A national Coronavirus Commission on Safety and Quality in Nursing Homes has identified more than two dozen major flaws in the response of government and the nursing home industry to the covid-19 pandemic. However, the panel, created by the Trump Administration, was relatively passive in its recommendations for how to fix those shortcomings.
It feels a bit like reading the report of a physician who correctly diagnoses a very complicated disease for a non-compliant patient, but whose recommended treatment is not aggressive enough to cure the condition.
The panel created a valuable roadmap for ways to correct some of those shortcomings. Unfortunately, the political staff at the Centers for Medicare and Medicaid Services (CMS) that commissioned the report immediately attempted to recharacterize it as “a resounding vindication” of the Trump Administration’s own response to the pandemic.
If the Administration truly believes its actions to date have been a success and refuses to acknowledge shortcomings, it is hard to imagine it would be willing to adopt many of the recommendations. Yet, public relations spin won’t change an environment where as many as 76,000 residents and staff have died from the pandemic.
In many respects, the report is remarkable. The commission put together a 186-page report in just three months. It describes 27 broad ways, and 100 specific steps, that government and nursing facilities could take to reduce infections even as they recognize the need for residents to resume social contact with family members and each other.
The recommendations call for reform in several broad areas:
· Improved access to testing and personal protective equipment.
· Recognition of the need to balance infection control with quality of life of residents.
· More transparent communication with residents, their families, and the public.
· Better training and support for care workers.
· Recognition of the need to improve the physical infrastructure of many nursing homes.
· Better data-driven guidance for nursing home operators
· More funding.
The report does a good job identifying where government and the nursing homes industry failed to respond to the pandemic. But in too many cases, it relies on unenforceable federal guidance to achieve its goals, rather than a more robust mix of safety mandates and additional resources.
For instance, under current regulations, nursing homes are required to have only a part-time staffer responsible for infection control. Importantly, the report identifies this as one of the reasons why many facilities still struggle to manage the pandemic. But it does not urge CMS to mandate a full-time infection control officer for nursing facilities. Instead, it calls on the agency to identify resources facilities could use to hire such a staffer. The problem: These resources don’t exist.
PPE and testing, still
The panel was made up of 25 members, including industry, consumer, and workforce representatives, state officials, and academic experts. Building consensus among such a diverse group in such a short time probably was impossible. Only 13 members fully endorsed the report, 11 agreed but with reservations, and one— Eric Carlson of the advocacy group Justice in Aging—refused to endorse it.
In the short-term, the report urges the CMS to “assume a greater leadership role” in developing and executing a national strategy to improve access to rapid and accurate testing and personal protective equipment (PPE), enhance infection control staffing, and standardize data collection.
Perhaps more than any issue, the absence of testing and PPE has been responsible for the high number of cases and deaths in long-term care facilities. The panel is hardly the first group to call on the Administration to take the lead in addressing these gaps that have persisted for more than six months. Will it have any more impact?
In the longer-run, the commission urges major reforms in training and resources for staff as well as redesign of facilities to reduce the spread of infectious diseases. However, the commission stopped short of making more specific, but more controversial, recommendations such as increasing pay for direct care workers or restructuring the entire funding model for nursing homes.
Most disappointing, though not surprising, was the Administration’s response. It insisted the report validated steps it already has taken in response to pandemic, something the commission did not do, or even attempt to do. Commission member David Grabowksi, a professor of public health at Harvard, said on Twitter, “Purpose of report was to provide CMS with roadmap out of crisis, not evaluate federal response.” And, he adds, “Lots of work to do.”
Yes, there is. At this point. It seems unlikely that he Trump Administration will act on many of the commission’s recommendations. Perhaps the next Administration will.