It is inevitable that at some point throughout the pandemic, the large majority of senior living communities will experience a Covid-19 infection incident. This fact is irrespective of whether the community is expensive or value-priced, located in one neighborhood versus another, or serves more vulnerable or less vulnerable populations. Many buildings will experience multiple infection incidents over the likely year-long lockdown period. Almost certainly, the infection will be introduced to the building from the regular staff, and of course, it will be unintentional. Infections could also be introduced into a building from outside vendors (Hospice, Home Health, doctors, outside tradespeople, movers, etc.) or residents returning from the hospital or doctor visits.
Of course, there will be infections: we are living in a pandemic, and there are too many variables beyond the control of any community. Here’s my advice on thinking of coronavirus outbreaks in communities: There is no shame in getting coronavirus in a building; the shame is not handling it well when it happens. So what’s the drill when the inevitable happens? We will focus on Assisted Living and Memory Care Communities here because they are relatively consistent in their approach, being regulated by the Texas Department of Health and Human Services. Nursing homes, regulated by CMS (Centers for Medicaid and Medicare Services), have even stricter protocols, but a slightly different mission. Unregulated Independent Living communities are inconsistent in their approach to coronavirus mitigation.
In short, the three-part coronavirus strategy is: Keep it out, contain it, safely re-open.
Keep it Out
The first line of defense has been to limit the number of people who can bring the coronavirus into the building. CDC guidelines and state regulations prohibit any “non-essential” visitors, including families. Assisted living communities have discretion regarding the meaning of “non-essential,” visitors and vendors’ limitation varies widely from community to community. Customary common-sense measures include requiring telemedicine appointments instead of in-person visits wherever possible and delaying discretionary appointments such as dental cleanings. The most strict standards include barring outside caregivers and limiting or even prohibiting Home Health and Hospice professionals. New residents and those returning from the hospital are tested and isolated in their apartments for 14 days. Tours for prospective residents take place by videoconference only. The only exception where families can visit is for end of life situations.
Strict social distancing measures among residents have been implemented to contain the virus’s possible spread within a building before it is recognized as having entered. Meals are delivered to rooms instead of residents gathering in the dining room, and activities are limited to 10 or fewer residents and with social-distancing measures. Hand sanitizing stations are ubiquitous. All staff members wear masks, and residents who can tolerate them are asked to wear them too. All staff entering and exiting a building have their temperature taken, as do all residents. Often residents have their temperature taken daily. All staff are encouraged to report feeling poorly and encouraged to stay home when in doubt. Written materials prepared by regulators encourage communities to refrain from financially penalizing staff for taking time off, but this is inconsistent among communities. High-touch areas within the community are wiped down frequently, and proactive cleaning measures have been increased.
Once a suspected case appears within the community, the protocol is for immediate isolation, increased precautions, and testing. Sometimes after a positive case is found, the community and staff are quickly tested, which is preferred. More often, the tests are given only to residents and staff thought to be at the highest risk due to contact with the infected individual. The decision for the scope of testing comes from local health officials. Because the disease is dynamic, no matter how testing is done, often more cases show up after the first round of tests. This slow drip of new cases is frustrating to residents, staff, and families alike.
Even before the test results are back for the first suspected case, contact tracing begins, increased health monitoring ensues, and potentially the precautionary isolation of exposed residents commences. If testing confirms two or more cases, a “cluster” is declared and reported to authorities. Most communities prefer to send infected residents out to a holding facility, but regulators have also instructed communities to plan an isolation area within the community. The isolation area must have dedicated staff so that caregivers don’t transfer the infection to the non-COVID part of the facility. The isolation area is supposed to be well ventilated and have meaningful separation from the rest of the community, indicating that just putting up curtains isn’t sufficient. In some cases, residents can isolate themselves in their apartments instead of moving to an isolation area.
In Central Texas, Hearthstone Nursing and Rehab, next to St. David’s Round Rock Medical Center, is the only designated holding facility for receiving COVID-positive patients from assisted living or memory care facilities. Because of its architecture, Hearthstone separated half of its facility, 60 beds, for COVID-positive residents. Demand for space has been high, and sources indicate demand for beds has exceeded capacity by over 50% at times. I know of COVID-positive residents who early in the pandemic were sent out from assisted living communities to hospitals and subsequently transferred to long term acute care hospitals, rehab hospitals, and nursing homes as far away as Temple. Because of their other patients’ risk, most LTAC and rehabilitation hospitals prefer to avoid Covid-19 patients. Medicare rules generally prohibit convalescing Covid-19 residents in these category hospitals because of the expense. But given the pandemic, exceptions have been made.
Residents are further restricted when there is an active cluster of coronavirus in the building. Activities are frequently canceled, and residents have stricter restrictions regarding leaving their apartments and wearing masks. Cleaning and hygiene procedures are also further intensified. Resident temperatures are taken twice a day, and other health metrics are more closely monitored. Move-ins of new residents are suspended.
The assisted living communities I’ve spoken with will only accept their Covid-19 residents back once they have had a negative test and have been symptom-free for at least seven days. These residents are typically required to isolate themselves in their apartments for another 14 days after arriving back at their original community. Residents who were not sent out are usually deemed coronavirus free after two negative tests and do not isolate further.
Staff who have tested positive and are returning to work generally need either two negative tests or, if testing isn’t available, to have been symptom-free for at least ten days after a positive test. Even asymptomatic staff who have tested positive but who never develop symptoms need to pass these thresholds to return to work.
New residents’ admissions usually begin after 4 to 6 weeks after a cluster has been identified in a community. The timing for beginning new admissions is supposed to be 14 days after the community’s last positive test.
Local health officials are supposed to be informed as soon as there are suspected cases in a community, but certainly when positive cases are identified. Management should communicate with residents, staff, families, healthcare providers, and other interested parties regularly about the status of the virus in the building and ongoing measures to mitigate its impact on all community residents. Typically group email updates are sent no less frequently than weekly during this time. Some communities are less specific than I would like when sending out these updates because they are worried about HIPPA and negative publicity. Information deficits are a frequent source of friction with families in particular.
Staffing is a critical consideration during a coronavirus outbreak. Communities will have reduced staff available because of positive cases among caregivers and staff who have been exposed and are placed on leave as a precautionary measure. Plus, additional burdens are placed on staff when increased precautions are implemented when active cases are in a building. Management is supposed to have a staffing plan for these situations. Overtime for current workers, moving management into caregiving activities, hiring temporary caregivers from outside agencies, moving staff from other affiliated or friendly assisted living communities, and hiring new caregivers are all strategies that I have seen used. The surge required during an outbreak causes a lot of stress at all levels of the organization and among residents and their families.
Personal Protective Equipment
PPE, the availability of which was highly problematic at the start of the pandemic, isn’t currently a concern. Communities are supposed to have sufficient stockpiles in-house to meet emergency needs.
That was a very informative article Michael. Well done.