Who Will Get Nursing Homes Off Life Support?

COVID-19 exposed systemic problems in nursing homes and other long-term care facilities that had been in plain view for decades—if anybody had bothered to look and take action. Everybody looked when COVID-19 hit because SARS-CoV-2 struck nursing homes especially hard. According to the Centers for Disease Control and Prevention (CDC), of the 661,274 COVID-19 deaths in the United States, 135,427 were nursing home residents (about 20.4%). Nursing homes were the nexus of the pandemic. Now, with the delta variant going after younger, and mostly unvaccinated people, the fixing of nursing homes may have once again slipped a notch or two on society’s to-do list. There’s a bill in the US Senate that would require that every nursing home have a fulltime infection preventionist on staff. That sounds great to Linda Spaulding, RN-BC, CIC, CHEC, and a member of Infection Control Today^®’s Editorial Advisory Board. However, every idea to improve nursing homes turns on this question: Where’s the money going to come from? “Somebody in the government needs to start talking about why they’re not funding them to be better prepared like they are the hospitals,” Spaulding says, in a wide-ranging interview with ICT^®. “Yet they’re holding them to the same standard as they’re holding hospitals.”

Infection Control Today^®: Let’s start with something easy: What needs to be done to fix the problems in nursing homes?

Linda Spaulding, RB-BC, CIC: There seems to be a big disconnect between emergency management run by the states and the federal government and long-term care facilities. Back in September of 2016, CMS [Centers for Medicare and Medicaid Services] came out with a draft ruling about emergency preparedness and long-term care facilities. And essentially it mirrored what the hospitals do. The big difference between that is … a couple things. One, the hospitals got annual grants of thousands of dollars to help boost up their emergency preparedness. Buying tents for outside communication equipment, running drills, buying PPE [personal protective equipment], that kind of thing. It was called the HRSA [Health Resources & Services Administration] grant. And I don’t know if they’re still being given to hospitals or not, but this went on for many, many years. And then in September of 2016, CMS came out and said, “OK, long-term care facilities have to have emergency preparedness plans.” But there was no money

Linda Spaulding, RN-BC, CIC, CHEC

behind that mandate. And of course, they had to put together an emergency preparedness program. And that was updated. The standards were updated in 2019 and again in March of 2021. But of course, still no money. Well, nothing was going on, right? And then COVID-19 hit. And now a lot of nursing homes are not prepared for keeping sick residents with COVID-19. Hospitals are refusing to take them because they are at their max. A lot of hospitals go into the medical triage, which is the people who have the best chance for survival will get the hospital bed, and long-term care facilities aren’t always included in that. When I was looking into this, a lot of the facilities … they have emergency preparedness plans, and all nursing homes across the country probably do. And CMS has been surveying those facilities and relicensed them every year before 2016, and after 2016. Yet, here we have an example of Louisiana when they recently evacuated all those long-term care facilities because of a hurricane. From what I understand they put over 800 residents into a large building but didn’t have toilet facilities and care supplies and that kind of stuff. OK, so that group of nursing homes, it sounds like they’re going to get their licenses taken away. Now, Louisiana went through Hurricane Katrina, yet, mandates have always been there for nursing homes. And they have emergency preparedness plans that CMS signs off on every year. Something’s gone wrong. Either we’re just looking at words on paper, and not enforcing the rule because they do have a plan. But in that plan, it says that they’re supposed to do at least two exercises a year for emergency preparedness, and what would they have to do if they had to evacuate and they ran out of food, the water stopped, whatever. Or a COVID-19 situation. Long-term care facilities weren’t prepared. They had COVID-19 patients and they had COVID-19 employees. And they needed help with staffing for that long-term care facility. They called everybody they could think of calling and they said everybody was very nice to us. They felt for us, but they had no help to send us. And then you watch the news. And you see FEMA [Federal Emergency Management Agency] send in military to all the hospitals around the country. And then when long-term care gets in the news, again, it’s because they did something wrong.

ICT^®: A bill before the US Senate called the Nursing Home Improvement and Accountability Act of 2021 would mandate that a fulltime infection preventionist be staffed at every nursing home. The American Health Care Association and National Center for Assisted Living (AHCA/NCAL), who represent nursing homes, like the idea but ask, as you’ve been asking, where’s the money going to come from? Do you see the funding problem getting solved at all?

Spaulding: I don’t know if it can be solved or not, because nobody’s talking about it. Somebody in the government needs to start talking about why they’re not funding them to be better prepared. Like they are the hospitals, yet they’re holding them to the same standard as they’re holding hospitals. Now, I’m sure that there are some things that I don’t know about. And a lot of nursing homes are privately owned. But then if you’re going to hold them accountable, then do it before we have a disaster, like a pandemic, or like a hurricane. Hold them accountable every year until they get those plans written and working and good. Because the time to hold nursing homes accountable is not the time when everything’s falling apart, and they don’t know what to do, and there’s nobody there to guide them. And even if they all had a fulltime infection control person, that’s not going to solve the problem that we have with COVID-19. Hospitals don’t take the residents. One infection control person in a nursing home isn’t going to do any more than what the administrator can do, and the director of nursing can do. And that is figure out a way to staff the building to take care of the residents. There’s got to be some discussion that starts happening about this, or the problem’s never going to be solved.

ICT^®: Where do infection preventionist fit in all this?

Spaulding: Well, for the last few years, they’ve mandated that long-term care facilities have a designated person to do infection control. But we can take … I’m going to use you as an example, right? I take you today, and I hire you into my long-term care facility, and I say, “You are now our designated infection control person.” That’s what happens. They hire a nurse that has never done the job before. And they give her or him the title of infection preventionist. They give them a little training. But after that, there’s no guidance for that person to be able to recognize when things are going wrong. You’ll find a really good person once in a while who is self-motivated, who has worked in acute care. And who reads a lot, learns a lot. But if you’re just going to hire somebody, give them the title, give them a job description and then that’s as far as it goes, you’ve got some problem.

ICT^®: Also, the person who has the title of infection preventionist at a nursing home is also doing several other jobs, correct?

Spaulding: Right. A lot of places are still using the director of nursing as that designated infection prevention person. And the director of nursing has all kinds of tasks that she has to do all day long. Long hours. And she still has to be responsible for infection control. What you see is some facilities are still just counting the numbers of infections, but not analyzing why they’re having those infections, or learning how to prevent those infections from happening, or discussing what kind of education that person still needs. Again, the dollars aren’t behind the education. “Oh, the long-term care facility doesn’t need a person.”

ICT^®: Have you seen anything that gives you hope that maybe things will change in nursing homes because of COVID-19 specifically?

Spaulding: Well, you know, we had hoped that after Hurricane Katrina, when they showed all those long-term care residents sitting in water up to their necks…. That didn’t change anything. So, I’m not sure. Maybe, with what has happened with COVID-19, and all the catastrophes that we’ve had recently, with the bad weather and the fires and everything, maybe something will change, but it’s going to take somebody at the top to say, “We have to come up with a structured idea of what our expectations are, not just words on paper. [A structured idea] that is realistic for people to put in place.” We have state emergency managers that haven’t given the time of day to long-term care facilities ever. We have other states that have included them in the periphery. But for the most part, when this facility that I was talking to needed help, the state emergency preparedness group was not there for them.

ICT^®: If somebody is in a nursing home, the feeling might be that they’ve live a long life and they’re not a priority to save when something like this happens. And yet when COVID-19 happened, because of that attitude, COVID-19 seemed to burst out of nursing homes into the rest of society.

Spaulding: Yes, exactly. That might be what’s going on behind the scenes. Nobody’s going to come out and say that’s what it is. But when you look at the actions that are happening…. Politicians will go on TV and talk about nursing homes, and how we have to protect our elders … but, again, those are words being said. Or words on a piece of paper. But there’s not enough action behind it. If they’re not plenty of nursing homes because they’re privately owned, well then license them appropriately. If they’re not doing what you want them to do, they either have to do it or take away their license at that point. Don’t wait until we're in the middle of a pandemic, and then say, “Oh, now you’re going to lose your license because you did X, Y, and Z.” They were set up for failure to begin with. CMS or whoever’s making these rules, has to set nursing homes up to succeed, not to fail.

This interview has been edited for clarity and length.