This is a call for Americans to demand revision of the current mandates from Center for Medicare and Medicaid Services (CMS) in regards to nursing homes. Understand, CMS provides the lifeblood (money) for any healthcare institution of any type, including nursing homes themselves, which means that no hospital, no physician’s group, no treatment center in the US is going to take a stand against anything they do, as it literally means being shut down. It is up to us to call out this injustice. Every single one of us could find ourselves directly affected by this type of policy.
You don’t need a medical degree to understand that humans don’t do well in isolation. The part that you do need to understand is how the primary way by which the novel coronavirus is spread: close human to human contact; not surfaces, not casually passing in the hall, face to face contact for 15 minutes. This is extremely important because the current mandates are in place due to fears about spread from surfaces and casual contact, meaning no one can be near anyone else: total isolation. By specifically addressing the primary method of transmission, we can end the suffering of our must vulnerable. We can also better manage those who do contract this illness but do not require hospitalization.
The current CMS Guidance for Infection Control and Prevention of Coronavirus Disease for Nursing Homes which mandates enduring, universal isolation of residents without consideration of their wishes is categorically unconstitutional.
A large percentage of the mortality from COVID-19 in the US has been in nursing homes. This delineates two important issues: first, these are the most at-risk, and second, whatever we are doing, it’s not working very well. To be fair, we were operating on very little knowledge at the beginning, but we now have much better data on which to create effective policy. Furthermore, the pandemic has exposed a completely unethical governance: the complete loss of personal freedom of residents. Just because someone needs assistance with activities of daily living or even has cognitive impairment does not mean they should relinquish the ability to make decisions for themselves, even if those decisions are taken from advanced directives.
When an elderly person enters a nursing home, they are choosing how they wish to live the final stages of their life. I have been involved in this process with family members more than a half a dozen times, and I don’t ever remember someone saying, “if we decide it is for your safety, we may remove every form of meaningful contact with the outside world – including your family – and there is nothing you can do about it.” If this were a clause in the contract and you were the client, I am betting you would have second thoughts. Think about it: would you voluntarily be admitted or admit a loved one to a nursing home right now? If you think you will never be in a position where this is an important topic for you, think again.
They say tomorrow is promised to no one. The older you get, the more accurate that statement becomes. Right now, we are so concerned with the safety of our elderly that we have forgotten that they are living human beings that deserve a voice, particularly in regards to their own lives.
Advanced directives were created because of the emotional difficulties in managing the care of a loved one in a life-threatening situation. We are all encouraged to make our wishes understood – preferably in a legally binding document – well before they are needed. If there is a takeaway from all of this, it is the necessity to include how you want to be treated during a global pandemic in that document.
The foundation for development of policy and regulations of nursing homes should be based on respect for the personal wishes of the resident wherever possible (quality of life) balanced with the maintenance of safety of all residents. This philosophical guidance should not be superseded by sociopolitical climate, no matter how dire the situation appears.
The current facility mandates from the Center for Medicare and Medicaid Services (CMS) do not follow these tenets. The living conditions mandated due to the COVID-19 pandemic are not just uncomfortable, they are cruel. Furthermore, the most egregious regulations do not meaningfully increase the safety of the residents nor take into consideration the real-world limitations inherent in the system, limitations that will not be overcome with more stringent inspections or financial penalties, particularly in the midst of a crisis. They also provide no guidance for facilities on what to do if a patient becomes infected.
Here are the CMS mandates. (They are referred to as “guidelines” but they are not. Failure to adhere to these standards means fines or loss of CMS certification and inability to collect money from Medicare and Medicaid).
This is a big document, but the most important statements can be easily summarized:
- No outside visitors.
- No communal dining or other internal or external group activities.
Briefly, residents are isolated in their rooms, indefinitely. This is no different than solitary confinement, the serious adverse effects of which are well documented. When a person is moved into a nursing home, the purpose is to care for them. Placing them in isolation – even in short duration in an attempt to protect them from harm – should be avoided at all costs.
The current CMS regulations mandate universal isolation of all residents regardless of their wishes. This is forced isolation, and it without question unconstitutional, even in the face of a pandemic.
There are better ways of alleviating isolation, mitigating the spread of the virus, and allowing individual resident preferences to be met. In addition, simple changes could prepare a facility for management of patients that do become infected but whose disease does not require transfer to an acute care setting such as a hospital.
Current understanding of COVID-19:
- The virus is primarily spread by close person-to-person contact defined as face to face contact within 6 feet for greater than 15 minutes.
- Surface contamination, though theoretically possible, is not considered a primary means of spread. Furthermore, this risk can be easily mitigated through routine handwashing.
- Casual contact such as passing in a hallway is not a primary method of spread.
- The presence of an infected person within a room or space such as an elevator does not pose a significant lingering risk to others who might enter the same room or space at a later time.
Some Important considerations:
Nursing homes do not have the same capabilities as a modern hospital. Because the work is difficult and the pay is low, they often operate below optimum staffing, the educational levels of employees is similarly limited, and important supplies such as PPE may be scarce. These are chronic, systemic issues that will not be corrected through increased inspections, fines, or other regulatory pressures that are intended to assure quality. Failure to work within the realities of these facilities will have direct negative impact on residents. For example, closing a facility that is operating below an expected standard may leave those residents with no place to go. Though not an optimal situation, the overall benefit of the residents much be the primary concern.
- Individual decision concerning method of isolation (internal vs. external). To minimize the spread of viral disease, some restriction on person-to-person contact is necessary. However, a restriction of all person-to-person contact is proven to be mentally and physically injurious, therefore residents shall be given the option of limitations on external contact (no outside visitors or non-essential caregivers) or reduced internal contact (no communal meals or activities). Residents are divided into two groups, and they choose which group is best for them:
- External visitation: Continued visitation from outside family and friends and/or household caregivers such as sitters/companions. These residents are expected to stay in their room excepting necessary appointments such as physical therapy, and these will be done in isolation.
- Internal visitation: Continued communal meals and activities as desired. No outside family, friend, or non-essential medical visitation.
- Requirements for all visitors and staff:
- Temperature taken on entry – no one in with temperature >99.0 F.
- All outside visitors are to wear medical-grade surgical masks (provided) when travelling in the building and to go promptly to the destination room.
- Maintain strict social distancing (>6 feet) whenever possible including while moving through the building.
- Outside visitors are not to mix with residents or staff in small spaces (such as elevators).
- Staff precautions.
- Where possible, staff will be split into 2 groups in proportion to size of resident group census such that residents choosing External Visitation will work with one staff group and residents choosing Internal Visitation will work with a different group. Though it is unlikely that facilities will be able to strictly apply this policy, it will still reduce the risk of cross-group contamination.
- Staff that work at multiple facilities should be preferentially assigned to the External Visitation group.
- All staff working with External Visitation residents will use N95 masks at all times in the presence of these residents.
- Residents testing COVID positive whose condition does not require transfer to another facility shall be placed on External Visitation guidelines, with strict requirement that all visitors (family, friends, medical) wear an N95 mask during the visit.
These recommendations would not only mitigate the spread of COVID-19 better than current mandates, they allow residents to continue absolutely critical meaningful human interaction, they restore resident control and individualization in terms of how they want to live, and they provide a simple and workable solution for residents who test positive so that they are neither unnecessarily discharged from the facility nor allowed to put other residents at risk. Furthermore, the recommendations are simple and easily implemented, even in facilities with significant limitations in terms of staffing and resources.
John M. Salmon IV, MD