Category: Mike’s Column

Celebrating the holidays with family and residents will be vastly different this year. Facilities are attempting to make the holidays a celebration despite the “no visitor” policy. DSS released a provider information notice or PIN about its position on holiday gatherings in light of COVID-19 (C-19).

          Residents in long-term facilities are at higher risk of severe illness or death from C-19 because of chronic medical conditions. Facility staff are strongly urged not to attend any gatherings or keep gathering to immediate family only. DSS is advising administrators to inform residents’ family members to not take the resident home, to not subject them to others, to participate in the effort to “flatten the curve.” It wants residents and families to consider the number and rate of C-19 cases in the community where any gathering will take place. DSS states gatherings with attendees who are traveling from different places pose a higher risk than gatherings with attendees who live in the same area.

          For residents returning from any outing must screen returning residents for signs and symptoms of C-19, and immediately test symptomatic residents and isolate them in a single room pending test results. Ask each resident or family member if they were in contact with someone who tested positive for C-19 or did not take any precautionary measures (physical distancing, wearing a face covering, or engaging in exposure-type activities.

          DSS’ guidance continued with stating outdoor gatherings are safer than indoor gatherings. If gathering indoors, increase fresh air circulation by opening windows or doors, as much as possible, especially in rooms where people are gathering. A gathering of no more than three households is permitted in a public park or other outdoor space. Gatherings are defined as “social situations that bring together people from different households at the same time in a single space or place.” Gatherings should be two hours or less. DSS does not want people in gatherings to sing, chant, shout, cheer, engage in physical exertion, or any other activity that increases the release of respiratory droplets and fine aerosols into the air.

          Licensees are encouraged to distribute the COVID-19 Safety Tips for Gatherings (a flier produced by DSS [attached]) to residents, facility staff, families, and friends, and post the flier in a public area near the facility entrance. When gathering away from the facility, licensees, facility staff, and residents should stay at home if sick, maintain at least six feet of physical distancing, wear face coverings, wash hands often, limit the number of people handling or serving food, limit contact with surfaces and shared items then disinfect those surfaces and items, and limit mixing different household attendees.

          Facilities may hold communal activities and dining while adhering to C-19 infection prevention practices: residents may eat in the same room with physical distancing and consider additional limitations based on status of C-19 infections in the facility. Face coverings should be worn by residents going to and from the dining area and whenever not eating or drinking. Group activities may also be facilitated with physical distancing among residents, appropriate hand hygiene, and use of face coverings. Encourage as many of these activities to occur outdoors when feasible, but communal holiday activities and dining may not include visitors.

The Department of Social Services’ (DSS) has at least 40 PINs or provider information notices about Covid-19, some with good and useful information, and some with difficult direction. Local licensing offices want facilities to follow these PINs, update the first Covid-19 plan of operation, and now update facility emergency plans with a new, detailed Covid-19 plans of operation. One barrier, as DSS recently stated, the entire situation is “fluid,” subject to successive PINs updating previously issued PINs, changing “requirements,” and mandating a constant updating of facility procedures.

It would have been ideal if DSS had created a clear “here’s what we want” PIN, instead of successive PINs overturning previously issued PINs, amending previously issued PINs, and then present newly created requirements easily found and deciphered. Yet, credit to DSS’ Pamela Dickfoss (retiring at the end of November) in trying to keep facilities informed.

Most, if not all, PINs referenced other resources to follow or review: California Department of Public Health (CDPH), Center for Disease Control (CDC), and DSS. Also, each PIN directed facilities to comply with the “stricter provisions” without telling facilities which entity had the stricter provisions. Several PINs advised following CDC guidelines, but did not include those guidelines, and CDPH frequently required facilities to follow skilled nursing provisions making “social model facilities” compliance too complicated and difficult.

Is the Everbridge survey process a requirement? One PIN said facilities are “strongly encouraged” to complete the survey and return, whereas another PIN used the words “facilities should.” Technically, these are not legally required, but if it helps with tracking C-19 cases, do the surveys.

Facilities may be forced to pay for C-19 testing which went from testing “10% of staff every 14 days” to “25% of staff every 7 days.” Right now, a facility is not compelled to pay for testing, and testing is “free,” through public health sources, i.e. the county.

PIN 20-34-ASC addressed flu prevention including having staff and residents receive flu shots. It quoted the CDCs definition of what an epidemic outbreak is: “2 or more residents with onset of flu-like illness within 72 hours of each other.” Such an outbreak is a DSS-reportable event. Flu and C-19 is not a good combination for the industry.

For an easy and affordable C-19 addendum, go to Products and Services on our website. It’s just $9.99!! We also have our basic C-19 plan at the same site, and it’s free!

What are your plans if families cannot visit your residents during the fast-approaching holidays? What will you say to your residents and their families about visiting, enjoying, and celebrating family-time holidays?

          A recently released study found a high amount of deaths have occurred among dementia residents that was attributed to “shelter-in-place” orders and residents prevented from seeing their families. The “excess mortality,” the study stated, was directly tied to residents’ “isolation and loneliness.” The rate, compared to previous years, increased 900%. Also reported were increases in resident falls, pulmonary infections, and depression.

          A researcher from the University of Pennsylvania gave his perspective: “The loss of interaction and caregiving that residents’ families provide to…residents is significant,” said Jason Karlawish, M.D. “If you think of Alzheimer’s as a disability, family members are almost like a cognitive wheelchair for patients who have lost part of their mind. They (family members) are essential. Social and mental stimulation are among the few tools that can slow the march of dementia.”

          Criticism is mounting against city, county, and state governments about opening universities, bowling alleys and malls, but keeping care facilities closed.

          Providers are begging for state and federal relief from having to purchase protective personal equipment (PPE) that has skyrocketed in price, up as high as 386%, and a halt to mandatory Covid-19 testing for staff and patients. The testing is costing facilities up to $15,000 a week. Then, in the midst of escalating costs, advocacy groups are pushing to increase minimum wage to healthcare works to a “livable wage” meaning providers should increase wages to staff as much as 15.5% claiming the industry would “greatly benefit.” That increase could be as much as $1.55 more per hour.

          Hey, advocacy groups, who ends up paying for that wage hike? Who are you advocating for—the residents, the staff, or providers? (Now you may see why staff opted to remain on unemployment rather than work.)

          PPEs, testing, and higher wages hurt the providers and residents. “Someone must pay for all of it.” That someone is the resident, of course.

          What is the maximum a resident and his or her family, not willing to pay, but able to pay? With the rising costs…that someone who must pay is the resident.

Half of assisted living providers are operating at a loss, and 64% say they will not be able to sustain operations for another year, according to survey results released in August by the National Center for Assisted Living. In the poll, assisted living providers shared they are facing a financial crisis like that experienced by nursing homes as their COVID-19 response has significantly increased costs while also affecting revenue streams.

One of our students said he would be better off if minimum wage had not taken effect in July 2020 for Los Angeles County, which increased to $15.00/hour for employers with 26 or more employees and to $14.25/hour for employers with 25 or less employees (a full $1/hour increase from 2019).

Unlike nursing homes, assisted living providers have not received any direct federal funding while incurring significant cost increases for personal protective equipment, staff “hero pay,” cleaning supplies and testing. Nursing homes are also facing fines up to $8000 if employees are not tested for Covid-19. This does not yet apply to assisted living. Assisted living operators have not received federal support in the form of PPE and testing, which many providers are paying for out of pocket. Only 15% of assisted living providers received some funding from the Coronavirus Aid, Relief, and Economic Security (CARES) Act Provider Relief Fund for all Medicaid providers—of which less than half of assisted living operators are eligible. (It is possible those facilities in the Assisted Living Waiver Program could be eligible.)

Associations representing senior living and other long-term care providers have asked Congress for $100 billion to cover the COVID-19-related costs of testing, PPE, and staffing. No response yet as Congress is waiting until after the November elections.

Recently, the California Supreme Court ruled that the 1982 Long-Term Care, Health, Safety, and Security Act allowing residents to sue skilled nursing facilities does limit their compensation to $500 regardless of the total number of violations. Will its decision apply to RCFEs?

California Welfare and Institutions Code 9701 defines a long-term care facility as “any nursing or skilled nursing facility” and “any residential care facility for the elderly.” The Supreme Court decision only seems to cover skilled nursing facilities, but this decision may open the door for decreased judgments against all assisted living facilities.

The concept of assisted living predated the enactment of Medicare, but there were no laws or regulations addressing how to operate care homes. In The Gerontologist, Keren Brown Wilson, PhD said residential care and assisted living started evolving into a more formalized setting in 1979.

In 1973, California enacted the community care facilities act with the purpose of providing quality care in a homelike setting to mentally ill, and developmentally and physically disabled adults and children. Disabled elderly were being housed with those adults but the setting was not optimal. In 1985, the legislature enacted the RCFE Act to give the elderly a better option.

In 2020, the number of RCFEs may be rebounding after the horrific closure of over 1,000 between 2007-2009. Although the number of RCFEs only increased by one from July 2018 to June 2019, the apparent increase from July 2019 to June 2020 is estimated at 127. However, it also appears the number of “placed elderly” did not significantly increase in proportion to the increase in facilities.

What is your vision of California RCFEs after Covid-19? I think the industry will receive more oversight from the Department of Public Health Services (nursing home regulators) with stricter guidelines for compliance and more laws and regulations. If that happens, there will be more operators exiting the industry, more facilities going “underground,” more elders abused in horrible care homes, more caregivers financially abused (something we see now) and an attempt to return to days without government intervention.

The number of licensed RCFEs will go down, but more will open—illegally.

What is going on?

I bet you have asked yourself that question more than once in the past few months. Robin and I have talked to many of you, and because we are now marketing into Central and Northern California, we have met many new students in our live streaming courses. You have asked that question and many other questions which Robin and I have attempted to answer with clarity and honesty.

The truth: no one really knows what is going on with COVID-19, admissions, visitors, temperature taking, hospice and home health visits, trips to the ER, etc. I give DSS credit for attempting to keep administrators and vendors informed. It takes ferreting out info from DSS’ provider information notices (PINs, found on CDSS’ website), but the info is there.

In a recent PIN, facilities can admit clients AND can allow visitors. (See our COVID-19 plan of operation under Products and Services for a visitor screening.) DSS is recommending limiting entry to individuals who need entry, i.e. facility staff and service providers, such as home health or hospice, who keep the operations running and ensuring the needs of persons in care are met. My recommendation is nurses only, not CNAs or “bath aides” as facilities are required, by the admission contract, to bathe and provide care. If a county or state official needs to enter to inspect or assist you, DSS believes these individuals are necessary.

Facilities can allow immediate families or friends. To allow visitors, make sure the appropriate signage is posted regarding the risks associated with COVID-19 and the recommended precautions visitors will take. Establish specific visiting hours and use only ONE entry point. It may be best to allow visitors in when staffing levels are higher to monitor visitors’ handwashing and moving throughout the facility. To tour prospective residents, employ the wearing a facemasks, gowns, and gloves. (Facility is NOT required to provide these items but can, if available, keeping in mind future needs for staff must come first before visitors.)

It is OK to take persons to essential medical care such as dialysis, doctor visits, etc.

Facilities must require all staff and visitors to wash their hands upon entry at a handwashing and/or alcohol-based hand sanitizer stations immediately inside all entryways with signage reminding people to wash before entering. Ask each person who enters to immediately wash their hands or use the hand sanitizer before doing anything. Remind visitors and others to maintain social distancing. If possible, keep a distance of at least six (6) feet between yourself, the client, and staff. If someone is coughing, sneezing, or has a fever, do not allow them to enter.

Go to our Products and Services Page and download, free, our COVID-19 plan of operation. There is a visitor screening you can use when allowing persons into your facility.