Sluggish start could force mandatory 'universal testing' at long-term care facilities
The plan to test every resident and staff member of long-term care facilities in Delaware for COVID-19 took longer to get going than expected.
State officials announced a plan more than two weeks ago for universal testing in long-term care facilities, which were associated with nearly two-thirds of the state’s COVID-19- related deaths as of May 15. But universal testing is not mandatory for these facilities— and it took until just days ago for a majority of them to start participating.
State public health director Dr. Karyl Rattay said Tuesday during the Governor’s biweekly press briefing she was surprised only 15 percent of facilities had started the testing at that point. She said the state was considering making testing for staff in long-term care facilities mandatory.
“We are disappointed that having it be voluntary, the uptake has been much lower than we had expected,” said Rattay Tuesday.
But more facilities have started testing since then. State officials say 75 percent of them have begun universal testing as of Thursday.
"The directions aren't as precise as perhaps they could have been." - Cheryl Heiks, DHCFA
Public health officials said two weeks ago they were prepared to distribute 25,000 test kits to facilities. Facility staff are expected to administer the tests after being trained.
Cheryl Heiks, executive director of the Delaware Healthcare Facilities Association, says facilities started receiving the supplies late last week or early this week.
“Our providers are very appreciative of the fact that the state is providing the test,” she said. “The directions aren’t as precise as perhaps they could have been. But we’ll figure it out. We’ll get it done.”
Heiks says facilities want the information universal testing will give them — but the process has been slowed by the fact that facilities were left on their own to make laboratory arrangements for test processing, decide who will write scripts for testing staff, and make plans to replace asymptomatic staff who may test positive.
“We did hear feedback there was some concern about staff being tested and being positive and then not being able to work,” said Rattay during the Tuesday briefing. “Long-term care facilities are struggling with staff shortages right now. But there are actually some protocols to help them work through that when there are shortages.”
Ohio-based HCR ManorCare runs several facilities in Delaware, including two with multiple COVID-19-related deaths. As of May 15, the state had reported six virus-related deaths at ManorCare Health Services in Wilmington and two at the ManorCare location in Pike Creek.
HCR ManorCare spokesperson Julie Beckert says the company has tested every resident at its Wilmington location. Nearly half of the residents who tested positive were asymptomatic, she says.
But the company has not tested its staff in Delaware over concerns that it would be a conflict of interest for a facility’s medical director, tasked with overseeing patient care, to order staff members’ tests.
“It should be the individual’s PCP [primary care provider] or the county or a lab,” Beckert wrote in an email. “It shouldn’t be one medical director who is not their primary to manage it, and it would be a conflict of interest for him to do so. ”
“We support employee testing, but it needs to be done by a third party,” she added.
Beckert notes repeated testing will be necessary to maintain an accurate picture of risks in facilities.
“Employees leave the building and are out in the community, so the test is as good as when they were tested,” she said. “But our staff is wearing PPE and following all the infection control guidance.”
"Ultimately, you can't fight what you can't see." - Lori Mayer, Genesis Healthcare
The national, Kennett Square-based company Genesis Healthcare runs several long-term care facilities in Delaware. One is Milford Center, which had seen 31 COVID-19-related deaths as of May 15— the most of any long-term care facility in the state at that point.
Genesis Healthcare’s other Delaware facilities include Lofland Park Center and Seaford Center in Seaford, Silver Lake Center in Dover, Hillside Center in Wilmington and Brackenville Center in Hockessin. Brackenville Center had seen nine virus-related deaths as of Friday. Hillside Center had seen three.
Lori Mayer, a spokesperson for Genesis, says the company has created a testing plan for its affiliated nursing homes that includes both residents and staff.
“Ultimately, you can't fight what you can't see,” she wrote in an email. “We put a plan together that would provide universal testing to our six affiliated centers in Delaware. We have been moving forward with that plan and thus far have completed resident testing in one center. We are using private labs, at our own expense, in Delaware and in other states that have capacity.”
Genesis Chief Medical Officer Dr. Richard Feifer released a statement last week in response to the White House Coronavirus Task Force’s May 11 recommendation of universal testing in nursing homes within two weeks.
“This is a welcome and needed development for which we are grateful, as broad, rapid and frequent testing is the best way to get ahead of the outbreak,” said Feifer in the statement. “We have been advocating for this for many weeks. However, it is unclear how it will be accomplished without a consistent supply of tests, proper support and clear rules for implementation.”
Feifer called for a consistent approach nationwide to testing in long-term care facilities. He said these facilities need access to emergency funding to support expedited testing, Personal Protective Equipment (PPE), and additional staffing.
“Testing just once is not a sufficient option,” Feifer wrote. “Testing will need to be repeated regularly to monitor and protect residents and staff.
The American Health Care Association and the National Center for Assisted Living announced this week that testing every U.S. nursing home resident and staff member just once would cost $440 million. The groups calculated that testing the more than 4,100 nursing home residents and 4,700 nursing home staff in Delaware once would cost more than $1.3 million. The groups concluded that regular testing of nursing home residents and staff is "unsustainable" without state and federal funding.
"I think this in many ways was a pilot project for us to understand the barriers." - Dr. Karyl Rattay
Rattay said Thursday her team is “thrilled” the interest in testing among Delaware's long-term care facilities has increased so much. She attributes the increase in part to advice from the U.S. Centers for Medicare & Medicaid Services (CMS) and legal counsel that testing is in facilities’ best interest.
But making universal testing in long-term care facilities mandatory is still on the table— and would be consistent with federal recommendations, Rattay says.
In the case that universal testing becomes required by the state, Rattay expects support for facilities to increase.
“I think this in many ways was a pilot project for us to understand the barriers,” she said. “It’s important for us to make it easy for them to do the testing, and that is a priority for us to work out the logistics to make it easier for them.”
Rattay says public health officials are currently working to enable all long-term care facility tests to be processed through the state’s public health lab in Smyrna.
Gov. John Carney has emphasized the need to protect residents of long-term care facilities in Delaware.
“If you think about this whole approach to the virus, [long-term care residents] are the most vulnerable,” said Carney Tuesday. “Just look at the data— it jumps right out at you. It’s obviously what’s been recommended by the White House Task Force and the CDC. We really have to lean into it, and so do they— the operators of those nursing homes.”