The Trump Administration has finally said it would require nursing homes to report cases of COVID-19 to the Centers for Disease Control and Prevention (CDC) and, eventually, to families of residents. The move is welcome, but it is far too little and, for many families, far too late.
On Friday, The New York Times reported that more than 36,500 residents and staff at nursing homes had contracted coronavirus, and that at least 7,000 have died–roughly- one-fifth the total number of reported COVID-19 deaths in the US by that date. In an April 15 industry survey by the trade publication McKnight’s Long-term Care News , 34 percent of facilities reported at least one positive case of COVID-19. That implies that more than 5,000 US nursing homes have COVID-19 cases among residents or staff.
With this spread of the deadly disease in care facilities, it is hard to imagine why it has taken the Centers for Medicare and Medicaid Services (CMS) so long to require reporting. Even Industry, perhaps reading the handwriting on the wall, endorsed limited disclosure 10 days ago.
The need is critical. If public health officials are going to get a handle on COVID-19, they need to identify hotspots. And the absence of both testing and reporting by nursing homes kept them blind to the hottest of those hot spots.
At the same time, not telling families who need to decide where to move a frail loved one who can no longer stay at home is unconscionable. While facilities already are required to report outbreaks of infections to state regulators, the states don’t have to make that information public. Thus, a family often must choose a facility with no information about whether it is having a real-time outbreak of COVID-19, or what it is doing about it.
This is even more troublesome because it currently is impossible for families to visit facilities, since all have been locked down for weeks—and likely will be for months to come.
For all of those reasons, CMS’s decision is welcome but it is not enough. Here is why:
It is limited to nursing homes. Other long-term care facilities, such as assisted living, independent senior living, small group homes, and continuing care communities (also known as life care communities) are regulated by the states, and not the federal government. State regulation is highly variable, and even where states do require facilities to tell regulators about outbreaks of infectious disease, many do not require public reporting.
While we know far too little about COVID-19 in nursing homes, we know almost nothing about outbreaks in other congregate care settings. And while about 700,000 frail older adults and younger people with disabilities live in nursing homes (and another 600,000 are these for post-acute rehab), about 800,000 live in 29,000 other residential care settings. States need to take immediate steps to gather COVID-19 information from these facilities and make it public.
Timing. While CMS announced new disclosure with great fanfare yesterday, it never quite said when it would require the new reporting. Notification to the CDC still must await a formal rulemaking. And public disclosure seems to be even more distant. The CMS announcement said only the agency “will also be previewing a new requirement for facilities to notify residents’ and their representatives to keep them up to date on the conditions inside the facility, such as when new cases of COVID-19 occur.”
Sorry, but this is not a new movie. Families don’t need a preview. They need a reporting mandate. Now.
The rules appear lax. CMS said violations of reporting “could result in an enforcement action.” Maybe the rule will be tougher and more specific. But CMS should use its nuclear option. It should stop making Medicare payments to facilities that fail to report, or issue late or misleading reports. This is about more than mere technical paperwork violations.
Staffing. Even as CMS says it will require some disclosures, it is allowing facilities to waive others. For example, nursing homes will not have to report staffing data for the first quarter of 2020 due to the pandemic. While CMS says this is an effort to relieve a paperwork burden for hard-pressed facilities, Harvard University’s David Grabowksi notes that nursing homes already have the data and it takes little effort to report it to CMS. Given the crushing burden COVID-19 has put on staff, it is important for regulators and the public to know how the pandemic has affected care workers.
It is good that CMS is requiring nursing homes to report COVID-19 cases, and that it finally may be acting to support facilities in other ways such as by increasing availability of testing for staff and residents. But, what took CMS so long? What has it been thinking?