Elder Law Prof Blog

CMS Coronavirus SNF Commission

More good news from CMS-the members of the Independent Coronavirus Commission on Safety and Quality in Nursing Homes have been announced.  The 25 experts

The commission members are:

• Roya Agahi, RN, MS HCM, WCC; Chief Nursing Officer, formerly of NYC Health + Hospitals, soon to be of CareRite, New York

• Lisa M. Brown, PhD, ABPP; Professor of Psychology, Palo Alto University, California

• Mark Burket, CEO, Platte Health Center Avera, South Dakota

• Eric M. Carlson, JD; Directing Attorney, Justice in Aging, California

• Michelle Dionne-Vahalik, DNP, RN; Associate Commissioner, State Health and Human Services Commission, Texas

• Debra Fournier, MSB, BSN, ANCC RN-BC, LNHA, CHD, CPHQ; COO, Veterans’ Homes, Maine

• Terry T. Fulmer, PhD, RN, FAAN; President, The John A. Hartford Foundation, New York

• Candace S. Goehring, MN, RN; Director, State Department of Social and Health Services, Aging and Long-Term Support Administration, Washington

• David C. Grabowski, PhD; Professor of Healthcare Policy, Harvard University, Massachusetts

• Camille Rochelle Jordan, RN, BSN, MSN, APRN, FNP-C, CDP; Senior Vice President of Clinical Operations & Innovations, Signature Healthcare, Kentucky

• Jessica Kalender-Rich, MD, CMD, AGSF, FAAHPM, FACP; Medical Director, Post-Acute Care, University of Kansas Health System, Kansas

• Marshall Barry Kapp, JD, MPH; Professor Emeritus of Law, Florida State University, Florida

• Morgan Jane Katz, MD, MHS; Assistant Professor of Medicine, Johns Hopkins University, Maryland

• Beverley L. Laubert, MA; State Long-Term Care Ombudsman, State Department of Aging, Ohio

• Rosie D. Lyles, MD, MHA, MSc, FACA; Director of Clinical Affairs, Medline Industries, Illinois

• Jeannee Parker Martin, MPH, BSN; President and CEO, LeadingAge California

• G. Adam Mayle, CHFM, CHC, CHE; Administrative Director of Facilities, Memorial Healthcare System, Florida

• David A. Nace, MD, MPH, CMD; President, AMDA – The Society for Post-Acute and Long-Term Care Medicine, Pennsylvania

• Lori Porter, LNHA, CNA; CEO, National Association of Health Care Assistants, Missouri

• Neil Pruitt, Jr., MBA, MHA, LNHA; Chairman and CEO, PruittHealth, Inc., Georgia

• Penelope Ann Shaw, PhD; Nursing Home Resident and Advocate, Braintree Manor Healthcare, Massachusetts

• Lori O. Smetanka, JD; Executive Director, National Consumer Voice for Quality Long-Term Care, Maryland

• Janet Snipes, LNHA; Executive Director, Holly Heights Nursing Home, Colorado

• Patricia W. Stone, PhD, MPH, FAAN, RN, CIC; Professor of Health Policy in Nursing, Columbia University, New York

• Dallas Taylor, BSN, RN; Director of Nursing, Eliza Bryant Village, Ohio

Here's the info about the Commission's mission:

The Commission will conduct a comprehensive assessment of the overall response to the COVID-19 pandemic in nursing homes. Based on its assessment, the Commission will make recommendations on actions and best practices for immediate and future actions.  Three key areas of focus for the Commission include:

• Ensuring nursing home residents are protected from COVID-19 and improving the responsiveness of care delivery to maximize the quality of life for residents;

• Strengthening efforts to enable rapid and effective identification and mitigation of COVID-19 transmission (and other infectious disease) in nursing homes; and

• Enhancing strategies to improve compliance with infection control policies in response to COVID-19.

Crossing my fingers....

Good News from CMS-Resumption of Staffing Data

A recent press release from CMS notes that CMS ... Plans to End the Blanket Waiver Requiring Nursing Homes to Submit Staffing Data

[T]he Centers for Medicare & Medicaid Services (CMS) announced plans to end the emergency blanket waiver requiring all nursing homes to resume submitting staffing data through the Payroll-Based Journal (PBJ) system by August 14, 2020. The PBJ system allows CMS to collect nursing home staffing information which impacts the quality of care residents receive. The blanket waiver was intended to temporarily allow the agency to concentrate efforts on combating COVID-19 and reduce administrative burden on nursing homes so they could focus on patient health and safety during this public health emergency.

The memorandum released today also provides updates related to staffing and quality measures used on the Nursing Home Compare website and the Five Star Rating System.

The memorandum is available here.

CMA Releases Family Caregiver Brief

The Center for Medicare Advocacy (CMA) has released an issue brief on Medicare and Family Caregivers. "This Issue Brief examines the role Medicare currently plays, and could play, in assisting
beneficiaries and their family caregivers." The issue brief covers Medicare law, the need for coverage, issues with receiving Medicare home health care services, problems with access to coverage, the limited number of aides, and more. The Brief also discusses Medicare Advantage and in-home services.

CMA makes theses recommendations 

1. Ensure the scope of current allowable home health benefits, generally, and home health aides, specifically, are actually provided. Simply put, ensure that current law is followed;
   2. Create a new stand-alone home health aide benefit that would provide coverage without the current skilled care or homebound requirements, using Medicare’s existing infrastructure as the vehicle for the new coverage; and
   3. Identify other opportunities for further exploration within and without the Medicare program, including additional Medicare revisions, demonstrations, and initiatives overseen by the Center for Medicare and Medicaid Innovation (CMMI).

After providing some actual examples, the Brief provides insights into other additions to Medicare that would provide more services to beneficiaries.  The conclusion  provides that "Medicare home health coverage is not being implemented to the full extent of the law. If it were,
countless beneficiaries and families would be better off. Nonetheless, at best, the current Medicare benefit leaves far too many patients and caregivers behind. In order to provide quality home-based
care for individuals, and support for their caregivers, significant changes are needed to the
Medicare program and the broader health insurance system." (citations omitted).

FAQ from CMS on SNF Visits

A few days ago CMS released a four page FAQ re: visiting residents in SNFs. Frequently Asked Questions (FAQs) on Nursing Home Visitation.

The FAQs include

1.What steps should nursing homes take before reopening to visitors? 

2. The reopening recommendations maintain that visitation should only be allowed for
“compassionate care situations.” Do compassionate care situations only refer to
end-of-life situations?

3. Can facilities use creative means, such as outside visits, to begin to allow for
visitation within the CMS and CDC guidelines; even before reaching phase three?

4.Can nursing home residents participate in communal activities before reaching
phase 3 of the nursing home reopening plan?

5.What factors should nursing homes consider when making decisions about
visitation?

6. Should residents or visitors who have tested positive for COVID-19 participate in
visits?

7. Are nursing homes required to allow visits from the ombudsman when requested by
a resident?

Nursing Homes: Making Room for COVID-19 Residents?

Each day I get a email from Kaiser Health News (KHN) that contains articles collected from the prior day on various health topics.  Since COVID-19 arrived, the number of articles concerning nursing homes has greatly increased. I've refrained from writing about those-mainly because there are so many of them.  But here's a recent article that I felt was too important to pass by.

The New York Times,ran an article with this eye-popping headline:  ‘They Just Dumped Him Like Trash’: Nursing Homes Evict Vulnerable Residents. "Nursing homes across the country are kicking out old and disabled residents and sending them to homeless shelters and rundown motels." The article makes the point that caring for COVID-19 patients is more lucrative than long-term care residents. 

"Many nursing homes are struggling in part because one of their most profitable businesses — post-surgery rehab — has withered as states restricted hospitals from performing nonessential services. ... Treating Covid-19 patients quickly became a popular way to fill that financial void... Last fall, the Centers for Medicare and Medicaid changed the formula for reimbursing nursing homes, making it more profitable to take in sicker patients for a short period of time. COVID-19 patients can bring in at least $600 more a day in Medicare dollars than people with relatively mild health issues, according to nursing home executives and state officials."  Don't forget, however, that profit isn't the motive in every instance-remember back when the hospitals were jammed with COVID-19 patients and asked nursing homes to take some?

With SNFs shut down to outside visitors, Ombudsman visits may also be curtailed. And although the law requires that SNFs "find a safe alternative location for the resident to go, whether that is an assisted living facility, an apartment or, in rare circumstances, a homeless shelter... some homes have figured out a workaround: They pressure residents to leave. Many residents assume they have no choice, and the nursing homes often do not report them to ombudsmen."  Only a handful of facilities have a moratorium on resident evictions during the pandemic.

Hello CMS-are you watching this?

 

More Reasons for a Serious Bi-Partisan Commitment to Citizenship for DACA Health & Long-Term Care Workers

Shared by my colleague, Professor Medha Makhlouf, who heads Dickinson Law's Medical-Legal Partnership Clinic, this thoughtful article explaining the importance of DACA-recipient health care workers in the United States, especially now:    

The Covid-19 pandemic is stretching our public health system to its limits and challenging our ability to meet the urgent and critical medical needs of the country as never before. As executives responsible for the legal affairs of major hospitals and lawyers working in Covid-19 hot spots, we know how crucial it is to have every available front-line medical worker fighting this pandemic. . . . 

 

New data from the Center for American Progress reveals that the DACA-recipient health care work force includes more than 6,000 diagnosing and treating practitioners, including respiratory therapists, physicians assistants and nurses; some 8,000 health aides, including nursing assistants and orderlies; more than 7,000 other health care support workers; and some 5,500 health technologists and technicians.

 

The Association of American Medical Colleges told the Supreme Court that nearly 200 physicians, medical students and residents depend on DACA for their ability to practice medicine and serve their communities. Those 200 trainees and physicians alone would care for hundreds of thousands of patients per year in normal times — the association estimates as many as 4,600 patients per year, per person. Under the demands of the Covid-19 pandemic, those numbers will be much higher.

 

The Center for Migration Studies found that 43,500 DACA recipients work in the health care and social-assistance industries, including more than 10,000 in hospitals....

The decision on the DACA case is expected this week.  "If the Supreme Court upholds the decision to terminate DACA, nearly 700,000 people — including those health care workers — will lose their ability to work and live in the United States."  For more, ready the full NYT article, There's Only One Thing Stopping Trump From Deporting Health Care Workers.  

For once, the members of Congress from both sides of the aisle should be ready with emergency legislation for citizenship (or at a minimum, permanent residency status) for these essential workers.  It is the least we can do for people who are doing the most. And it is vital for the best interests of public health across the nation.  A win-win, if we can just focus on what's important.  

WOW!  Moments after I posted the above, I see the news flash that Supreme Court Rules Against Trump Administration Attempt to End DACA, A Win for Undocumented Immigrants Brought to U.S. As Children.  

After reading the opinion(s), it is clear that while DACA recipients have a temporary reprieve, the real need is serious consideration of true relief from fear of deportation.  Must they really wait until after the election?  

This "Should" Be Easy: Support DACA Workers in Health Care and Long-Term Care

The Supreme Court 's ruling on the fate of DACA-residents and workers in the U.S. could be issued this week.  Regardless of the outcome on the case itself, everyone who cares about quality of health care, including long-term care, should also care about the United States' need to be honest about how much health care depends on the hard work and commitment to care provided by temporary-status and undocumented-status  workers in health and personal care jobs.  I've seen DACA workers in action in elder care, and I've seen their families ripped apart by harsh immigration rulings.

NPR's Morning Edition had a short and yet deeply important segment today on Health Care Workers Who Are Awaiting Supreme Court DACA Decision.   Do listen to the podcast replay --  it is just 4 minutes -- and think about whether this is a key opportunity for a true, bipartisan solution for DACA-children (families) who so often are working in some of the most challenging (and dangerous) U.S. jobs during the COVID-19 pandemic.  Let's do the right thing.  

Nursing Homes and the Right to Visitors During a Pandemic

The seminal 1987 Nursing Home Reform Act requires all nursing facilities to care for their residents in a manner that that "will promote ,maintenance or enhancement of the quality of life of each resident." 12 USCA Section 1396r(b)(1)(A).  The same law, at Section 1396r(e)(3),  addresses "access and visitation rights:" 

A nursing facility must - ... 

(B) permit immediate access to a resident, subject to the resident's right to deny or withdraw consent at any time, by immediate family or other relatives of the resident;

 

(C) permit immediate access to a resident, subject to reasonable restrictions and the resident's right to deny or withdraw consent at any time, by others who are visiting with the consent of the resident;

(D) permit reasonable access to a resident by any entity or individual that provides health, social, legal, or other services to the resident, subject to the resident's right to deny or withdraw consent at any time .... 

During the pandemic lockdown, states prohibited most visitations, citing the risk of infection from the outside community that could endanger not just the visitor's loved one, but potentially all residents.  States are now beginning to lift or at least ease visitation restrictions, and families are beginning to talk more openly about the impact of the isolation on residents who have not contracted the virus.  

 

This week, NPR has begun airing stories about the challenge of balancing the risks of visitors against the benefits of not just family member visits, but family member involvement in care and socialization for residents.  From one story about Luann Thibodeau and her husband Jeff, who has multiple sclerosis:

 

It wasn't candlelight and soft music that made the 40th anniversary of Luann and Jeff Thibodeau so memorable. It was gazing at each other through the window of Jeff's nursing home in Texas and eating carryout from the Olive Garden. Just the two of them. And a nursing assistant.

 

"She fed him, and I ate mine, and that was it," Luann Thibodeau says. "So that was our 40th wedding anniversary."

 

Luann Thibodeau would bring her husband, Jeff, dinner every night, except Tuesdays, when she had Bible study. Since she's been unable to visit, she says that her husband has become increasingly disinterested in food as his multiple sclerosis has worsened.

 

The Thibodeaus have not been in the same room since mid-March. That's when visitors were banned from nursing homes to slow the spread of the coronavirus. But family members say that talking via FaceTime and holding up signs at windows are no substitute for the hands-on care and emotional support their visits provide.

 

Family members often are an integral part of the care residents in nursing homes receive. They make sure meals are being eaten, clothes are being changed. They also offer invaluable emotional support. . . . 

 

Luann Thibodeau has seen that decline in her husband. She used to bring dinner for him every night except Tuesdays when she goes to Bible Study. She says that as his multiple sclerosis has worsened, he's become increasingly disinterested in food. [She explains]. "I bully him into finishing a meal. And I'll say to him, 'Jeff, you know, this is what an adult man eats. So you need to eat this.' "

 

A staff member can't do what she does. Nursing home residents have rights. So if Jeff Thibodeau tells a nursing assistant that he's done eating after three bites, she has to abide by his wishes.

 

Without his wife's push, the results of her absence is striking.

For more, listen to the NPR podcast or read the parallel written narrative in "Banned From Nursing Homes, Families See Shocking Decline In Their Loved Ones." 

The federal Nursing Home Reform Act's Bill of Rights has never been an easily enforceable mandate, and particularly in a global crisis the needs of the many can override the rights of individuals.  But there does need to be a long-range plan on how better to facilitate visitation, recognizing it as an important part of any person's quality of life.  

 

Medicare Trustees Report 2020

And you know when the SSA Trustees Report is out, the Medicare Trustees Report is soon to follow. The Medicare Trustees report is available here.   There's no quick summary available, but the introduction and the overview provides some helpful info.

First, and importantly, this report doesn't take COVID-19 into account: "The projections and analysis in this report do not reflect the potential effects of the COVID-19 pandemic on the Medicare program. Given the uncertainty associated with these impacts, the Trustees believe that it is not possible to adjust the estimates accurately at this time."

Second, "Projections of Medicare costs are highly uncertain, especially when looking out more than several decades. One reason for uncertainty is that scientific advances will make possible new interventions, procedures, and therapies. Some conditions that are untreatable today may be handled routinely in the future. Spurred by economic incentives, the institutions through which care is delivered will evolve, possibly becoming more efficient. While most health care technological advances to date have tended to increase expenditures, the health care landscape is shifting. No one knows whether future developments will,on balance, increase or decrease costs."

Third, "Notwithstanding recent favorable developments, current-law projections indicate that Medicare still faces a substantial financial shortfall that will need to be addressed with further legislation. Such legislation should be enacted sooner rather than later to minimize the impact on beneficiaries, providers, and taxpayers."

Fourth, "The estimated depletion date for the HI trust fund is 2026, the same as in last year’s report. As in past years, the Trustees have determined that the fund is not adequately financed over the next 10 years. HI income is projected to be lower than last year’s estimates due to lower payroll taxes. HI expenditures are projected to be lower than last year’s estimates because of lower-than-projected 2019 spending, lower projected provider payment updates, and incorporation of time-to death into the demographic factors used in the projection model. Partially offsetting this decrease in expenditures is higher projected spending growth for Medicare Advantage beneficiaries." (citations omitted)

Fifth, for Part B, "The SMI trust fund is expected to be adequately financed over the next 10 years and beyond because income from premiums and general revenue for Parts B and D are reset each year to cover expected costs and ensure a reserve for Part B contingencies."

Finally, note this: "The Trustees are issuing a determination of projected excess general revenue Medicare funding in this report because the difference between Medicare’s total outlays and its dedicated financing sources is projected to exceed 45 percent of outlays within 7 years. Since this
determination was made last year as well, this year’s determination triggers a Medicare funding warning, which (i) requires the President to submit to Congress proposed legislation to respond to the warning within 15 days after the submission of the Fiscal Year 2022 Budget and (ii) requires Congress to consider the legislation on an expedited basis. This is the fourth consecutive year that a determination of excess general revenue Medicare funding has been issued, and the third
consecutive year that a Medicare funding warning has been issued."

Pandemic Scams

Not surprising, but come on scammers.  Well anyway, there's a proliferation of scams tied to COVID, not that any of us should find this unexpected.  See, e.g., Corona Virus Scams,  recently published in the ABA Senior Lawyers Division magazine, Voice of Experience.

So it was good news to see The Protecting Seniors from Emergency Scams Act would help prevent scammers from taking advantage of seniors during the coronavirus pandemic and future emergencies introduced in the Senate.  Here's the info about the bill:

The Protecting Seniors from Emergency Scams Act directs the Federal Trade Commission (FTC) to report to Congress on scams targeting seniors during the coronavirus (COVID-19) pandemic and make recommendations on how to prevent future scams during emergencies. The bill also directs the FTC to update its website with information that will help seniors and their caregivers access contacts for law enforcement and adult protective agencies, and directs the FTC to coordinate with the media to distribute this information to ensure seniors and their caregivers are informed. 

Keep an eye on this bill; hopefully it will get some traction!

National Continuing Care Residents Association Joins Other Senior Living Advocates in Opposing COVID-19 Immunity

On June 1, 2020, the National Continuing Care Residents Association (NaCCRA) released its public statement detailing the organization's opposition to COVID-19 immunity or waivers of liability for nursing homes, adding to the growing chorus of opposition. They explain:  

CCRCs mainly provide three levels of care under one roof or on the same campus, normally comprised of independent living, assisted living, and skilled nursing care -- the latter two considered licensed long-term care facilities.  Our members can reside at various times in any of the three levels of care.  Fore example, one spouse can live independently while the other can live in assisted living or skilled nursing.  There are numerous variations of these living arrangements depending on the level of care required.

 

NaCCRA and its members are very sympathetic to the CCRC managers and front-line care/service workers as they labor during the coronavirus pandemic with its many challenges.  However, residents living and dying, many times alone, in nursing homes or assisted living apartments, should not be deprived of their legal rights or protections even in these most extraordinary times.

 

NaCCRA and its member residents living in continuing care settings are alarmed at the push to grant liability immunity to providers and operators of long-term care facilities in the face of the COVID019 epidemic.  Many states have acquiesced to provider association lobbyists at the expense of residents' legal protections.  NaCCRA believes that long term care providers must not be given a pass on negligence in any form simply due to a pandemic, which makes seniors in such congregate settings even more vulnerable.  

 

Therefore, we strongly oppose the liability waivers for COVID-19 legislated by some states.  WE urge that these be repealed and advocate on immediate moratorium on any future waivers for providers/operators of CCRCs and long-term care facilities.  It is our position that existing laws and negligence standards are more than adequate to protect long term care facilities that are sued if they have followed the proper standards of care and protocols.

My thanks to Jim Haynes, the current president of NaCCRA, for keeping us advised on their position.  

Social Security Trustees Report for 2020

With everything else we had going on, this one slipped past me. The SSA Trustees released their annual report in April. Here's the summary from the press release (note-this doesn't include COVID-19 impact analysis)

The Social Security Board of Trustees today released its annual report on the long-term financial status of the Social Security Trust Funds. The combined asset reserves of the Old-Age and Survivors Insurance and Disability Insurance (OASI and DI) Trust Funds are projected to become depleted in 2035, the same as projected last year, with 79 percent of benefits payable at that time.

The OASI Trust Fund is projected to become depleted in 2034, the same as last year’s estimate, with 76 percent of benefits payable at that time. The DI Trust Fund is estimated to become depleted in 2065, extended 13 years from last year’s estimate of 2052, with 92 percent of benefits still payable.

In the 2020 Annual Report to Congress, the Trustees announced:

• The asset reserves of the combined OASI and DI Trust Funds increased by $2.5 billion in 2019 to a total of $2.897 trillion.
• The total annual cost of the program is projected to exceed total annual income, for the first time since 1982, in 2021 and remain higher throughout the 75-year projection period. As a result, asset reserves are expected to decline during 2021. Social Security’s cost has exceeded its non-interest income since 2010.
• The year when the combined trust fund reserves are projected to become depleted, if Congress does not act before then, is 2035 – the same as last year’s projection. At that time, there would be sufficient income coming in to pay 79 percent of scheduled benefits.

“The projections in this year’s report do not reflect the potential effects of the COVID-19 pandemic on the Social Security program. Given the uncertainty associated with these impacts, the Trustees believe it is not possible to adjust estimates accurately at this time,” said Andrew Saul, Commissioner of Social Security. “The duration and severity of the pandemic will affect the estimates presented in this year’s report and the financial status of the program, particularly in the short term.”

Other highlights of the Trustees Report include:

• Total income, including interest, to the combined OASI and DI Trust Funds amounted to $1.062 trillion in 2019. ($944.5 billion from net payroll tax contributions, $36.5 billion from taxation of benefits, and $81 billion in interest)

• Total expenditures from the combined OASI and DI Trust Funds amounted to $1.059 trillion in 2019.

• Social Security paid benefits of $1.048 trillion in calendar year 2019. There were about 64 million beneficiaries at the end of the calendar year.

• The projected actuarial deficit over the 75-year long-range period is 3.21 percent of taxable payroll – higher than the 2.78 percent projected in last year’s report.

• During 2019, an estimated 178 million people had earnings covered by Social Security and paid payroll taxes.

• The cost of $6.4 billion to administer the Social Security program in 2019 was a very low 0.6 percent of total expenditures.

• The combined Trust Fund asset reserves earned interest at an effective annual rate of 2.8 percent in 2019.

The full trustees' report is available here.

Webinar: State Elder Justice Coalitions

Busy tomorrow, June 2, at 2 edt? Take a break and register for this webinar from DOJ's Elder Justice Initiative. State Elder Justice Coalitions: Informing Services and Influencing Public Policy:

Join us for the webinar, State Elder Justice Coalitions: Informing Services and Influencing Public Policy. With increased attention to elder justice, Elder Justice Coalitions are forming throughout the country. While their composition varies, state Elder Justice Coalitions address such issues as public policy, practice, professional training, and public awareness. Members of the National Network of State Elder Justice Coalitions (NNSEJC) Steering Committee will illustrate examples from coalitions across the nation. Topics include development and structure; priorities and notable accomplishments; sustainability; and the roles of the NNSEJC. Time will be allotted to answer attendee questions. 

Please view our recent article, Building a National Elder Justice Movement, State by State
(pp. 111-116), at: https://online.flippingbook.com/view/185807/112/

Click here to register for this webinar.

SNFs and COVID: Going Forward

Looking forward from COVID , here is a story from Wired, Some Nursing Homes Escaped Covid-19—Here's What They Did Right.

The story focuses on steps that can be taken, and the importance of doing so early. But even more so, the story examines the design of nursing homes. Think about it.  As the article points out

Residents, who are older, frail, and often have comorbidities like heart disease or diabetes, are more susceptible to severe Covid-19 infections. Many need help performing basic tasks like eating, dressing, or bathing—care that can’t be delivered through a video appointment, making it more likely they could get an infection from the aides who help them, or pass the virus along to their caretakers. Those aides may work at several different facilities, and unknowingly carry it from one home to another.

The layout of these facilities also furthers contact in various areas. Most residents share bedrooms, bathrooms, activity rooms, and dining rooms—and staffers share a break room. Those group spaces are designed partly to cut costs, and also to encourage socializing. But shared spaces have also helped spread the virus. Senior facilities do have protocols to handle outbreaks like the flu, but the pandemic arrived so quickly and the SARS-CoV-2 virus is so contagious that many facilities were caught unprepared. “There’s an extent to which this virus just had the upper hand,” says Anna Chodos, a geriatrician at the UCSF. Unlike hospitals, most nursing homes aren't ordinarily well stocked with gear like masks and gowns, which aren’t necessary when containing the flu.

The article examines the challenges as restrictions are lifted and the path forward for SNFs in navigating the challenges of the world with COVID-19. We all know this won't be easy.

[P]recautions are only helpful to a point, according to [one expert]. “These outbreaks are continuing and they’re going to continue in nursing homes,” she says. There are still a lot of unanswered questions about how and why the virus has spread so quickly in some homes, but not in others. Based on early data, she says: “It’s about the size of the facility and the amount of spread in your community.”

Nevertheless, [she] warns that while researchers are working furiously to figure out solutions, they still don’t have all the answers: “It's a turbulent time and we're trying to make clinical and operational decisions with incomplete information.”

The article then discusses caring for elders in their homes rather than SNFs and what it would take for that to become a common occurrence.  With potential looming budget cuts from states, the potential for that shift may be a long time coming.

This article does a good job in covering the various issues faced by those who run SNFs as well as those faced by individuals who have family in SNFs.  Read it!

The Most Important Coronavirus Death Statistic?

From Forbes, a deep dive into "The Most Important COVID-19 Statistic: 43% of U.S. Deaths Are From o.6% of the Population."  This will undoubtedly be an ongoing topic for examination for statisticians and analysts.  

Looking at Reasons for Opposition to Federal Immunity for Long-Term Care Facilities Related to Covid-19

A long-time friend and advocate for quality of life as we age contacted me today to discuss what to think about any attempts at federal legislation to immunize long-term care facilities from liability related to Covid-19.  I admitted I hadn't had time to think about this yet!  So, I'm starting my thinking now.   My blogging colleague, Becky Morgan, said earlier this month that even at the state level, immunity is not an "easy" issue.  

Historically, when Congress passed the Nursing Home Reform Act of 1987, it was an important attempt to create minimum national standards for quality of care, in light of a long nightmare of horror stories about inadequate care across the nation.  But, even as it established standards (such as a prohibition on "restraints" without documented medical necessity), it did not establish a "right to sue" by individuals claiming failure to comply with the standards.  That was probably a compromise worked out with the various lobbying groups, but the consequence of that was states were left to decide on their own about whether and to what extent rights exist for a patient to sue for negligent care. So, one could say that it would be "unprecedented" for Congress to actively shield the long-term care industry from quality of care standards, stepping on the toes of the states.   (Plus, at first blush, I don't see how Congress has any authority to craft immunity for facilities that are not subject to Medicare/Medicaid funding and oversight).

On the other hand, depending on how broad or narrow any such legislation was drafted, limited immunity might be appropriate on a narrow ground.  States have been relying on existing federal Medicare/Medicaid law that effectively prevents nursing homes from turning away Covid-19 infected residents as long as they have open beds and the patient qualifies for Medicaid/Medicare.  So those nursing homes have been, in effect, forced to take infected patients, which greatly increases the potential for cross infection, even with "good" infectious disease procedures in place.  But isn't this a "problem" that should be fixed, rather than pasted over?  

Advocacy groups on behalf of older persons, disabled persons, and consumers and workers are making it clear they oppose broad federal immunity.  See the May 11, 2020 letter to Senate Chairman Graham and Ranking Member Feinstein, signed by California Advocates for Nursing Home Reform, The Center for At Risk Elders (CARE), Center for Medicare Advocacy, Community Legal Services in Philadelphia, Justice in Aging, Long-Term Care  Community Coalition, National Association of Local Long Term Care Ombudsmen, National Academy of Elder Law Attorneys, National Association of Social Workers, National Association of State Long Term Care Ombudsman Programs, the National Disability Rights Network, Services Employees International Union, as well as individual law firms.  

See also the letter of May 11, 2020 sent by AARP.

Addendum:  See also  140 Groups Now Oppose Immunity; Nursing Homes Want Immunity and New York Regrets Giving It to Them, posted May 14, 2020 on Public Citizen.

LTC Facilities: Roundup of Stories

It's hard to keep track of the numerous stories on COVID-19 in LTC facilities, reopening LTC facilities, CMS waivers, CMS guidance, shield laws in various states, and more. Although Professor Pearson and I have been blogging about these issues for a few weeks, I wanted to list a few more stories here (without discussing them) just in case you missed any of them.

• Nursing Homes Seek Immunity Amid COVID-19 Crisis, Alarming Advocates
• Nursing Homes to Get $4.9 Billion From HHS to Combat Virus (1) (may require subscription)
• U.S. nursing homes plagued by infection control issues pre-COVID-19: report
• Trump Administration Issues Guidance to Ensure States Have a Plan in Place to Safely Reopen Nursing Homes
• Trump wants nursing homes to test all staff and residents. That may not be possible.
• Toolkit on State Actions to Mitigate COVID-19 Prevalence in Nursing Homes
• Older does not equal expendable. We need to act in a way that protects our elders from coronavirus
• Halted Nursing Home Inspections Draw Ire of Lawmakers, Attorneys\

I have no doubt there are more...and will continue to be more.... so stay tuned.

Is What CMS Doesn't Say as Important as What CMS Does Say in Recommendations for "Reopening" Nursing Homes?

On May 18, 2020, Centers for Medicare and Medicaid Services (CMS) released a ten-page Memorandum making recommendations to state and local officials for operation of "Medicare/Medicaid certified long term care facilities (hereafter 'nursing homes') to prevent the transmission of COVID-19." 

In some ways, nursing homes may be breathing a sigh of relief as the memo does not use any mandatory language directed at the operators.  In some instances CMS identifies "choices" for the states, such as whether to require all facilities in a state to go through reopening phases at the same time, by region, or on individual bases.  The memo says that facilities "should" have CDC-compliant testing plans, including "capacity" for all residents and staff members to have a single baseline test with retesting until all test negative. What does that mean?  You should be able to test everyone before you ease visiting restrictions, but you can choose not to do so?   On page 4, CMS cross-references ("cross-walk") to reopening phases for all "senior care facilities" under President Trump's Opening Up America Again plan.  The document describes "surveys that will be performed at each phase" of the reopening process, referring to the states' obligations to conduct surveys on prioritized timelines, although with no hard numbers for such oversight suggested.

CMS recommends that each nursing home "should spend a minimum of 14 days in a given phase, with no new nursing home onset of COVID-19 cases, prior to advancing to the next phase," and CMS says states "may choose to have a longer waiting period (e.g., 28 days) before relaxing restrictions for facilities that have had a significant outbreak of COVID-19 cases." 

Significantly, there is nothing in the latest CMS guidelines regarding staff members who work at more than one facility, thus posing a clear potential for cross-contamination.  That seems to me, at least, especially short-sighted.  

Is This the Time for Renewed Consideration of "Negotiated Risk Agreements" in Care Settings?

In 2011, Joshua R. Wilkins, then a graduating student at Dickinson Law, won one of the top awards for a student writing competition sponsored by the National Academy of Elder Law Attorneys (NAELA).  Joshua wrote about "Consumer Directed Negotiated Risk Agreements."  His introduction began:  

Negotiated risk in the assisted living context is a largely misunderstood concept. Opponents and proponents of the concept often fail to agree on fundamental concepts underlying negotiated risk. Similarly, states have enacted legislation authorizing or prohibiting what is described as negotiated risk – however those states have defined the concept so differently than other states that it is difficult to understand the concept as a cohesive whole. Negotiated risk can be broadly defined as the shifting of responsibility for certain consequences between the resident and the assisted living facility. Further concepts of definition vary greatly between lawyers and industry actors, and will be discussed later.

As a polestar, the general opinions regarding negotiated risk should be summarized. Opponents of the concept believe that negotiated risk is an illegitimate and unenforceable imposition upon the rights of assisted living residents by facilities attempting to contract away liability for resident injuries.  Proponents color negotiated risk as a method for residents to exercise greater control over their living conditions and tailor the services supplied and guidelines imposed by the resident’s facility.

 

This paper proposes an alternative approach to negotiated risk that incorporates concerns of opponents of negotiated risk, and the selling points of proponents. A consumer directed negotiated risk agreement – one prepared by the resident’s independent attorney, would assist the resident in directing their standard of assisted living, while protecting their interests. A document of this type would require new state legislation authorizing the enforceability of risk shifting, and also delineating the boundaries that such an agreement could be used for. Additional benefits to this type of negotiated risk is that concerns over resident safety and welfare during the admissions process could be addressed without completely overhauling the market-based approach that is a hallmark of assisted living. Also, because residents seeking negotiated risk agreements would have to enlist the aid of an independent attorney, they would be more likely to benefit from advice regarding many other aspects of aging that they may not have otherwise obtained – including Medicaid and estate planning, education about possible exploitation, and review of pertinent resident admissions forms and contracts.

In proposing a consumer-driven approach, Joshua recognized critics' past reasons for opposing "negotiated risk" agreements, including the serious concern that facilities could mandate such "agreement" as an automatic wavier of all appropriate standards for care.  That's not true choice.  Attorney Eric Carlson, long-known for his advocacy for seniors, wrote an early article, Protecting Rights or Waiving Them?  Why 'Negotiated Risk' Should be Removed from Assisted Living Law, Journal of Health Care Law & Policy (2007).   

The specific risk that I'm thinking of these days is the risk that attends continued interaction with family members and friends for residents of assisted living or dementia care facilities.  Coronavirus is just one of the risks that comes about through such interaction, and certainly the emerging details of facilities that fail to adopt or enforce sound infection control measures are, at best, disturbing even without this particular disease.  Further, just because one resident is willing to "accept" risk coming from outside interactions, that doesn't mean the entire resident community would feel the same, and yet their own exposure to the risk increases with every fellow resident's outside contact.  And staff members' safety is also impacted by third-party interactions.  

Perhaps negotiation of the risk agreement provisions regarding community/family interactions should be made viable only where stronger safeguards can be developed against "casual" infection sources.  We have standards for "green" architecture.  Are there similar standards for "clean" architecture in senior living settings (and beyond)?  

New Research: How Timing Affects Low-Income and Aged Bill Payers

New research described in the Bulletin on Retirement and Disability published by the National Bureau of Economic Research provides new support for thinking about ways to help maximize use of benefits to pay for core living expenses.  Researchers Lint Barrage (UC Santa Barbara), Ian Chin (Michigan), Eric Chin (Dartmouth),and Justine Hastings (Brown) examine how timing of receipt of Supplemental Nutrition Assistance Program (SNAP) benefits affects a household's ability and success in paying for utilities, such as electric bills.  They observe:

Our results suggest that, for low income households, timing of income from government benefits and the timing of bills due may have long-run consequences. If bills are not received when income is received, households are more likely to miss payments, which may compound into disconnections which may further impact family financial and health outcomes.

 

These results add to a growing literature suggesting that government benefits programs and/or private industry innovate in ways to help low income households balance budgets throughout the month and avoid potential poverty traps. In the case of electricity bills, moving bill receipt to coincide with SNAP benefits receipt could improve repayment rates. This could help low income families avoid poverty traps, but also lower electricity rates for all rate payers in regulated markets, since collection and electricity service disruption are costly and must be covered by regulated electricity rates. Further research is needed to implement and measure the impact of changes in timing of bill receipt through, for example, a randomized controlled trial, and to expand the outcome measures of impact to include measures of financial well being such as credit scores. 

For more, read How Bill Timing Affects Low-Income and Aged Households, NBER RDRC Working Paper 19-09) and the Bulletin summary. 

Our thanks to George Washington Law Professor Naomi Cahn for this reference.  I suspect that the timing of core household bills and public receipt of pandemic-driven federal stimulus payments would make for another interesting study.