The Centers for Medicare and Medicaid Services (CMS) appears to be preparing to allow nursing homes to open their doors to families and other visitors, despite the COVID-19 pandemic. If not done carefully, this would be folly, and could put residents, staff, and families at risk.
The new rules, which still are under consideration, would reverse March 16 CMS guidance that barred non-medical visits. And it may accelerate the April 20 guidelines for reopening facilities. Those were included in the recommendations for restarting the economy that President Trump issued last month but then effectively urged governors to ignore.
The Wall Street Journal reports (paywall) that CMS is considering a similar three-phase opening for long-term care. Facilities could begin allowing limited visits once they report no cases for 14 days. They could increase access, as well as communal activities, if they go another two weeks without an active case.
The problem, of course, is a facility may go weeks with no cases. But if a visitor brings COVID-19 in, it will spread like wildfire.
Why open now?
Why is the Trump Administration planning to open long-term care facilities now? It is hard to fathom. But it follows Trump’s recent pattern of trying to make it appear that the COVID-19 pandemic is behind us, and at the same time, abdicating difficult decisions to others.
Like the administration’s move to shift responsibility for reopening businesses to states, this also would put the burden of deciding who is allowed to visit on states, as well as on facilities themselves. And it would create White House deniability when angry family members confront management of nursing homes and assisted living facilities, demanding to be let in.
The possible move, which began leaking last week, surprised operators and their trade groups. They already were developing their own task force to create industry-wide guidelines for reopening. But, according to the newsletter McKnight’s Senior Living, they don’t expect that panel to finalize recommendations until late June or July. It is not clear when the CMS guidance would take effect.
Paying a price for isolation
Residents are paying a severe price for being isolated in long-term care facilities. While we don’t know for sure, it is likely that they are suffering from more loneliness and depression. They also are at greater risk because their families are not able to advocate in person for them —an especially important role in the difficult environment COVID-19 when care is likely to go wrong.
But it makes absolutely no sense to reopen facilities to visitors now. Nursing homes still don’t have enough coronavirus tests. Assisted living has even less. And tests often take many days to produce results. Absent immediate results—like those available to the White House staff—opening care facilities puts staff and residents at risk from visitors, while at the same time placing those visitors at risk.
And that means more than taking a visitor’s temperature at the front door, a highly unreliable test for coronavirus. Many of these scanners do not correctly detect fever. And, it turns out, elevated temperature is not always a good predictor of COVID-19.
Passing the buck
Reopening also requires an ample supply of masks, gowns, and gloves for all visitors, and proper training in their use.
Nursing home and assisted living operators at horrified at the idea of reopening prematurely to visitors. Some are reluctant to have family members adding to what already is a chaotic situation, with staff shortages and jury-rigged efforts to isolate COVID-19 residents.
Others worry about having to deny entry to angry relatives. The current CMS rules give operators valuable cover: Now, they can blame government for keeping the doors closed. Without that guidance, managers will have to take the heat themselves.
This is, I fear, is yet another way for Trump to pass the buck to others and avoid responsibility for the effects of the pandemic. If a facility turns relatives away, it is the facility’s fault. If it lets people in, and cases accelerate, it is the facility’s fault.
But the main reason for their fear is the obvious one: This is no time to add to already enormous infection control challenges.
Facilities, families, and state, federal, and local government need to work together to design a safe way for families to visit their loved ones. But this has to happen in a careful, well-considered, and properly timed way. And it should be based on careful benchmarks that all parties adhere to. The US has failed to establish coherent, enforceable protocols for much of its COVID-19 response. It would be a tragedy if it fails to do so when it comes to opening up long-term care facilities that have seen so much death already.