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On December 15, 2016, the country’s largest nursing home lobby wrote a letter to Donald Trump, congratulating an elected president and urged him to cancel new regulations on the long-term care industry.
One item on the wish list is a new emergency preparedness regulation. For this reason, nursing homes are needed to draw up plans for hazards such as new epidemics.
Election of Trump, American Health Care Association, or AHCA, write, has shown that voters oppose “very burdensome” rules that jeopardize thin industrial profit margins.
“Part of the public message is to ask for less Washington’s influence, fewer regulations, and more empowerment to the free market that has made our country the largest in the world,” wrote the AHCA. “We received that message and look forward to working with you to improve the lives of residents at our facility.”
The letter is another salvo in the industry’s struggle against regulations designed to stop diseases such as COVID-19 from the destruction of the elderly population in the country’s nursing home, according to a review of documents and data by New Mexico In Depth; News & Observers Raleigh, North Carolina; and ProPublica.
The lack of a pandemic plan helps explain why nursing homes have been arrested unprepared for the new corona virus, said patient supporters and industry observers. Across the country, more than one in four nursing homes have registered outbreaks, according to mediareport. More than 16,000 nursing home residents and workers have died, accounting for 17% of COVID-19 deaths nationwide, according to a AARP Tally on May 18. That number is likely to underestimate the true extent of the damage.
Ongoing questions about regulations might also play a role. The 2016 rules mandate planning for all types of hazards, citing Ebola as an example. In 2019, the Trump administration clarified that nursing homes need to include specific plans for epidemics of unknown and contagious diseases – such as coronavirus.
Plan must be an address how the facility will respond in an emergency – determine how the nursing home will decide to take shelter or evacuate and how they will provide residents with food, water, medicine and electricity. Nursing homes should train their staff on this plan and practice it at least twice a year, if possible by participating in training with local institutions.
Some nursing homes are slow to comply, according to inspection data analysis, supervisory reports and interviews with ombudsmen and advocates. Inspectors have found more than 24,000 shortcomings with emergency nursing home plans between November 2017, when the so-called “all hazard rules” come into effect, and March 2020, according to public data reviewed by news organizations. Violations occurred in 6,599 facilities, equal to around 43% of state nursing homes.
Because of the way the Medicare and Medicaid Service Centers track data, it is not possible to say exactly how many violations of emergency planning are specifically related to failure to plan outbreaks of communicable diseases. Failure to meet routine infection control standards was excluded from the analysis.
But supporters of nursing homes say that a more detailed plan that takes into account staff shortages and equipment is likely to result in fewer deaths and illness in nursing homes affected by coronavirus. Current rules require nursing homes to make contingency staff preparation, but do not require the provision of personal protective equipment, or PPE.
“It’s just a river of sadness, and it can be prevented,” said Pat McGinnis, executive director of the California Advocates for Nursing Home Reform.
The contingency plan helped facilities train their staff early and guide difficult decisions during the crisis, said Ted Goins, president and CEO of Lutheran Services Carolinas, a non-profit organization based in Salisbury, North Carolina, which manages several high-ranking elderly care facilities.
“COVID-19 is a perfect example of why we have an emergency plan at our facility, and I’m sure that’s why this is a requirement,” Goins said.
AHCA refused to provide executives for interviews. In a statement, the group said the pandemic showed that nursing homes should be a greater priority for resources but not for regulations.
“When we assess the COVID-19 pandemic and how to prepare our health care system for future outbreaks, more regulation is not always the answer,” AHCA said in the statement. “There will be time to look back and determine what we can do better for a future pandemic or crisis.”
One place to start: a nursing home and rehabilitation center in Albuquerque, New Mexico, with five deaths and 42 infections related to the COVID-19 outbreak and no plans to deal with a pandemic, according to New Mexico employees and public records.
“A pandemic response? I mean, I don’t think anyone is really ready for a pandemic of this level or this quickly, “said Edwardo Rivera, facility administrator.” We do have a few things in place, but no one can prepare us for what COVID- The 19th. “
Robert Potts, 91, has flown American leaders around the world.
A retired Air Force colonel who flew combat missions in Korea and Vietnam, Potts returned to the United States to serve as Air Force One and Air Force Two pilots in the 1960s, according to service records and family members. He spoke of the flight of President John F. Kennedy and first lady Jacqueline Kennedy.
After he fell at home and hit his head in March, Potts ended up at Advanced Health Care of Albuquerque, part of a national network of 22 post-hospitalization rehabilitation and skilled care facilities.
The Albuquerque facility is the best rehabilitation center with a private bedroom and wine glass in the dining room. It treats patients who need physical, occupational or speech therapy after hospitalization.
In early April, AHC staff and residents of Albuquerque began conducting positive tests for the corona virus. Worried about the health of her father, Potts daughter, Susan wanted to take her home. Someone from the facility – Susan could not remember exactly who – convinced the family that Potts had tested negative for COVID-19.
When the AHC from Albuquerque van arrived at Potts ‘residence in prosperous Northeast Heights in the city on the afternoon of April 10, the Potts’ family guards were there to greet him. Rosemary Ortiz, 57, recalls that the driver assured him that Potts was negative for COVID-19.
However, Ortiz noticed that Potts had symptoms associated with this disease: runny nose and dry cough. The next day, Saturday, the symptoms worsened. On Sunday morning, he complained of shortness of breath and chest pain. He was dizzy, recalled Ortiz.
Ortiz took him first to an emergency treatment facility, where he registered a temperature of 100 degrees. On the recommendation of a nurse, Ortiz took Potts to the Presbyterian Hospital in downtown Albuquerque.
“Wouldn’t that be something if I had a COVID and I gave it to you, to the family,” he remembers he told him.
“Don’t say that, we don’t want that!” Ortiz responded.
In Presbyterian, Potts tested positive for COVID-19. He was admitted to the fourth floor ICU.
Ortiz returned to his home that night, a two-room casita in the Albuquerque Southern Valley that he shared with a roommate.
He was worried that Potts was dying.
Something very basic
The drive to ensure that nursing homes are better equipped for emergencies starts in the midst of disaster and illness.
After Hurricane Katrina in 2005, the Inspector General for the U.S. Department of Health and Human Services found that nursing homes were not prepared to face emergencies despite adhering to existing federal standards. The regulatory body recommends strengthening federal requirements to be more specific about the elements that must be present in a disaster plan and encouraging more coordination with state and local emergency management officials.
In 2009, the Government Accountability Office checked preparedness for the flu pandemic and recommends that the federal government do more to advise health care providers about contingency plans and monitor their performance. The shortage was confirmed by the swine flu outbreak that year, which made nursing home residents sick throughout the country.
In 2013, concerns about an outbreak of infection began to take concrete form. Medicare and Medicaid Service Centers, or CMS, proposed update emergency preparedness requirements for all health service providers participating in Medicare and Medicaid, including nursing homes.
“This is really something very basic,” said Richard Mollot, executive director of the Long-Term Concern Community Coalition, which advocates for residents of nursing homes and their families.
But nursing home operators don’t see it that way. They objected to the new requirements, arguing it would be expensive and burdensome. Over the next three years, they repeatedly voiced their concerns when the CMS completed the new rules.
“We are concerned that CMS has underestimated the amount of time, training and resources needed to implement many of these requirements,” the Catholic Health Initiative, which operates 40 long-term care, assisted living facilities and housing, said in a formal response for the CMS proposal.
The Sustainable Care Leadership Coalition, which represents post-acute and long-term non-profit and public care providers in the New York metropolitan area, told CMS that additional personnel and equipment – such as backup generators – needed to comply with new regulations risk the economic stability of some of its members. “We see the proposed changes as important from a financial perspective, exceeding the appropriate minimum standards for participating in the Medicare and Medicaid programs, and we hope they will need a significant staff and operational increase,” the organization the word.
CMS refused the appeal, issued last rule in September 2016. Nursing homes and other facilities have one year to implement the changes.
A few months later, the AHCA sent a letter to Trump. The group was followed up by ask Tom Price, Trump’s first HHS secretary, to stop implementing new requirements and write new rules. “We are happy to work with your team and CMS staff to provide more specific advice,” the industry group said.
The following year, the Trump administration proposed to fulfill some of the AHCA’s wishes. Organization has warned that creating and updating a plan risks taking time from the patient.
Advocate for residents of nursing homes mind that CMS contradicts its own conclusions. Public health officials say setbacks will cancel repairs that have the potential to save lives.
CMS finally decided to remove the mandate for nursing homes to document coordination with local authorities.
But agencies continue to insist on the need to plan pandemics and other new disease outbreaks: “CMS determines that it is very important for facilities to include infectious disease planning in their emergency preparedness programs,” he said in a memorandum issued in February 2019.
On March 10, just a day before the authorities announced New Mexico’s first positive COVID-19 case, Kate Brennan listened to sports radio on her way to work at the AHC of Albuquerque, located in an industrial and business district. The facility’s most senior physical therapist, he listens anxiously to news about the spread of coronavirus.
He stopped in the parking lot at the same time as Edwardo Rivera, the top administrator. What will they do to protect patients and staff from the COVID-19 outbreak, he asked.
“Katie, it’s nothing more than a cold. It’s not a big problem,” he said.
Rivera said he couldn’t remember making a statement like that. But on March 13, CMS issued a new COVID-19 size for nursing homes nationally. The agency recommends screening people and staff for symptoms of fever and breathing, limiting “all visitors, effective immediately,” except for end of life visits, and canceling all group activities and eating together.
The steps seemed to surprise Rivera and his management team. Their response over the next few weeks is confused and uncertain, said family members of employees and patients.
On March 15, the Albuquerque AHC announced the cessation of family visits. Staff and contractors are inspected at the facility’s door for fever. But group therapy at the gym did not stop immediately, according to former employees who were there at the time. Patients are given the choice to eat in their own room, according to the employee’s cellphone text, but food in the dining room facilities continues.
Brennan was increasingly worried that the AHC was not sufficiently prepared. Apart from CMS regulations, Brennan and several others said they had never received any training on how to deal with epidemics.
“We never talked about COVID-19 training, I know that. Never. Never, “said Brennan.
Nurse Carole J. Welch agreed, as did two other AHC employees of Albuquerque who were interviewed on the condition that they remain anonymous. Fire training is the only disaster planning and training that Welch and Brennan are aware of, they said.
“Nothing has ever been mentioned about COVID-19,” Welch said. “At a meeting of all staff, everyone signed an entry sheet. If state inspectors have asked them to document in-service training or entry sheets for COVID-19 training, unless they are making it up, nothing. “
Welch and Brennan also have not participated in community training or training in recent years other than fire training.
Rivera said several COVID-19 training sessions had been held since early January. Asked whether the AHC Albuquerque had conducted staff training to prepare for a pandemic – explaining how coronaviruses could be transmitted and what precautions were needed to avoid its spread – Rivera said they had conducted such training “for the time being,” claims were strongly rejected by staff.
In March, the New Mexico Department of Health sent inspectors to the AHC Albuquerque as part of a statewide effort to review the facility’s emergency response plan in anticipation of a coronavirus pandemic. There are no shortcomings noted in planning or training. Ministry of Health officials did not answer questions about whether inspectors specifically examined the pandemic response section of the facility’s emergency plan.
But Rivera acknowledged that the AHC did not have a pandemic response plan, as required by federal regulations, only a more general disaster response plan. He noted he has not coordinated with local health officials to plan or drill epidemics to identify potential problems.
“We don’t coordinate much when it comes to epidemics with this mode [state] Ministry of Health, “Rivera said. “They did review all of our policy procedures and emergency preparedness plans and everything was checked and OKEd. But there was never any official training with the Department of Health.”
When asked directly whether the AHC Albuquerque has a generic contingency plan and not a specific plan for pandemic needs (such as infection control and PPE supplies), Rivera said: “Right.”
For Brennan, Rivera’s attitude was too weak for the situation faced by patients and residents of the facility. He believes that the lack of guidance puts him and his patients at risk.
Brennan said he would not work with patients without an appropriate PPE and announced he was taking personal leave on March 16. He was fired. Welch asked to be changed from full time to a nurse on duty on April 5 because of the same concerns as Brennan. He later learned that he too had been fired.
“I think in 2 weeks we will see a lot of things happen … and maybe our standards will rise … or not have to,” Brennan texted the supervisor. “But in the meantime, I feel we must do more, become more.”
Rivera declined to comment on personnel matters.
“Cost of human life”
AHC Albuquerque’s failure to make a pandemic plan is not unique among nursing homes. A 2018 report by Democratic staff from the US Senate Finance Committee concluded that nursing homes are still not ready even for more general emergencies such as hurricanes.
While some houses have devoted a lot of energy to protecting their inhabitants from disasters, many facilities do the least, according to David Grabowski, a health care policy professor at Harvard Medical School.
“I don’t think it was ever the main focus area,” Grabowski said, “somewhat because CMS didn’t force this and actually raised their feet to the fire.”
Inspectors who verify whether the nursing home meets emergency preparedness standards should read the plan to ensure it is updated and “covers potential hazards.” They must also confirm that the nursing home has trained its employees in contingency plans and made sure that the facility has made preparations to communicate and delegate authority in a crisis.
The most frequently cited problem for nursing home emergency preparedness is failing to retrain their plans in community training, usually organized by local emergency management or hospital-led health care coalitions.
Because inspectors are tasked with identifying immediate hazards, they may lack focus on researching contingency plans, said Eric Carlson, directing Justice in Aging lawyers, who advocate for elderly seniors who are poor.
In 2019 and 2020, inspector general HHS found that inspectors in at least five states – California, New York, Florida, Texas and Missouri – do not fully oversee the new emergency preparedness rules. CMS said it would expand its oversight of state enforcement.
Another indication of underenforcement is how much violations vary across the country. Advocates and experts say variations are more likely to reflect different state inspection priorities than how many facilities are actually carried out.
California has one of the highest citation rates, with inspectors finding more than three violations of emergency preparedness per facility since November 2017, according to the analysis. At least 56 facilities have been cited for failing to plan potential pandemics.
New Mexico cites nursing homes for lack of emergency preparedness at almost the same level, but it is impossible to say how much of these deficiencies is specifically related to failure to plan to deal with new infectious diseases. At present, nursing homes account for 31% of all COVID-19 deaths in New Mexico.
Quotation rates in New York, where more than 5,800 residents of nursing homes die with confirmed or suspected infections, are much lower, about one deficiency per nursing home.
North Carolina noted some shortcomings. Although the country has more than 400 nursing homes, its inspectors only issued 44 emergency preparedness quotes for 40 facilities, none of which were associated with the failure of nursing homes to prepare for an epidemic.
Despite these seemingly clean records, the North Carolina nursing home has been damaged by COVID-19. Nursing home residents make up more than half of the country’s deaths. About 20% of facilities experience an outbreak, and some cannot stop the spread of the virus before almost every population is infected.
At Louisburg Healthcare and Rehabilitation, all but five of 61 facility occupants contracted the virus and 19 died. Despite federal directives to coordinate with local emergency managers, nursing homes did not submit their plans for review.
Jeff Bright, emergency manager of Franklin County, where the nursing home is located, said the first time he spoke with the facility administrator was after the outbreak began. “The initial conversation was, ‘Oh my God, we are overwhelmed,'” he said.
In a statement, the nursing home management company, Liberty Healthcare, acknowledged that local emergency officials had not yet reviewed the facility’s emergency plans. But the company said the plan contained a section on influenza pandemic responses that had proven helpful. The state inspector has reviewed the nursing home emergency plan three times since new rules were put in place, the company noted, and each time the facility was found to be appropriate.
Regulators must do more to ensure that nursing homes and local emergency officials work together, advocates say.
“Facilities should be better equipped for this,” Melanie McNeil, Georgia’s long-term care ombudsman, said. “The cost of human lives. That is the cost of not being prepared. We know that people who are cared for in the long run are vulnerable. “
The plague began
Brennan’s worries were proven to occur on April 3 – the 13th day at the AHC Albuquerque for elderly Navajo patients in Room 222.
That day, the man coughed in the dining room and therapy gym, according to the former employee at this time. The next day, on Saturday, he was still coughing and feverish, so the staff quarantined him in his room and gave a nasal swab for the COVID-19 test.
News of the positive test results came the next day, April 5 – Palm Sunday. He was the first person known to be infected at the facility.
That morning, the director of nursing facilities told staff to assign only one certified nurse assistant, or CNA, to enter a patient’s room, Welch said. But CNAs working in Room 222 were not told to avoid contact with other patients to avoid the risk of spreading coronavirus, according to Welch. Some people who attended CNA were later diagnosed with COVID-19.
Rivera said CNA took the necessary precautions, including the use of personal protective equipment. But employees present at the facility on April 5 said CNA was wearing a surgical mask, not one of the more protective N95 masks.
Rivera acknowledged that staff might play a role in spreading the virus in mid-April.
“I would say it was not immediately” spread among residents by staff, Rivera said. “At that time, we had all our patients, remember, in isolation at that time, in their rooms.”
Between April 5 and May 8, 42 people – 18 patients and 24 staff – at AHC Albuquerque will be tested positive for the disease, according to the state Department of Health. Patients are sent home or to other nearby facilities such as The Watermark helping live centers and the Canyon Transition Rehabilitation Center, but only after negative testing twice, Rivera said.
Five residents were killed, including two men and two women in their 70s and 80s, and Roslyn K. Pulitzer, 90, a distant relative of the newspaper family who created the Pulitzer Prize, the highest journalistic honor in the country.
Pulitzer, a psychotherapist and fine art photographer, took his last breath holding Kay Lockridge’s unshaven hand, his 36-year-old colleague, at 8:45 am on Thursday, April 30, at the University of New Mexico Hospital’s intensive care unit.
“If we knew they had a case, Roz wouldn’t go there,” said Lockridge, a journalist. “I wish we knew.”
Outbreaks, pruning staff and doctors who do not work
The AHC from Albuquerque has a history of problems with infectious outbreaks, according to employees and state health department inspection reports 2009-2020.
There is a recurrent infection involving Clostridium difficile, commonly called C. diff, according to current AHC and former Albuquerque employees and state inspection reports. C. diff is a drug-resistant bacteria that causes diarrhea and potentially deadly inflammation of the intestine. Rivera said the facility did not have a C. diff case in 2020. He did not return calls related to previous outbreaks.
The recurring problem with C. diff is the red flag for infection control issues, said Dusti Harvey, an Albuquerque lawyer who previously worked for the Sun Healthcare Group, a long-term post-hospitalization nursing and post-rehabilitation company.
Federal regulations for nursing homes, including those for infection control, have existed since 1989, Harvey noted.
“This is something that nursing homes should be doing for the past 30 years,” Harvey said. “Nursing homes should be set for COVID-19 before that happens.”
The AHC from Albuquerque also lacked staff, according to the employee. Changes in billing for physical therapy have led to layoffs in September 2019. The facility has also begun accepting older, more fragile patients.
This situation is “the perfect storm for things to go awry with the introduction of COVID-19 into the facility,” Brennan said. “Lack of staff, lack of cohesion, lack of communication, lack of direction. They bring in more patients who are not fit for effective group therapy because of their many medical problems. “
Rivera stressed that changes to Medicare payments did not affect patient demographics and that staff placement was not a problem.
The last concern for some employees is Dr. Ralph S. Hansen, medical director of the facility and one of two designated infection control specialists. Neither Hansen nor the other designated specialist, a nurse, currently has any confidence in the management of infectious diseases, according to records from the American Medical Specialization Board and the New Mexico Nursing Council.
“Dr. Hansen has a background in infectious diseases,” Rivera said. But Hansen has not done staff training, he admitted.
Old workers and former workers described Hansen as “not working” and “disconnected.” Missed patient antibiotic doses and delayed lab results were not performed.
Hansen was fired by a medical group in California and then handed over his medical license in California after he allegedly stole another prescription sanitary napkin and Ritalin who was prescribed himself by his own name and fictitiously 326 times between 2004 and 2007, according to California Medical Board records. He was charged in 2007 with 15 counts of crimes of theft, forgery and obtaining substances controlled by fraud, records show. In a plea bargain in November 2007, he claimed to only get material controlled by fraud.
But the following year, he moved to New Mexico, where he issued a conditional medical license in March 2009 requiring monitored drug abuse treatment and a quarterly self-report on adherence to treatment, the board notes show. He went to work for the state prison in Los Lunas and the state Department of Health. In 2014, the New Mexico Medical Board granted Hansen unlimited medical licenses, according to records. He stopped working for the country in October 2015.
Hansen did not return calls and messages repeatedly.
On May 7, the COVID-19 outbreak in the Albuquerque AHC had peaked and was largely resolved, Rivera said. On Monday, May 11, the facility had only five patients who tested positive.
Rivera didn’t return the last phone call looking for the latest numbers.
At least two more people might be countless victims of the plague on the AHC Albuquerque.
After Rosemary Ortiz took Robert Potts to the hospital, he returned to his own home, the two-room casita where he had lived since he was a child.
The following week, Ortiz experienced a cough and shortness of breath. He immediately became dizzy and had a fever, with a terrible headache. Despite the small size of the house, he had difficulty walking to the front door.
Ortiz tested positive for corona virus.
“I am very sick, I think I will not see my children or my mother again,” he said. “I thought I would die.”
At home, Ortiz keeps his distance from his roommate, afraid of infecting him. But then he heard the woman cough.
His roommate also tested positive for coronavirus.
Reached by telephone, Ortiz stopped to catch his breath and announced that he had weeded his yard, stood back up. On Tuesday, May 26, he was still positive with coronavirus, even though he felt better.
Inside, Ortiz’s roommate is still sick and coughing.
“But I think he’s better,” Ortiz said.
Ortiz learned that Potts had been transferred to the Transitional Canyon facility for hospital treatment after several weeks at the Presbyterian hospital. Ortiz said Potts’ health had improved and he might be released to go home in a few weeks.
“I miss him. I really miss Mr. Potts,” he said.
Bryant Furlow is a reporter for New Mexico In Depth. Carli Brosseau is a reporter for The News & Observer of Raleigh, North Carolina. Isaac Arnsdorf is a reporter for ProPublica.
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