Pittsburgh doctor joins federal commission to protect nursing homes from future outbreaks

June 29, 2020

WASHINGTON — The outbreak of COVID-19 has in many ways been the ultimate test for David Nace, who has dedicated his academic research and professional career to protecting residents in long-term care facilities from infection.

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As chief medical officer for UPMC Senior Communities, Dr. Nace managed to keep the virus out of 36 senior living facilities housing roughly 3,000 older adults in 21 Pennsylvania counties.

This summer, with mounting COVID-19 deaths at nursing homes nationwide, Dr. Nace will join two dozen other geriatric care experts on an independent commission tasked with advising the Trump administration on how to prevent future outbreaks.

Along with a sense of urgency to stem the spread of the virus, Dr. Nace said in an interview last week, he believes that a rare opportunity is at hand. The national grief regarding nursing home deaths could lead to an expansion of funding and resources, which he identified as the systemic problem at long-term care facilities.

“We’re getting what we’re paying for,” said Dr. Nace, a University of Pittsburgh professor in the Division of Geriatric Medicine and president of the Society for Post-Acute and Long-Term Care Medicine.

Meanwhile, he plans to push for an overhaul of the regulatory structure that he believes has focused too much on penalties and failed to appreciate the complexity of care.

The Centers for Medicare and Medicaid Services, an arm of the U.S. Department of Health and Human Services and the agency that regulates nursing homes, has taken the approach that “the beatings need to continue until the morale improves,” Dr. Nace said.

“There’s been an expectation that facilities do a lot, but at the same time the tools and resources have not be available widely,” he explained. “If we do the same thing we’ve always done — which is to assign blame, and go in and try to figure out who we’re gonna fine — we’re not gonna get anything different than we’ve gotten for the last 30 years. It will not change anything.”

Dr. Nace was among 25 nursing home experts named this month to a new commission tasked with advising the Centers for Medicare & Medicaid Services on how to improve quality at the facilities.

“This should be about how to we move forward,” he added.

Crying out for justice

But finger-pointing was on the rise in Washington, where policy-makers have grappled with rising anger and alarm as nursing home COVID-19 deaths reached at least 29,000, according to CMS figures.

While inspections and enforcement of nursing homes fall largely to state health departments, pressure is growing for a federal response to missteps at the facilities.

Earlier this month, CMS Administrator Seema Verma called for state agencies to step up infection-control inspections at nursing home facilities and hike penalties.

“There is no substitute for boots on the ground,” Ms. Verma said, referring to state inspectors. “In many of the surveys we have done, we have found that hand-washing continues to be a challenge.”

In some ways, the nursing home debate mirrors discussion about policing reform, which is centered on federal measures to increase accountability of local police departments and lowing burdens to prosecuting officers — while also investing more in training and recognizing the demands of the job.

Families of the residents “are crying out for justice in their cases,” said Rep. Conor Lamb, D-Mt. Lebanon, during a virtual roundtable on nursing homes last week. “You hear them every time saying they don’t want this to happen to anyone else.”

Mr. Lamb’s district includes the state’s worst COVID-19 outbreak, which occurred at the Brighton Rehabilitation and Wellness Center. At least 332 positive cases and 82 deaths were recorded there, according to state data.

Three separate inspections at the Beaver County facility since April revealed infection control violations. They included a state survey in early May that discovered that residents were put in “immediate jeopardy” — the most serious finding — by a lack of basic hand-washing and cleaning protocols essential to stop the spread of the virus.

After learning of that inspection, Mr. Lamb called for a federal investigation, which CMS conducted and resulted in a fine of $58,260 that continues to grow by $110 a day until all the problems are resolved.

Mr. Lamb, who co-chairs the Congressional Task Force on Aging and Families, said Congress would be reviewing legislation in response to the nursing home outbreak. While he has criticized the nursing home industry, he called for boosting resources and training.

“Better pay and working conditions for staff in these facilities can go a long way toward making lives better for the residents and prolonging their lives,” Mr. Lamb said during the roundtable, hosted by the task force.

“I think it’s those deeper structural underlying conditions around these nursing homes that this task force is well-suited to address,” he said.

The owners of the Brighton facility, Comprehensive Healthcare, responded to the inspection with an emailed statement that staff continue to “work relentlessly to enact the evolving protocols set forth by government health officials,” while acknowledging, “few individuals have been perfect in their response to COVID-19.”

Penalties or investment?

CMS’s independent commission of 25 members includes resident advocates, infectious disease experts, directors and administrators of nursing homes, state authorities, a medical ethicist and a nursing home resident. Finding a consensus on how to weigh increased oversight and expanding resources may prove to be difficult.

As a member of that commission, Dr. Nace argued that COVID-19 exposed long-standing funding issues stemming largely from low government reimbursements. About 70% of care is funded by Medicaid, which pays for health care costs for low-income residents. The rest is covered by Medicare, which pays much higher rates than Medicaid, or by private insurance.

“We’re getting what we’re paying for,” Dr. Nace said.

Dallas Taylor, director of nursing at Eliza Bryant Village, a facility in Cleveland with about roughly 100 mostly Black residents, said 97% of revenue comes from Medicaid. Ms. Taylor, another member of the commission, said the facility loses $50 a day on average.

Those shortfalls have proved to be challenging during the outbreak. While universal testing of residents is a “no-brainer,” she said, “at a Medicaid facility, where does that money come from to test all the staff and residents?”

“That’s a lot of cost and manpower,” said Ms. Taylor, whose facility reported 14 cases of COVID-19 at the start of the outbreak but has stamped out the virus in recent weeks. “We know there’s a second wave coming, and we want to be prepared.”

Testing all 4.4 million nursing home and assisted living community residents and staff one time would cost $672 million, Mark Parkinson, president and CEO of the American Health Care Association, estimated in an op-ed article Thursday.

Yet egregious acts by the industry have captured attention, too. 

A New York Times report last week revealed that some nursing homes have involuntary discharged residents to potentially unsafe locations to make way for patients with COVID-19. Housing patients with the virus eases the burden on hospitals and can yield higher revenue for nursing facilities.

Toby Edelman, senior policy attorney for the Center for Medicare Advocacy, blamed the Trump administration for creating a “lethal combination” of lax oversight, a waiver of key resident protections, legal immunity for facilities and few strings attached to billions in federal funding allocated for nursing homes.

In addition to barring family visits, Ms. Edelman said, oversight officials, known as ombudsmen, have been barred from entering, and state surveyors have been required to limit the scope of their inspections to infection control issues.

“I hope Congress can be able to effectively channel public outrage into necessary changes,” she said during the congressional task force roundtable last week.

An incomplete picture

Meanwhile, incomplete and often unreliable data will likely challenge policy-makers seeking to accurately target resources.

CMS, after requiring all nursing homes to report data on COVID-19 cases, tallied more than 60,000 confirmed COVID-19 cases and at least 29,000 deaths linked to the virus.

But 1 in 5 nursing homes did not respond to the survey, CMS officials said, and facilities only had to report data from recent weeks, not cumulative numbers. The Brighton facility, for example, reported just 10 COVID-19 deaths, when a total of 82 residents have died from the virus.

Federal and state inspection data also clashed, a conflict that potentially affects Pennsylvania’s federal dollars.

This month, CMS released stricter guidelines that require states to conduct one-time infectious disease inspections of all nursing homes by July 31 — or risk losing some funding.

CMS data showed that Pennsylvania surveyed just 16% of its nearly 700 nursing homes as of earlier this month, which ranked the state near the bottom and well below the national average of 54% of nursing homes inspected.

The Pennsylvania Department of Health contends that the number of nursing homes inspected is much higher, saying its 115 inspectors had completed 851 surveys from March through May 31.

“We are continuing to work with CMS to determine what data they are looking at and how we can make sure the data aligns,” Nate Wardle, a spokesman for the state health department, wrote in an email.

Daniel Moore: , Twitter @PGdanielmoore