Virginia National Guard soldiers and airmen collected samples for COVID-19 testing at a long-term care facility April 28, 2020. (U.S. National Guard photo by Cotton Puryear)

Within a week after Canterbury Rehabilitation & Healthcare Center in Henrico reopened its doors to new admissions, the nursing home accepted a handful of what medical director Dr. Jim Wright referred to as “unknowns” — residents who had been transferred from the hospital without being tested for COVID-19.

The facility, which had just weathered one of the deadliest nursing home outbreaks in the country, had established its own strict testing program for patients in response. When the newly admitted residents were tested onsite, one came back positive. Luckily, Wright said, Canterbury already had a separate quarantine unit set up for new arrivals. But he still described the positive result as a “pretty tense time” for the facility, which lost a total of 51 residents to the disease.

“I am very hesitant now to accept any patient who has not had at least one test,” he added. “You just want to know what’s coming through your door.” 

In Virginia, though, hospitals can release patients to nursing homes without COVID-19 testing as long as the patient isn’t displaying any symptoms of the disease, despite repeated pleas from industry groups over the past two months to change course. The state isn’t alone  — current recommendations from the U.S. Centers for Disease Control and Prevention specifically emphasize that “testing should not be required prior to transfer of a resident from an acute-care facility to a nursing home.”

But amid a disjointed federal response, a nationwide wave of virus deaths at nursing homes and strong evidence of asymptomatic spread among early nursing home outbreaks in Washington, some states are taking matters into their own hands.

Florida, which banned the transfer of COVID-positive patients from hospitals to nursing homes, passed an emergency rule in early May forbidding hospitals from discharging residents to any long-term care facility without two consecutive negative tests within 24 hours. Industry groups in Virginia — where nearly 60 percent of all COVID-19 deaths are linked to outbreaks in long-term care facilities —  began asking the state to reconsider its own guidance around the same time. 

In a May 5 letter to Gov. Ralph Northam, leaders from the state’s largest long-term care associations — LeadingAge Virginia, the Virginia Assisted Living Association, and the Virginia Healthcare Association-Virginia Center for Assisted Living — asked the state to direct resources toward “priority testing” of all patients discharged from hospitals to long-term care settings. 

“We are aware of situations of asymptomatic individuals discharged from hospitals and admitted to long term care facilities who test positive at a later date,” the letter reads. “While we understand the challenges associated with testing asymptomatic individuals, waiting for these residents to develop symptoms almost guarantees additional infections.”

Behind the scenes, some leaders had been even more insistent. In an April 30 email to Dr. Laurie Forlano, head of Virginia’s long-term care task force and the state’s deputy commissioner for population health, LeadingAge Virginia CEO Melissa Andrews wrote that long-term care providers “desperately need[ed]” asymptomatic patients to be tested before being discharged.

In the emails, obtained by the Mercury through a Freedom of Information Act request, Andrews wrote that the current guidelines were even more puzzling given the state’s soon-to-be-lifted ban on elective procedures and the announcement by some hospital systems that patients would be tested for COVID-19 before receiving treatment.

“I’m sorry for continuously banging the same drum, but this new development is confusing for our providers,” she added. “We keep hearing that hospitals don’t have capacity for testing asymptomatic discharges to LTC, but they now have capacity to test all patients prior to admission?”

The COVID-19 death toll at Canterbury Rehabilitation and Healthcare Center in Henrico became one the highest known in the nation at a longterm care facility in April. (NBC12)

Tensions surrounding testing in nursing homes have been simmering since the early days of Virginia’s COVID-19 pandemic, when a group of medical directors blamed the state’s restrictive testing criteria, which initially required long-term care residents to test negative for the flu and other respiratory diseases, for endangering some of its most vulnerable residents.

In a March 18 email, VHCA-VCAL CEO Keith Hare sent Health Secretary Dr. Daniel Carey an anonymous summary of the state’s testing situation from “a member’s medical director,” who wrote that the state’s lab “does not appear to be prioritizing specimens from [long-term care facility] residents” and was “wasting precious testing capacity testing individuals who are unlikely to have severe illness and those who are not [health care providers].”

But the increasing urgency over asymptomatic testing guidelines was also reflective of a rapid shift in COVID-19 research, said Dr. Christian Bergman, the medical director of Bonview Rehabilitation & Healthcare in Richmond and assistant professor of geriatric medicine at Virginia Commonwealth University who also serves on the state’s long-term care task force.

The state’s initial guidance on discharges from hospitals to long-term care facilities was developed in conjunction with industry groups and the Virginia Hospital and Healthcare Association, which began drafting the document in late March or early April, Bergman said. By the time it was finalized on April 22, new research was becoming nationally available on the asymptomatic and presymptomatic spread of COVID-19 in nursing homes. 

The joint letter to Northam references early data from the CDC reflecting that 57 percent of COVID-positive older adults without symptoms at the time of testing would go on to develop symptoms seven days later. Another major catalyst was an April 24 study in the New England Journal of Medicine, which reported that residents without COVID-19 symptoms at a skilled nursing facility in Washington — most of whom later developed signs of the disease — “most likely contributed” to “rapid and widespread transmission” before ultimately testing positive.

“After that data became available, it was a bit of a scramble where everyone was trying to figure out what to do, and that’s when the associations sent that letter to the governor,” Bergman said. Since then, he’s joined a group of medical directors on the task force in asking the Virginia Hospital and Healthcare Association and other industry groups to reconsider the guidelines, especially in light of the state’s phased reopening guidance for nursing homes, which dramatically expands the testing requirements for facilities.

Julian Walker, vice president of communications for VHHA, wrote in a Tuesday email that the state’s hospitals have been “engaged in discussions” about changing the guidelines since May. “As of this point, the forms have not been updated, in part due to the need for [the U.S. Centers for Medicare & Medicaid Services] and other agencies to finalize updated guidance,” he added. “A draft document has been created to update the guidance regarding discharge protocols and those discussions very much remain active.”

Dr. Laurie Forlano, the Virginia Department of Health’s deputy commissioner of population health, speaks at a news conference in April 2020. (Ned Oliver/ Virginia Mercury)

But Forlano said Monday that the Virginia Department of Health doesn’t currently see a need to revise the recommendations. Part of the calculus, she said, is that some hospital systems in the state are voluntarily testing patients before discharging them even if the recommendations don’t require it (Walker wrote that decisions on testing are often made “in conjunction with a facility accepting a patient”). Both VDH and the CDC have also released guidance on how to handle new admissions with “unknown status,” which includes grouping them separately from COVID-positive and COVID-negative residents “if facility space allows,” according to the state’s guidelines.

Wright, a vocal advocate for testing, said that state and federal recommendations remain suggestions that don’t have to be followed by facilities.  While the CDC recommends that patients with an unknown testing status be quarantined in individual rooms, that’s not always possible in every nursing home or long-term care facility — especially those with models centered around Medicaid payments.

“You could have someone coming into your facility who you’re assuming is negative but is actually positive,” he said. “And you’re going to put them in with another patient who is negative, thereby infecting them.” Data from the outbreak at his own facility — distributed to state officials, VHHA, and other industry leaders in an April 24 email — also showed that some residents continued to test positive for COVID-19 more than two weeks after their initial result. 

Wright said that the research isn’t clear on whether those patients should still be considered infectious more than 10 days after their initial diagnosis. But it could also highlight potential flaws in releasing patients from quarantine or isolation without testing based solely on the time elapsed since their first positive test or initial onset of symptoms — something which CDC recommendations currently allow.

Strict guidelines on how to group residents weren’t in place early on in the pandemic, and it’s still unclear how extensively COVID-19 spread through Virginia’s long-term care facilities by way of asymptomatic patients. It’s also not clear how much oversight the state exercised over nursing homes — which can even accept COVID-positive patients if they claim to have adequate infection control, staffing and personal protective equipment — early on in the pandemic. 

The Roanoke Times reported in June that Virginia was nearly last in the nation when it came to overseeing COVID-related infection control protocols in nursing homes. VDH spokeswoman Maria Reppas attributed the apparent lack of surveys to CMS, which “initially said that VDH could do remote infection prevention inspections in lieu of onsite inspections” due to a shortage of personal protective equipment.

“Under that arrangement, [the Office of Licensure and Certification] completed 191 remote inspections of VDH-licensed providers,” Reppas wrote in an email last month. “However, CMS later told OLC that none of those remote inspections would be counted as official surveys of record.” The state is working to complete onsite surveys at each of the state’s 287 qualified nursing homes by July 31, she added. But some completed infection surveys show facilities with high death counts and issues that amplified for weeks, including a nursing home in Luray that housed positive patients with negative patients and allowed infected residents to walk through common spaces.

“No matter how good your protocols are, you’re only human,” Wright added. “There’s always a chance for failure. But for someone who’s known to be positive — everyone’s going to be more careful.”

UPDATE: This story was updated Tuesday to include comments from the Virginia Hospital and Healthcare Association.