramp up testing and to create a Long-Term Care Task Force charged with finding ways to slow down the spread of the virus inside these facilities.
Gov. Andy Beshear said the state has increased testing for the virus in these facilities, and more resources than ever are available for them to fight it, but he cautioned that as he begins to reopen the state’s economy, it will be even more important to protect some of Kentucky’s most vulnerable people.
“As we make these new decisions, as we try to ease restrictions, we’ve got to make sure that we don’t increase the exposure,” he said at his Sunday, April 26, briefing. “Listen, this is what has happened in these facilities when we’ve had everything shut down . . . So, we’ve got to be really careful when we start expanding our opportunities that we’re not allowing additional access to these facilities.”
As of Sunday, Kentucky reported that 610 residents and 280 employees in 60 long-term-care facilities had tested positive for the virus. Ninety-five residents and one employee have died of COVID-19. In Kentucky overall, there have been 4,074 confirmed cases and 208 deaths.
In several of Kentucky’s surrounding states, long-term-care facilities account for a smaller share of COVID-19 deaths, the Kaiser Family Foundation reports: Tennessee had 37 deaths, or 22% of its total; Illinois had 284, or 18%; and Virginia had 78, or 22%. West Virginia, Missouri, Indiana and Ohio are not among the 23 states that have reported their long-term-care deaths yet.
The overall rate among those states is 27%. LTCs accounted for over half of COVID-19 deaths in six states: Delaware, Massachusetts, Oregon, Pennsylvania, Colorado and Utah. The Centers for Medicare and Medicaid Services told all nursing homes April 19 to report cases to the Centers for Disease Control and Prevention, but the data is not yet available.
Kentucky’s higher rate could partly result from differences in how states define a COVID-19 death. In Kentucky, any person who dies having tested positive is counted, regardless of other conditions. Some states have narrower definitions.
The dangers are very real for residents of nursing homes, personal-care homes, family-care homes and assisted-living facilities, given their group living conditions and their many underlying health conditions.
The challenges for protecting them include finding ways to isolate, in buildings that often have few single rooms, those who have been infected; and ways to protect staff who care for this most vulnerable population – especially when basic supplies, like gowns, masks, and gloves, otherwise known as personal protective equipment, is so scarce.
“Staffing, PPE and testing are the common themes of everybody who is really concerned about what do we do next if this goes south on us,” said Keith Knapp, the state official and former long-term-care administrator who acts as convener of the task force.
One task-force member is Sherry Culp, executive director of the Nursing Home Ombudsman Agency of the Bluegrass in Lexington. She said there are about 315 Kentucky nursing homes, with about 28,000 residents, and about 206 personal-care and family-care homes, with about 7,400 residents.
Personal protective equipment
PPE is needed to not only protect vulnerable residents, but to also protect staff, and nursing homes were running short of these supplies long before the pandemic hit, said Betty Shiels, director of Kentucky Emergency Preparedness for Aging and Long Term Care, a public-private coalition.
“They were running short on PPE because they were using so much of it up because they were being hard hit by the flu,” she said
In an interview, Dr. Muhammad Babar, a geriatrician and independent physician who is on the task force, called the PPE shortages in these facilities “big” and spoke to some of the challenges around procuring it.
“That really limited our facilities, which are still struggling with PPE,” he said. “The cost has increased tremendously, and as we all know our states are competing with each other.”
Babar is regional hub medical director for Signature HealthCare, which has 42 nursing homes in Kentucky, more than any other operator; the medical director of four of them in Louisville, an assistant clinical professor at the University of Louisville, and the founder of Doctors for Healthy Communities Inc. and Muslim Americans for Compassion.
Beshear speaks almost daily about the challenges of procuring enough PPE for health-care providers in the state, and often pleads for donations, which can be made at any of the 16 state police posts, or can be arranged by calling 1-833-GIVE-PPE or going to givePPE.ky.gov.
Adding to the challenge, the federal government requires the state to make daily reports of its PPE stock in order to be eligible to make a request for additional PPE, and that requires daily reporting from all of the state’s health-care providers, including long-term-care facilities.
Shiels, who is also on the task force, said the facilities have been doing everything they can to follow the CDC guidelines, given the PPE supplies that were made available from the strategic national stockpile, which are now depleted. She recognized that long-term care facilities took second priority to hospitals for PPE supplies, but said that was largely because hospitals have higher acuity patients.
Since then, she said, PPE has been “trickling in” and nursing facilities are doing the best they can with what they have available. “I’d say there is varying available supply of PPE for nursing homes right now,” she said.
Culp encouraged facilities to keep reaching out to public health for PPE because “this is an evolving situation.”
Betsy Johnson, president of the Kentucky Association of Health Care Facilities, the long-term-care industry’s trade group, said her association’s main focus has been to secure PPE and testing for members and residents. “It’s not been easy,” she said, “and I wouldn’t say we’ve had a great deal of success.”
Testing capacity is finally picking up in Kentucky, but Johnson said it is still “iffy” and “I do know that we were not prioritized for testing, either.” She said the association’s stance is that testing needs to be a priority in these facilities.
“In order to protect our residents, we have to prioritize testing for skilled nursing facilities – all residents, all staff, all the time – to ensure that we know what is going on in that building,” she said. “You can be asymptomatic and still be shedding the virus.”
Acting Health Secretary Eric Friedlander said last week that the health cabinet has been testing all residents of some facilities, starting with those that need the most help, and that it is working with all facilities that have a positive case.
Beshear said Sunday that nursing homes are classified by red, yellow and green categories, based on several factors, and the state is testing the red group first.
He said for a nursing home to qualify for testing by the state, it must “be working with our Department of Public Health, it’s got to collaborate on its established process on how it deals with potential infection and its response, and it’s got to comply with a facility plan we put out there of best practices.”
He added, “I don’t want to sugar-coat it, the coronavirus is deadly in these settings. It’s why we cut all visitors at a time when people maybe didn’t understand why we were doing it, and so this is a setting where it is a matter of life and death, and we are doing the best we can in a very difficult circumstance with a virus that comes for those that are already vulnerable.”
Health officials have called for “sentinel surveillance,” which involves rigorous, frequent testing to find hidden carriers of the virus, isolate them limit its spread.
Staffing has been an issue for nursing homes for decades. They have successfully lobbied against laws or regulations to require certain staffing levels. Johnson said her members have trouble finding and keeping staff because unemployment rates have been low and they have a non-competitive wage scale because of low payments from Medicaid, the program that pays the bill for most residents.
“I think this COVID-19 pandemic has allowed us to really highlight the fact that our skilled nursing facilities simply need more support,” she said. “We need support from our policymakers in government. We need support from our communities. We need support from the media.”
Culp noted that while the federal CMS agency normally keeps a tally of staffing at these facilities, it has removed this requirement during the pandemic. “That really concerns me, that when this is all over, we will not have a good picture of how the short staffing may have played into this,” she said.
CMS has a site, https://www.medicare.gov/nursinghomecompare/search.html, that ranks nursing homes on staffing, health inspections and quality of care. A tabulation of deficiencies in Kentucky nursing homes during the three years through mid-2019 is available from the nonprofit investigative newsroom ProPublica at https://projects.propublica.org/nursing-homes/state/KY.
The state has several measures to help facilities with staffing issues, including the Medical Reserve Corps, which can be used to improve emergency response capabilities and the creation of a rapid response team of providers who can be deployed as needed. Knapp said the state is also working on a “strike force” of health-care professionals to help facilities deal with immediate crises.
An advertisement in the The Messenger newspaper in Madisonville shows that the state is paying registered nurses $65 an hour, licensed practical nurses $50 an hour, and certified nursing assistants $32.50 an hour to work for the state’s COVID-19 crisis teams for seven days on and seven days off in long-term care facilities.
The state has temporarily waived certain training requirements for nursing aides, who provide most of the hands-on care for residents, to allow for temporary COVID-19 personal-care attendants. These new hires would not be allowed to provide care for residents in COVID-19 isolation areas.
The state has also partnered with Norton Healthcare to set up a 24-hour hotline staffed by health-care professionals to help long-term-care facilities manage complex infection-control issues and see if they need more support.
“Mostly they need to know that someone is out there willing to help, willing to support,” Friedlander said last week. “And we’ve found that on many calls, that is what is most needed.”
Many who work with nursing-home employees are quick to point out their dedication to their jobs. “There are a lot of dedicated people who are working in long-term care,” Culp said.
“They are good people,” Babar said. “They represent our society. They do their best every day in this broken healthcare system. They are doing a good job.”
Johnson said, “This group of people are the most dedicated. They are just hard workers who really want to do the right thing, with very little support.”
Visitation restrictions will remain in place
As restrictions are eased elsewhere in the coming months, Beshear has said, “Visitation is going to be extremely, extremely restricted” at long-term-care facilities, a decision that both Babar and Johnson support.
“I think we still need to make the sacrifices of not visiting our loved ones in the facilities, we need to protect them from the outside world and that visitation should be the last thing allowed,” Babar said.
He praised Inspector General Adam Mather’s decision to restrict visitation in long-term-care facilities, saying it saved lives.
“We were one of the very first states to stop visitation in our facilities, because of his leadership,” Babar said. “He has done a marvelous job because of the base of his knowledge.”
Prior to becoming inspector general, Mather was regional operations vice president for Signature, and some criticized his appointment because of his ties to the industry.
Johnson, whose mother is in a nursing home, said, “I haven’t seen Mom since the beginning of March, but I fully support that decision by both the federal and state government. We have to keep these elders safe. It is hard; it’s been hard on my family, but hopefully we’ll get through this and we’ll keep our elders safe at the same time.”
Culp said most of her calls right now are about the visitation restrictions and a need to know if their loved ones facility has been infected with the coronavirus.
The state recently started posting a daily update on Kentucky facilities that have coronavirus cases, listing the number of residents and staff testing positive and the number of COVID-19 deaths. It is at https://chfs.ky.gov/agencies/dph/covid19/LTCupdate.pdf.
Shiels, who does emergency preparedness training for nursing homes, said they are fully prepared to control infections, because that’s what they do everyday. She said the challenge with COVID-19 is that it is so contagious and PPE is in short supply. “Everybody has been doing the very best they can under extreme circumstances,” she said.
Inspectors have stopped routine visits to nursing homes during the pandemic, with a short list of reasons for investigation, including serious allegations and targeted infection control.
The Long-term Care Task Force’s guidance is posted on the state’s COVID-19 website, kycovid19.ky.gov. It recommends that residents be screened for fever and respiratory symptoms at least daily, including daily use of blood-oxygen meters, since “long-term care residents with confirmed COVID-19 infections may be less likely to show signs of fever and respiratory signs, and symptoms may be subtle.” Research has shown many people infected with the virus have low oxygen levels without recognizing it or any other symptoms.
“There are a lot of moving parts to this,” said Knapp, a newcomer to state government. Speaking later about the efforts of the health cabinet, he said, “This Team Kentucky thing, it’s more than a slogan, it permeates the place.”