[co-author: Kimberly Gillespie]*

Normal life at all levels of senior living facilities has been impacted by COVID-19. Facilities from skilled nursing (nursing homes) to assisted living, independent housing and life plan communities are all experiencing disruption from COVID-19 infections of residents and persons suspected of being infected by COVD-19. Following guidelines from the Centers for Medicare and Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC), the Office for Civil Rights, and state and local health departments, many important social interactions that make up the fabric of these senior living accommodations are being eliminated. Infection control policies and procedures, which were always important to avoid outbreaks of disease in these facilities, are now being closely monitored and have become a central part of life at all levels of senior living.

The Life Care Center of Kirkland, the first epicenter in the United States for sickness and death due to COVID-19, was surveyed by a joint team from CMS and the state of Washington, and the conclusion set forth in the CMS report focused on behaviors of management and health care workers that required change. CMS, in its report, indicated that there were three main reasons for the rampant spread of COVID-19 at Kirkland:

• a failure to identify and manage ill residents

• a failure to notify the Washington Department of Health about the increased rate of infections

• a failure to maintain a backup plan when the medical director contracted COVID-19, leaving the facility without a medical director.

As a result of the Kirkland findings, both the state of Washington and CMS have decided to step up regulatory inspections focusing on infection control at nursing homes. The state of Washington committed to having its regulatory teams visit all of the state’s nursing homes. CMS announced on March 23 that it will continue a focused approach to surveying, but that it will further restrict surveying for a three-week period to concentrate exclusively on (1) complaint/facility-reported incident surveys, (2) targeted infection control surveys and (3) self-assessments.

For those that CMS will not be able to inspect directly, it is providing a voluntary self-assessment tool that nursing homes can use to evaluate their infection control plans and readiness and to ensure they are in compliance with federal requirements.

In its letter to state survey agency directors dated March 23, CMS includes “Additional Instructions for Nursing Homes,” where it reiterates the importance of the self-assessment tool:

We expect facilities to use this new process, in conjunction with the latest guidance from CDC, to perform a voluntary self-assessment of their ability to prevent the transmission of COVID-19. This document may be requested by surveyors, if an onsite investigation takes place. We also encourage nursing homes to voluntarily share the results of this assessment with their state or local health department Healthcare-Associated Infections ("HAI") Program.

In addition, the CDC has also provided a checklist for nursing homes and other long-term care facilities.

In these ever-changing and challenging times, we offer the following suggestions and recommendations for senior living facilities across the country:

• Utilize telehealth consults for suspected COVID-19 patients before transferring to an acute care hospital. This approach will permit both the long-term care facility and the hospital to provide the best environment for the patient (See our article on the use of telehealth and CMS’s “Long-Term Care Nursing Homes Telehealth and Telemedicine Tool Kit”).

• Before accepting a new patient, be certain that adequate screening has taken place and you feel confident that the facility has the skill set and personnel to properly treat the new patient.

• As the virus spreads to a larger population, it may no longer be possible to screen new patients with or without COVID-19 on site. Consider alternative sites for screening and observing patients before formally accepting them into residence.

• Continue intense screening of health care workers and visitors being permitted into the facility. This is especially true if workers or visitors are providing services outside your facility. Consider increasing shifts or pay for those workers who need an incentive to leave their other place of employment. Levels of screening are changing constantly so be certain to monitor CDC and CMS guidelines depending on whether the facility is governed by either or both.

• Review visitation policies periodically to be certain they are still relevant to the level of infection being experienced. Consider limiting visitors entirely, restricting the number of visitors for a particular resident or patient, and/or using age as a criteria (bar those considered most susceptible to infection). Establish video conferencing for those who want to communicate with families and friends in light of restrictive visitation policies.

• Institute resident health care screening by taking temperatures and observation in independent living arrangements to be certain that you can identify COVID-19 infected persons. Immediately quarantine those in contact with COVID-19 patients or those who test positive for COVID-19.

• Urge end-of-life and hospice patient visitors to avoid physical touching of the resident in the event the resident or the visitor is a carrier without symptoms of COVID-19.

• Maintain privacy practices and limit the dissemination of information that could identify an infected resident.

• Take steps to disinfect all deliveries to the facility and make arrangements to have a central location for deliveries.

Conclusion

One of the most positive aspects of senior living facilities at all levels are the social events, activities and interactions among residents and staff. COVID-19 has interfered with normal life in these facilities. Following strict infection control guidelines and protocols should save lives but will be a daily reminder of the loss of the special social fabric that exists in any level of senior living.

* Counsel, Troutman Sanders