Elevating the Post-Acute and
Long Term Care Profession

May 24, 2021

Governor DeWine Comments. In today's press conference, Governor Mike DeWine credited the state's Vax-a-Million promotion for a 94% increase in vaccinations among 16 and 17-year-olds, 46% among 18 and 19-year-olds, and 55% among Ohioans 20-49 years of age. These figures are for the period May 14-19 compared to May 7-12. Despite a threat from Representative Jena Powell (R-Arcanum) to introduce legislation to stop the giveaway, the first Vax-a-Million drawing will take place at 7:29 p.m. on Wednesday. We encourage members to make sure their patients, residents, and staff sign up for future drawings once they receive at least their first dose of vaccine. More than 2.7 million people already have registered.

Governor DeWine also said only 22% of Medicaid beneficiaries have started the vaccination process, compared to the statewide average of 45%. The 22% presumably includes long-term services and supports recipients whose vaccination rate is around 4 times that of the general Medicaid population. The Governor called out Medicaid managed care plans to do more to get their members vaccinated and highlighted some of those efforts.

Ohio's latest cases-per-100,000 level is 89.8. Governor DeWine reiterated that health orders will be rescinded next Wednesday, June 2, whether or not the state reaches 50 cases per 100,000. Presumably, the rescission still does not apply to orders directed at assisted living communities and SNFs.

Weekly County Positivity Rates. The Centers for Medicare and Medicaid Services (CMS) published the county COVID-19 positivity rates today. For the second straight week, there are no red counties in the Ohio table. Lawrence County remains very much an outlier at 14.4%, but again this week has too few tests to be designated as red. The next highest is Harrison County at 7.4%. This week's color changes:

  • Fulton County: yellow to green.
  • Highland County: yellow to green.
  • Holmes County: green to yellow.
  • Meigs County: yellow to green.
  • Montgomery County: yellow to green.
  • Morrow County: yellow to green.
  • Paulding County: yellow to green.
  • Putnam County: yellow to green.
  • Summit County: yellow to green.
  • Vinton County: green to yellow.
  • Wood County: yellow to green.
GAO Report on Outbreaks in SNFs. The Government Accountability Office (GAO), a federal agency that answers to Congress, issued a report looking at outbreaks in SNFs based on National Healthcare Safety Network (NHSN) data. The report covers the period beginning when SNFs started reporting to NHSN in May 2020 to January 2021. The primary findings were that of more than 11,000 SNFs covered in the study, only 64 did not have outbreaks during that period and 44% had 4 or more outbreaks. GAO also found that at least 66% of the outbreaks were triggered by staff, in that only staff cases were identified the first week the outbreak was reported. GAO studied what they termed long (5 or more weeks) and short-term (4 or fewer weeks) outbreaks. Eight-five percent of all outbreaks were long-term. GAO cited a relationship between larger size and longer outbreaks, but ownership type and previous infection control citations were not related. There was wide variation among states, as shown in a graph in the appendix, with Ohio having the 10th-highest percentage of long-term outbreaks.

Visitation: CDC/CMS vs. ODH. As CMS and the Centers for Disease Control and Prevention (CDC) revised their guidelines on visitation (see CMS's QSO-20-39-NH and CDC's updated guidance), the Department of Health (ODH) orders for SNFs and assisted living communities have not kept up. There are several conflicts. For instance, the ODH orders limit the number of visitors for a given resident to two, including in compassionate care situations, while the federal provisions do not limit the numbers. Another instance is the ODH orders' direction for facility staff to escort visitors to the place of visitation. Perhaps most significantly, the state orders currently do not pick up the recent federal recommendation allowing fully vaccinated residents and visitors to dispense with masks and distancing while visiting.

We strongly recommend following the federal guidance when the guidance is more liberal toward visitation than the orders. ODH personnel have stated on multiple occasions that their surveyors don't cite against state orders for either SNFs or residential care facilities. In fact, there is risk of citation if a facility applies a more restrictive provision of a state order over a conflicting, more liberal federal guideline. For this reason, we would prefer to see the state orders eliminated - they cause too much confusion and risk.

If the state orders are more liberal about visitation, for instance the language stating, "[a] designated visitation area shall include a private single resident room," we suggest members consider following the state orders to avoid resident and family complaints, but only if the state provision does not require something specifically prohibited by the federal guidance. Again, in-room visitation is a good example. It is not flatly prohibited by the latest CDC guidance, which instead specifies that "ideally" it should not occur unless the patient has a private room.

OSHA Issues Updated FAQ on Vaccine Adverse Reactions. In an effort to encourage employers’ COVID-19 vaccination efforts, the Occupational Safety and Health Administration (OSHA) issued an updated COVID-19 frequently-asked questions document (FAQ) informing employers that OSHA will not enforce the 29 CFR 1904 recording requirements for side effects of the vaccine through May 2022. At that time, they will reevaluate their position on this enforcement discretion to determine the best course of action moving forward.  

Study in Health Affairs Finds No Reduction in SNF Staffing. The latest edition of Health Affairs, a well-respected journal published by Project HOPE, included a study that concluded there was no reduction in SNF staffing on an hours-per-patient-day basis during the first nine months of 2020, compared to 2019. The study reviewed data from the Payroll-Based Journal. AHCA/NCAL's Provider magazine has a fairly extensive review of the study, which is behind a paywall. The Health Affairs abstract reads as follows:

Prior research and the popular press have anecdotally reported inadequate nursing home staffing levels during the COVID-19 pandemic. Maintaining adequate staffing levels is critical to ensuring high-quality nursing home care and an effective response to the pandemic. We therefore sought to examine nursing home staffing levels during the first nine months of 2020 (compared with the same period in 2019), using auditable daily payroll-based staffing data from the Centers for Medicare and Medicaid Services. We found that the total number of hours of direct care nursing declined in nursing homes during the COVID-19 pandemic, as did the average nursing home census. When we accounted for changes in census, the number of nurse staff hours per resident day remained steady or, if anything, increased slightly during the pandemic. The observed increases in staff hours per resident day were small but concentrated in nursing homes operating in counties with high COVID-19 prevalence, in nursing homes with low Medicaid census (which typically have more financial resources), and in not-for-profit nursing homes (which typically invest more in staffing). These findings raise concerns that although the number of staff hours in nursing homes did not decline, the perception of shortages has been driven by increased stresses and demands on staff time due to the pandemic, which are harder to quantify.

Based on widespread comments from members, we believe staffing levels declined significantly in the nearly 8 months since September 2020, when the study's data period ended.