C A N H R Long Term Care Justice and Advocacy CALIFORNIA ADVOCATES FOR NURSING HOME REFORM 650 Harrison Street, 2nd Floor • San Francisco California 94107 • (800) 474 - 1116 • www.canhr.org • canhrmail@canhr.org Who’s Fault Is It - Are Nursing Homes to Blame for Their COVID Outbreaks? Published September 8th, 2020 As nursing homes across the country continue to be overrun with coronavirus outbreaks and the number of residents killed by COVID-19 continues to rise, a dispute has emerged over assigning blame. The nursing home industry, unsurprisingly, has been pushing a narrative that nursing homes are “victims” of coronavirus and blameless for the outbreaks in their buildings. In this version of events, the track records of nursing homes and the efforts of facility operators and staff are irrelevant to preventing outbreaks and limiting spread. Here is a good example of the industry’s story: It wasn’t a matter of bad operators getting COVID-19 and good operators not getting it. The facts indicate that your Five-Star rating, profit vs. not for profit status, or prior deficiency history are not predictors of whether COVID gets in your buildings. The most important factor in determining whether COVID-19 ends up in a building is the surrounding community of where the building is located. (American Health Care Association, Message from the President and CEO Mark Parkinson “We Won’t Back Down”; June 2020.) In spreading this narrative, nursing homes have relied on a study that found a correlation between community outbreaks and nearby nursing homes with COVID-19. That makes sense: the more virus present in the community, the more likely it is that a staff person catches it and brings it with them into the building. The problem with the industry narrative is that it conflates COVID “incidence” (having one case of COVID-19 in a facility) with COVID “extent” (the size of the outbreak within a facility, once it had a case). While incidence is very likely associated with community outbreaks, it is after the virus has entered a nursing home when the differences in quality of care among facilities will matter. Good and bad facilities both have COVID outbreaks; but extensive COVID spread is much more likely to occur in bad facilities. Studies that have closely examined the extent of outbreaks, in addition to incidence, have concluded that quality of care in a nursing home does matter; in fact, it matters quite a bit. One study identified three factors associated with increased risk of COVID-19 in nursing homes: higher numbers of past health deficiencies, larger facilities with more residents, and lower federal 5-star ratings. (Harrington, et al., “Nursing Staffing and Coronavirus Infections in California Nursing Homes) The strongest relationship, however, was registered nurse (RN) staffing. Nursing homes with .75 hours of RN staffing per resident per day were half as likely to have a COVID-19 outbreak. A second study looked at COVID-19 outbreaks and deaths from COVID-19 and found a significant association between the extent of outbreaks and four factors: 5-star ratings, the concentration of residents on Medicaid, the concentration of racial and ethnic minority residents, and RN staffing. (Li, et al., “COVID-19 Infections and Deaths Among Connecticut Nursing Home Residents: Facility Correlates”) RN staffing was also strongly associated with the number of COVID-19 deaths in facilities: every 20 minute increase in RN staffing predicted a 26% reduction in deaths. The study’s authors concluded that facilities with better care standards compliance are better able to contain the spread of coronavirus. The studies’ findings are entirely logical: the incidence of outbreaks is somewhat random while the extent of outbreaks is tied to facility performance. For incidence of outbreaks (whether coronavirus enters the building), preventative measures such as screening, testing, and limiting COVID exposure of the staff are important but not foolproof. The best facilities can experience an outbreak. Once an outbreak has occurred, quality of care matters a great deal. The training and habits of the staff related to infection control, the widespread use of PPE, and the quantity of staff to meet the needs of the residents is crucial to limiting spread. Good facilities implement vigilant testing and cohorting programs to identify and segregate positive staff and residents. RN staffing in particular is strongly associated with fewer cases and deaths because RNs are the infection control leaders in nursing homes. Ample RN staffing is a traditional hallmark of good nursing homes. Poor nursing homes cut RN hours to increase profit at the expense of quality of care. COVID-19 has placed an unprecedented strain on nursing homes throughout the country and has amplified the consequences of their significant variation in quality of care. Facilities with a history of good performance and adequate staffing have weathered the COVID storm and kept more of their residents safe and alive than facilities with a history of poor performance and inadequate staffing. Quality matters now more than ever and no amount of wishful thinking from the nursing home industry will change that. Think Quality Doesn’t Matter? Look at California. CANHR’s review of the 25 worst nursing home outbreaks in California bears out the close relationship between quality of care and COVID infections and deaths in nursing homes. These 25 nursing homes have had an average of 118 infected residents and at least 372 deaths as of July 30. They have an average CMS 5-star rating of 1.68, which is less than half the state average of 3.5, and were cited for an average of 2.48 infection control violations from 2017-2019, which is 34% higher than the state average of 1.85. Staffing in the facilities with the worst outbreaks was predictably worse than the state averages with 7% less direct care staffing and a whopping 39% less RN staffing. These numbers show that COVID outbreaks are worse in facilities with poor track records and less staffing. Quality and quantity of care matter! 2 25 Worst CA Outbreaks Analyzed Facility GLENDORA GRAND, INC. BEL TOOREN VILLA CONVALESCENT HOSPITAL COUNTRY VILLA SOUTH CONVALESCENT CENTER TERRACINA POST ACUTE ANAHEIM HEALTHCARE CENTER, LLC REDWOOD SPRINGS HEALTHCARE CENTER REO VISTA HEALTHCARE CENTER DYCORA TRANSITIONAL HEALTH - FRESNO THE HILLS POST ACUTE ALDEN TERRACE CONVALESCENT HOSPITAL TARZANA HEALTH AND REHABILITATION CENTER LAKEWOOD HEALTHCARE CENTER TURLOCK NURSING AND REHABILITATION CENTER # Cumulative Resident COVID Cases (7/30/2020) 5-Star Rating Infection Control Deficiencies 2017-2019 215 1 2 205 1 171 RN Staffing HPPD (4Q 2019) Resident Deaths (7/30/2020) 3.8 0.3 <11 3 3.8 0.2 11 1 3 3.7 0.3 20 135 0 3 3.3 0.1 <11 127 3 2 4.1 0.2 15 125 1 1 3.2 0 29 118 5 1 3.9 0.3 16 117 1 2 3.5 0.3 33 108 2 4 3.6 0.3 <11 107 3 2 3.6 0.2 24 107 1 5 3.8 0.2 15 105 2 3 4.2 0.2 <11 105 3 2 3.6 0.3 23 3 Care Staff HPPD (4Q 2019) KINGSTON HEALTHCARE CENTER, LLC COLONIAL CARE CENTER RIALTO POST ACUTE CENTER AVOCADO POST ACUTE MILLBRAE SKILLED CARE FOUR SEASONS HEALTHCARE & WELLNESS CENTER, LP COUNTRY VILLA EAST NURSING CENTER DOWNEY COMMUNITY HEALTH CENTER SEAL BEACH HEALTH AND REHABILITATION CENTER WINDSOR VALLEJO NURSING & REHABILITATION CENTER INTERCOMMUNITY CARE CENTER KEI-AI LOS ANGELES HEALTHCARE CENTER 104 0 3 3.6 0.2 19 103 1 3 4 0.4 14 103 1 1 4 0.2 <11 103 1 1 4.2 0.6 15 103 2 3 2.3 0.3 17 101 1 3 3.5 0.3 16 100 4 3 3.7 0.3 18 99 1 2 3.7 0.2 14 98 2 3 3.4 0.2 23 98 2 2 3.8 0.5 11 97 0 3 3.2 0.2 <11 97 3 2 3.7 0.3 33 Total Average State Average 2951 118 n/a 42 1.68 3.5 62 2.48 1.85 91.2 3.65 3.94 6.6 0.26 0.43 52% -34% 7% 39% CalHealthFind database CMS QCOR database LTCCC % below average Sources state CDPH COVID-19 Dashboard 4 LTCCC