The news release raised more questions than it answered.
On July 22, the U.S. Centers for Medicare and Medicaid Services announced “new resources” to help nursing homes combat the ongoing spread of COVID-19. Between the announcement of an additional $5 billion in funding and plans to deliver rapid antigen tests to facilities, CMS made an unexpected declaration: All nursing homes in states with a percent positivity rate of 5 percent or higher would be required to conduct weekly testing of all staff members.
The announcement came as a jolt to many of Virginia’s facilities. Nursing homes were left scrambling for much of May and June after CMS passed down sweeping recommendations for weekly testing that many feared would cost millions of dollars to implement. In June, the Virginia Department of Health adapted them into state-specific guidelines, leaving weekly testing recommended but ultimately optional.
Now, the state’s beleaguered nursing homes — which have shouldered roughly 55 percent of Virginia’s total COVID-19 deaths as many continue to operate on tight margins — are again facing the prospect of a significant increase in operational costs. Virginia’s percent positivity rate (the percentage of total COVID-19 tests that return positive), has been hovering slightly above 7 percent since mid-July. Amy Hewett, vice president of strategy and communications for the Virginia Health Care Association-Virginia Association of Assisted Living, said it’s still unclear what source CMS will use to determine statewide percent positivity rates, and whether nursing homes will be subject to the requirement even if the rate is much lower in their individual county or locality.
“There are still a lot of questions that haven’t been answered,” she added. More than two weeks after the news release, CMS has yet to codify the announced requirements into a formal regulation or set a timeline for doing so (the agency has not yet responded to several follow-up questions from the Mercury). But Dr. Jim Wright, the medical director at Canterbury Rehabilitation & Healthcare Center in Henrico, said he had no doubt they would eventually become a reality.
“We know it’s coming,” he added. “The federal government is sending machines to supposedly all of the nation’s nursing homes, and I don’t think they would do that unless they had plans of making weekly testing a requirement. So, it’s going to happen, unfortunately.”
Calls for weekly staff testing have been sounded throughout the pandemic by industry leaders and public health experts. At Canterbury, which weathered one of the deadliest nursing home outbreaks of COVID-19 in the country, the virus is believed to have entered the facility through an infected visitor or staff member. States from California to New York have credited asymptomatic health workers with unintentionally spreading the virus. In Virginia, fear of staff transmission motivated early requests for the state to release information on nursing homes with outbreaks.
But industry groups continue to express concerns that nursing homes still lack the resources for weekly staff testing. One major concern is personal protective equipment. The American Health Care Association-National Center for Assisted Living recently released CMS data showing that between 14 and 19 percent of Virginia nursing homes still don’t have a one-week supply of basic equipment including gowns, N95 respirators, and surgical masks.
Data from the Virginia Hospital and Healthcare Association showed that as of Friday, only five facilities were reporting difficulties obtaining protective equipment within the next 72 hours. But Wright called the VHHA numbers “misleading,” sharing concerns that other industry groups raised when the dashboard was first released.
“The vast majority of facilities say, ‘Yes, we have enough equipment to last 72 hours,’” he added. “What it doesn’t ask is, ‘How are you surviving?’ Are you reusing masks? Are you reusing gowns? Are you using fit-tested masks?” (Fit testing ensures that respirators are sealed tightly against the face to fully protect against viral particles.)
Hewett pointed out that the differences could lay in how the data is collected. CMS reporting is mandatory for facilities, but they have the option to report their supply needs to VHHA. Julian Walker, the association’s vice president of communications, said that the response rate for VHHA’s daily survey is “strong,” with an average 88 percent participation rate on weekdays among the state’s 287 licensed nursing homes (“The dashboard is another initiative supported by hospitals to help assist long term care providers during the COVID-19 pandemic,” he wrote in a Sunday email).
But CMS asks about supply needs over the course of a week while VHHA surveys ask about difficulties procuring equipment over the next three days, which can also affect how nursing homes respond, Hewett added. She said that federal data generally confirms what VHCA is hearing from its members, which is continued difficulties finding certain types of equipment and reuse of protective supplies following guidelines from the Centers for Disease Control and Prevention.
That’s a particular concern when it comes to testing, which is often conducted by staff members themselves. Swabs are generally taken from the nose or throat, putting testers in close proximity to bodily fluids and requiring full protective equipment. Facilities worry it will only speed up their burn rate. Mark Parkinson, CEO of AHCA-NCAL, said in a statement that state governments “need to take immediate action to protect nursing homes by ensuring facilities have adequate supplies of PPE.”
Then there’s the question of the testing itself. Part of CMS’ justification for requiring weekly staff testing was the announcement that the agency would begin sending rapid point-of-care antigen testing machines — said to deliver results within 15 minutes — to more than 15,000 nursing homes over the next few months. Currently, 23 facilities in Virginia have been prioritized to receive the devices.
Hewett said the delivery includes an initial batch of test kits, but nursing homes are required to replenish the materials themselves (another challenge given ongoing bottlenecks in the medical supply chain). And there are even bigger questions about the accuracy of the tests, particularly in a health care setting.
In a July 29 letter to Dr. Brett Giroir, the U.S. assistant secretary for health, LeadingAge — a national association of nonprofit aging services providers, including nursing homes — pointed out that antigen tests have a 20 percent false negative rate. That’s led other federal agencies to recommend a follow-up PCR test in the case of a negative result. Dana Parsons, vice president and legislative counsel for LeadingAge Virginia, said facilities are still waiting for finalized guidance from the Virginia Department of Health on how antigen testing should be used in a nursing home setting.
The devices will also require nursing homes to obtain special waivers from the U.S. Food and Drug Administration and train staff on running the tests. But Wright said the biggest issue remains the reliability of the tests.
“The sensitivity is around 80 percent,” he added. “So, they’ll miss two cases out of ten. The big concern is that antigen testing alone will not decrease transmission within nursing homes.”
That also circles back to cost. If negative results have to be reconfirmed with PCR tests, the current gold standard for picking up active COVID-19 infections, “our members are concerned about the time and expense of testing nearly everyone twice,” LeadingAge wrote. It estimated that the weekly cost of antigen testing could run up to $2,500 for a facility with 100 employees. Factoring in paid staff time and the cost of retesting, the potential weekly cost could reach more than $19,000.
Wright pointed out that many facilities might also remain reliant on outside PCR tests if CMS finalizes the new requirements before it delivers an antigen testing device to every nursing home. VDH has estimated there are roughly 30,000 nursing home workers in Virginia, with an estimated cost between $3 million and $5.25 million for weekly testing using PCR tests.
The Trump administration has pledged an additional $5 billion in CARES Act funding to certified nursing homes, but Hewett said there’s been no additional information on Virginia’s share or how the assistance will be allocated.
“The biggest concern is waste,” Wright added. “We know it’s not going to achieve the ends we want. It’s not going to decrease the risk of coronavirus spread. So, the money and the time and the manpower would be better spent elsewhere — for example, on proper PPE.”