Date: Monday, June 22, 2020 To: Jill Castellano, inewsource From: Debra Sheridan, IVY Marketing Group Contact: Debra Sheridan, 630-267-3900 Jon Cohn, Posinelli, 818-304-4025 RE: Responses to Questions about Avocado Post Acute Hi Jill: Thank you for your allowing us to additional time to prepare responses and your interest in sharing the ways that skilled nursing facilities are dealing with the COVID-19 crisis. It’s such a complicated and often misunderstood situation that primarily generates bad and scary media reports for healthcare facilities. The crisis is creating an enormous number of challenges, judgment calls, and ever-changing best practices and recommendations. The steadfast commitment of Avocado Post Acute is to provide the safest environment for what is an extremely fragile population. Since the crisis erupted early this year, Avocado has worked hard, following, and even exceeding recommendations and guidelines from the California Department of Public Health (CDPH), Centers for Disease Control (CDC), Center for Medicare and Medicaid Services (CMS) and infectious disease specialists. The term “unprecedented” is used so often these days, but it effectively captures the essence of this crisis. Because there’s not been anything comparative in the past to help us understand how the situation would evolve, there have been missteps, errors, and changing protocols. Jill, our sincere hope is that when you learn more about Avocado through the answers to your questions, you’ll recognize that much of what we were doing early on, has been upgraded dramatically as we’ve learned and understood more. We hope that you’ll note that we’ve turned a corner, and because of new management, enhanced protocols, private spending, and deep commitment, we are now considered to be a COVID-preferred facility by the County of San Diego Health and Human Services Agency. We are one of only four such facilities in the County. The status has been awarded to us due to the excellence demonstrated during an exhaustive in-facility survey, by County and State inspection, and by our near eradication of new disease transmission within the facility. We were deficiency-free in our COVID survey last month. We know that you have an extremely prestigious reputation and pride yourself on your unbiased and comprehensive reporting. We are thus pleased to share with you the progress we’ve made in the hope that you’ll share this important aspect of the Avocado Post Acute story. Please review the attached information. If we can be of further assistance to you, please let us know. 1. As you know, elderly people with underlying conditions are at a high risk of developing serious complications from COVID -19. When did Avocado Post Acute first start putting measures in place to protect patients from the possibility of contracting it? Avocado Post Acute experienced its first case of COVID-19 in early April. A resident of the community with serious underlying health conditions was taken to the hospital, where she tested positive for the infection. Unfortunately, she passed away in the hospital. We promptly started voluntarily testing with an outside lab. At the beginning of this pandemic, we were hampered by realities including limited understanding of COVID-19 and the scarcity of tests and PPE. These were critical factors in allowing the disease to go unchecked for days without any confirmatory testing ability. This has changed dramatically. As we’ve learned more about the infection, we’ve increasingly and aggressively instituted protocols to keep our residents as well as our staff, safe. The backbone of our successful strategy over the past months has been tied to the aggressive pursuit of rapid testing, far superseding county and state requirements. In addition to required protocols, we are taking additional measures in the interest of patient and staff safety. Given the opportunity and information necessary for success, we are outspending and outworking the virus. We have instituted the following initiatives, some of which go well above recommended guidelines. ● Aggressive testing Beginning in April, we have aggressively pursued and secured 24-hour testing for residents and staff. We were among the first communities to (voluntarily) begin testing. This, of course, drives our case numbers higher, but more importantly, it helps us to identify and then segregate people immediately to prevent further spread. Some facilities have delayed testing in order to protect their reputations. Baseline testing was only mandated in early June, and completion isn’t required until June 30th. By that time, Avocado will already be on its fourth round of testing the entire facility. By early testing, we risked our reputation in the interest of being proactive in securing our residents. ● Screening Staff and essential visitors are all screened upon entering the building for their shift. At that time, temperatures are taken, and health-related questions are answered. ● Visitors We started prohibiting outside visitors to Avocado Post Acute in early March. While it is difficult for residents not to have face-to-face contact with their families and friends, it’s important for limiting exposure to the virus on-site. We help coordinate window visits, and our social services staff helps residents to stay in touch virtually with their loved ones via phone calls and technology. ● Cohorting We began cohorting in April after our the first COVID-19 positive patient was diagnosed. Working closely with the CDPH, we have instituted aggressive cohorting of patients, segregating them into four unique strata. Because we are a large building, we are able to accommodate the four segments that are segregated from each other in separate wings and divided by double doors. All staff enter the building directly in their assigned wing and remain working exclusively in that area to limit exposure throughout the building. The segments are: o COVID-positive o COVID-negative o Transition-This includes patients/residents being admitted from the outside (i.e. hospital). They are quarantined for 14days. o People Under Investigation (PUI)-Individuals exhibiting possible symptoms of COVID-19 and awaiting test results. Roommates of residents exhibiting symptoms are also placed in the PUI section. This segment is not in recommended guidelines and is thus, another added layer of complexity and caution beyond government regulations. ● Contact Tracing We have instituted aggressive contact tracing. Any individual with COVID symptoms has a 24-hour test. Everyone that person has come in contact with is tested, triggering a secondary round of patient and staff testing to cast a wider net. It’s layers upon layers upon layers. If there’s any question at all of positivity, it triggers subsequent rounds of testing. This is completely voluntary. ● COVID-Preferred Facility We have been designated a COVID preferred facility by the County of San Diego Health and Human Services Agency. ● Human Resources Initiatives Some of our most pronounced protective measures focus on our staff. A number of these measures have not been adopted by other surrounding facilities. We do this out of an abundance of care and concern. o We test, screen, and segregate staff (see above) o We encourage staff to self-report symptoms and illness o We provide extra 2-weeks paid sick leave for staff who are COVIDpositive. This 2-weeks is in addition to their PTO and their sick bank. While this potentially costs a great deal of money, we do this to encourage early and aggressive reporting of symptoms. o We have provided bonus pay to hourly employees for the general staff, and a larger increase for those working directly with COVIDpositive patients o We provide a hero award for staff who become COVID-positive o Initially, there was a serious PPE shortage nationwide. Our management worked aggressively to find and secure appropriate PPE for our entire staff in order to ensure that they, and as a result our residents, are well protected o We hold in-services for our staff, emphasizing hygiene, donning and doffing PPE, and more o We have a drive-thru testing option for employees, at our own facility, who are experiencing symptoms while not on shift. We encourage them to come immediately for a 24-hour test. This helps us to know where we’re headed and helps us to be able to quickly react in order to eradicate the disease through aggressive early contact tracing. 2. State data shows that Avocado has had 100 patients with cases of COVID-19 and 13 deaths. How many of those were people who, to your knowledge, did not have COVID19 when they were admitted but developed it while at the nursing home? There have been 110 residents and 40 employees who have tested positive for COVID-19 and 16 deaths. While these numbers are very sad and unfortunate, they are accurate. It’s important to understand the following contributing factors: o One of the reasons our number of diagnosed cases is high is because we started testing early on. There are facilities that have still not reported testing. o We are a very large facility, with 256 beds. o Many of those who have tested positive have mild, If any symptoms o We accept patients who are extremely ill and/or on hospice. This makes our population extremely frail. o We have a secure unit for individuals with advanced cognitive issues and/or dementia. This makes it especially challenging to enforce social distancing and hygiene for these individuals. While we have enhanced protocols for this unit, it is especially challenging. o We have been COVID-free since June 2. This is with the exception of COVIDpositive residents who have been treated and released to us from the hospital because we are a COVID-preferred facility, designated by the County of San Diego Health and Human Services Agency. Those individuals are quarantined for 14 days. They are sent to Avocado as we have become a COVID-preferred facility. o Importantly, we have had many positive cases logged via online tools. These are the direct result of our willingness to admit outside COVID-19 patients requiring rehabilitation. While they did not contract the disease on our site, we have offered to care for them as a service to our community. The reporting deceptively elevates the number of cases reported online. 3. To your knowledge, when was the first time a COVID-19 positive individual was residing in your nursing home? What was done to keep that individual isolated and away from others and prevent other residents from contracting the virus? Please see answer to #1 4. Why do you think some residents at Avocado have developed COVID-19 while at the facility? As indicated above, there are three significant factors regarding our number of cases of COVID-19. One is the fact that we have been testing thoroughly and continuously for months, as early as possible. Many of the positive cases are, in fact, mild or asymptomatic. Additionally, we have a population that is especially frail. Furthermore, we are a very large facility with a greater number of patients than most others. Lastly, and most importantly, testing was not available to us in the early stages of disease. It is incredibly challenging to maintain resident health, when operating ‘in the dark’ with regards to disease status. It’s important to note that because of the changes and protocols we’ve instituted, we have been COVID-free except for COVID-positive patients who have been treated and released from a hospital and that we accept as a . Those individuals are quarantined for 14-days after admission. We are able to accept those patients because we are a COVID-preferred facility. We have been deficiency-free in our most recent COVID-19 surveys. 5. Are you allowing visitors? No, visitors have been prohibited since early March. 6. Do you feel you have adequate protective equipment and staff to care for COVID-19 patients and prevent the virus from spreading in the facility? We are very fortunate in that our management has aggressively secured appropriate PPE gear for our staff. We have secured washable gowns, gloves, and N95 masks. 7. Can you please provide a copy of your mitigation plan that nursing homes were required to send to the state describing how you are tackling COVID-19? This will be made available pending public distribution approval from CDPH. 8. How is Avocado keeping residents' families up to date on the number of COVID-19 cases in the nursing home? Are you alerting them when additional cases arise? COVID-19 updates are posted regularly on our website. Additionally, our administrator sends emails to family members as often as possible, with updates, as well as information about programs, activities, COVID-testing efforts, etc. 9. State data shows that 38 of your staff members have been diagnosed with COVID-19. What has Avocado done to protect staff? Are the same staff members caring for patients with COVID-19 and other patients without COVID-19, or are there separate staff members for these groups? Please see above. Additionally, we understand that some of our staff members work at multiple skilled care communities. Consequently, they may be more susceptible to bringing COVID into Avocado. In addition to us screening each staff member before entering for every shift and segregating staff into specific cohorted units (see above), we also test every staff person weekly. One more important factor about which we’d like for you to be aware, is the status of capital improvements in which the owners are investing during this time. We are in the process of improving outdoor living areas. As a large facility, we have four outdoor patio areas that we are renovating so that when families are again allowed to visit, they’ll be comfortable. We have also invested in equipment for enhanced infection control. State-of-the-art fogging machines help to kill the virus on contact, sanitizing rooms quickly and effectively. We are spending money supporting local vendors and seamstresses for PPE and purchasing abundant hand sanitizing dispensers for patient rooms and common areas. While many facilities are using County-provided testing equipment, we are spending extra money contracting with labs guaranteeing prompt results. **10-15. Please see the attached addendum Please note, as you’re reviewing this information, that we have instituted change in management as well as policies and procedures and in doing so have greatly improved our quality of service. We are thankful to Jon Cohn and his legal staff at Polsinelli for preparing the answers to questions 10-15 to meet your deadline. Should you require additional information, he can be contacted at 818-304-4025 or at JCohn@Polsinelli.com. . 10. As a part of this story, inewsource has been looking into the inspection/enforcement history of San Diego's nursing homes. The Center for Medicare Services' website shows Avocado has received 34 citations in the past 3 years, as well as 8 inspections resulting from complaints, and a $14,400 fine paid on 1/23/19. Some of the citations include: failing to provide proper pressure ulcer care for 8 patients, failing to properly administer medications, failing to keep physicians and family members informed of patients' medication and care needs, having a medication error rate of 8.57 percent and failing to report incidents of abuse or potential abuse to the state (including an incident where a nursing assistant closed and held a door in place, confining a resident to their room). On the state level, the California Department of Public Health website shows Avocado has 36 reported incidents/complaints this year already compared to the state average of 6 and last year, it had a total of 161 complaints/incidents compared to the state average of 4. There have been 93 substantiated complaints of abuse against Avocado in the past four years by the state. Should residents or potential residents be concerned about this history at the facility? Do you think these repeated citations indicate that the facility may not be well equipped to protect residents and staff from COVID-19? Skilled Nursing Facilities, such as Avocado Post Acute (“Avocado”), are highly regulated at both the state (the California Department of Public Health, “CDPH”) and federal level (the Centers for Medicare and Medicaid Services, “CMS”). The survey process is very subjective. As a result, Avocado has successfully disputed many of the alleged deficiencies and citations, reducing the level or wholly rescinding of the alleged deficiencies. Avocado has proactively taken steps to respond to all complaints, concerns, and allegations in order to eliminate future incidents. 11. CMS data also shows your facility has a higher rate of resident hospitalizations, ER visits, pressure ulcers and use of antipsychotic medications than the average Skilled Nursing Facility. What do you think the reasoning is for these high numbers? Avocado is a large 256-bed Skilled Nursing Facility that accepts high acuity patients with multiple comorbidities, including patients to its sub-acute unit. Avocado’s sub-acute unit provides intensive care to patients that are medically fragile and require special services, such as inhalation therapy, tracheotomy care, intravenous tube feeding, or complex wound management. The CMS data only reports numbers and does not account for resident acuity, clinical complications, comorbidities, or residents in the sub-acute unit. Avocado assesses each resident upon admission, develops a plan of care in accordance with the resident’s needs and physician orders, and provides residents with all necessary care and services. With regard to antipsychotic medications, Avocado staff does not prescribe medications. Rather, Avocado administers medications, including antipsychotics, as prescribed by the resident’s physician. Avocado also implements non-pharmacological interventions to address the underlying clinical condition, but when an antipsychotic is ordered the medication is administered according to the physician’s order. 12. Avocado Post Acute was also cited by CMS multiple times for failing to ensure residents were kept inside of a semi-secure unit. In at least one case, a resident who eloped was found injured. In another, a resident eloped 14 times. A third resident with neurological deficiencies wandered the community unsupervised for 3 days. Why wasn't the facility properly secured and what was done to address this? Even in Avocado’s secured unit, resident rights must be respected. Under federal regulations, 42 C.F.R. § 483.10(e), residents have the right to be free from restraints. Residents also have the right to go out on pass and reside in a “homelike” environment. 42 C.F.R. § 483.10(i). If a resident is an elopement risk, their right to be free from restraint and to reside in a homelike setting must be balanced with clinical need. 13. Avocado Post Acute was also cited by CMS on February 20 for failing to create action plans in response to prior citations that would have prevented similar problems from happening in the future. Why didn't your facility create these plans? Wouldn't they have helped ensure residents were receiving proper care? Avocado was not cited for a failure to create or implement “action plans.” Avocado properly assessed this resident as an elopement risk and, as a result, appropriately developed and implemented a care plan to address wandering behavior. One intervention included a Wander Guard bracelet, as ordered by the physician. Avocado does not physically restrain residents because the facility is their home. In fact, CMS data reflects that Avocado had 0% of residents who were restrained.1 14. Avocado has been fined more than $20,000 by the state, including a $15,000 administrative penalty in 2019 for not meeting the minimum requirement of 3.2 nursing hours per patient day, not replacing staff who didn’t show up to work, and not documenting accurate payroll and personnel records. Avocado also received a citation in June 2019 for failing to do a health exam of staff. Nursing home advocates have repeatedly said that staffing is key to successfully quelling the spread of the virus. 1 https://www.medicare.gov/nursinghomecompare/profile.html#profTab=4&ID=555076&Distn=9708.2&state=CA& lat=0&lng=0&name=AVOCADO%20POST%20ACUTE. Has Avocado put enough resources and attention into staffing over the years to ensure proper patient care? The Administrative Penalty issued in April 2019 related to allegations of insufficient staffing in 2017. In a business decision, Avocado elected not appeal this Administrative Penalty to avoid the costs associated with litigation. Instead, Avocado used its resources to ensure there were no future allegations related to insufficient staffing. There have been no citations issued to Avocado related to insufficient staffing since the 2017 allegations and Avocado ensures staffing ratios are met to meet resident needs. 15. Eldorado Care Center has been sued 30 times since 2006. In a 2020 medical malpractice lawsuit, the family of a former resident said she lost 60 pounds under Avocado's care, unnecessarily developed ulcers and sepsis and died because of the facility's negligence. How does Avocado respond to these allegations? Avocado has no comment on pending litigation.