Although reports and extrapolations vary, there is a grim consensus that whatever number you land on in quantifying COVID-19 deaths in nursing homes is almost certainly an undercount.
For the record, as of March 26, 2023, there were 165,347 nursing home resident deaths and 3,067 staff deaths caused by SARS-CoV-2 reported by the Centers for Medicare and Medicaid Services (CMS).1
The CMS numbers are based on data reported by nursing homes to the Center for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN) COVID-19 Long-Term Care Facility (LTCF) Module.
These requirements were issued in the spring of 2020, missing thousands of initial deaths and still somewhat confounded by variables, including reporting compliance and the elderly populations included. For their part, the NHSN states, “Facilities eligible to report data … include nursing homes/skilled nursing, intermediate care facilities for individuals with intellectual disability (ICF/ID), and assisted living facilities.2
A Kaiser Family Foundation (KFF) report last year put the number of long-term care (LTC) deaths at “more than 200,000,” and noted that surveillance and reporting gaps in the healthcare continuum that make the full picture indiscernible.3
Early in the outbreak, a USA Today data analysis — headlined “a national disgrace” — concluded that about 40% of the pandemic deaths were occurring in LTC.4
The percentage still surfaces in discussions, while another widely used estimate is approximately one-third. This apparently can be traced to a New York Times analysis that found nursing home deaths accounted for 31% of the total pandemic mortality, reporting — as of as of June 1, 2021 — “184,000 coronavirus deaths among residents and employees of nursing homes.”5
Thus, the Times analysis found more LTC pandemic deaths two years ago than the number currently posted on the CMS website.
APIC Steps Up
Fortunately, vaccine availability lowered death rates in nursing homes, but infection control improvements are a work in considerable progress. Knowing that this is the moment to push for change, the Association for Professionals in Infection Control and Epidemiology (APIC) is stepping up and calling for full-time infection preventionists in nursing homes.
APIC stated bluntly that a “lack of investment resulted in tragic deaths” in nursing homes, although the infection control deficiencies in these settings have long been known. “Nursing homes have woefully inadequate infection prevention requirements and infrastructure,” APIC said in a recent statement.6 “As a result, nursing home infection preventionists spend less than a third of their time on IPC (infection prevention and control)-related work. Only 40% have specialized training in IPC and less than 10% are certified.”
The statement was in conjunction with a recently issued report by the Government Accountability Office (GAO) on IPC practices in nursing homes.7 APIC members were among the experts consulted by the GAO in preparing the report.
Beyond preparing for the next pandemic — or some mutation and re-emergence of COVID-19 — APIC emphasized that healthcare-associated infections (HAIs) of all stripes kill about 380,000 LTC residents annually.
Currently, CMS requires at least a part-time infection preventionist and is toughening survey inspections after being targeted by an ongoing series of GAO reports. (See Hospital Infection Control & Prevention, December 2022.)
In addition to moving to a full-time infection preventionist, APIC is calling for the CMS to expand existing reporting requirements to include HAIs and drug-resistant pathogens, such as Candida auris.
“The pandemic taught us what can happen in a vulnerable population that lacks robust IPC programs,” APIC concluded. “It’s time for CMS to take the GAO recommendations to heart and require that each nursing home have a full-time, dedicated, infection preventionist on staff, and that they receive rigorous IPC training. Our seniors deserve nothing less.”
Although noncommittal on the issue of expanding LTC reporting to other HAIs, the CMS has “extended the requirement to report COVID-19 infections through 2024, beyond the anticipated end of the public health emergency, the GAO report stated.
In consulting APIC and other experts, the GAO recommended that the Department of Health and Human Services (HHS) continue to emphasize and prioritize infection prevention in nursing homes. This should include “learning from and correcting infection prevention and control weaknesses identified during and prior to the pandemic.”
With infection control in LTC now bright on the radar, continuing this emphasis makes sense, with one expert consulted saying “everybody’s talking about it,” the GAO reported. The CDC apprised the GAO that it “has learned a lot during the pandemic about weaknesses in IPC in nursing homes and ways [they] can improve.”
Of course, CDC recommendations are not binding, but the GAO report also recommended that the HHS “consider strengthening mandatory infection prevention and control training requirements in its federal regulations for all nursing home staff positions and for surveyors conducting nursing home inspections.”
CMS Increases Penalties
In that regard, CMS has strengthened its enforcement policy for infection control deficiencies with revisions focusing on severe and “actual” harm levels. “This revised guidance strengthens enforcement efforts for noncompliance with infection control deficiencies,” the CMS stated in a recent update to surveyors.8 “The enhanced enforcement actions are more stringent for infection control deficiencies that result in actual harm or immediate jeopardy to residents.”
CMS is providing guidance to its state survey agencies on handling enforcement cases before and after the revisions.
According to APIC, “This refocused [CMS] enforcement will increase civil monetary penalties, shorten notice for discretionary denial of payment for new admissions, and require the directed plans of correction to include hiring an external infection control consultant [or quality improvement experts].”
Additionally, CMS said it will impose enforcement actions when facilities are concurrently cited for noncompliance with COVID-19 vaccine immunization requirements for residents and staff.
Depending on the scope and severity of noncompliance, CMS surveyors may issue a plan of correction that includes a root cause analysis and working with quality or infection control experts.
CMS formed designated quality improvement organizations (QIO) in 2019, extending contracts to 12 experienced, community-based groups.
“The QIOs are being deployed to provide technical assistance to nursing homes, including a targeted focus on approximately 3,000 low-performing [LTC facilities] with history of infection control challenges,” the CMS stated.
Further, states may request QIO technical assistance specifically targeted to nursing homes that have experienced an outbreak. According to the CMS enforcement revision memorandum, these requests should be sent to Colleen Frey, acting division director, at [email protected].
“The QIOs help nursing homes identify their greatest infection control challenges, create action plans, and implement specific steps to establish a strong infection control and surveillance program in the nursing home,” the CMS emphasized. “For instance, they train staff on the proper use of personal protective equipment (PPE), cohorting residents appropriately, and transferring residents safely. They monitor compliance with infection control standards and practices in the nursing home.”
The CMS action appeared to be in response to a series of reports by the GAO, including one issued last year that recommended the CMS “provide additional guidance in the state operations manual on making scope and severity determinations for IPC-related deficiencies.”9
In addition, the HHS has agreed to a recommendation in the 2022 GAO report, which called for CMS “to establish minimum infection preventionist training standards.” These training standards await completion of an ongoing CMS comprehensive review of infection control in nursing homes, which has a targeted completion date of December 2023.
Editor’s note: Nursing homes can locate the QIO responsible for their state at
http://www.qioprogram.org/locate-your-qio. Questions about the CMS enforcement policies should be submitted to: [email protected].REFERENCES
