Since the COVID-19 pandemic first surfaced in the United States, the number of cases and deaths in nursing homes and other long-term care (LTC) facilities has been rising. As of April 23, 2020, more than 10,000 COVID-19 related deaths have been reported among long-term care facility residents, which is a conservative estimate because not all states publish these data. In six states, long-term care facility residents account for 50% or more of all COVID-19 deaths. The steady increase in deaths among long-term care facility residents has become an urgent concern for federal and state policymakers, long-term care facilities, family members of residents, and residents themselves.
On March 13, 2020, the Centers for Medicare & Medicaid Services (CMS) released guidance for nursing homes to help curb the spread of coronavirus infections, including a prohibition on visitors (except for end-of-life situations) and non-essential staff as well as daily screening of staff for fever and respiratory symptoms at the start of their shifts. CMS issued updated guidance on April 2, 2020 recommending use of facemasks by all personnel while onsite, and full Personal Protective Equipment (PPE) by health care staff in facilities where a COVID-19 transmission has occurred or when caring for a resident with a known or suspected COVID-19 diagnosis. More recently, on April 19, 2020 CMS announced it will issue guidelines to require nursing homes to report COVID-19 cases and deaths to the Centers for Disease Control and Prevention (CDC).
The CMS guidance documents pertaining to visitors, screening, and PPE serve as recommendations, rather than mandatory requirements, and apply only to nursing homes that fall under federal regulatory purview. States have the option to impose more stringent guidelines for NFs than those established by CMS, and to establish standards for assisted living facilities (ALFs) and other long-term care residential settings that are not federally regulated.
This analysis examines variation across states in providing regulatory guidance for NFs and ALFs for the three key measures identified by CMS: prohibiting visitors to facilities except for end-of-life situations, performing daily staff screening for illness, and universal use of PPE by facility staff (see Methods for detail).
We find considerable variation across states when it comes to protections against the spread of coronavirus infections in nursing facilities and assisted living facilities. Individual states differ in whether they address all, some, or none of the three measures – visitation, staff screening, and use of PPE – in both NFs and ALFs, as well as whether they require or simply recommend facility adherence to these measures (Figure 1; see map and tables). Many states have weaker standards for assisted living facilities than nursing facilities.
- Most states (29 states + DC) prohibit visitors in nursing facilities and close to half do the same for assisted living facilities (24 states + DC). But two states have no guidelines pertaining to visitation to NFs at all, and six states have no guidelines for visitation to ALFs.
- Staff Screening. It is more common for states to recommend rather than require daily screening of staff for illness in NFs (24 states recommend, 16 states + DC require) and ALFs (25 states recommend, 14 states + DC require).
- Use of PPE. More states recommend (23 states) than require (7 states + DC) staff to use PPE in NFs. Similarly, more states recommend than require staff to use PPE in ALFs (24 states recommend, 7 + DC require). But a large number of states have no guidance at all related to PPE use in NFs or ALFs (18 states and 17 states, respectively).
We found significant state variation in requirements for NFs and ALFs in terms of prohibiting visitors, screening staff for illness daily, and requiring that staff use PPE. While some states impose stringent requirements by prohibiting all visitors except for end-of-life-situations, require daily screening of staff for illness, and mandate staff use of PPE, others have issued no guidance for either NF or ALF visitors, staff screening, and staff PPE use. For both NFs and ALFs, nearly half or more of states and DC have prohibited visitors except for end-of-life situations, but more have recommended, rather than required, daily screening of staff and PPE use by staff. Little is known about the extent to which states are monitoring adherence to these guidelines.
CMS recently announced new regulatory requirements that will require NFs to inform residents, their families, and representatives of COVID-19 cases in their facilities. While not within the scope of our analysis, we observed that some states, such as New Jersey and New York, were already requiring NFs to inform families of COVID-19 cases before CMS issued its mandate. Notably, both of these states have extended this requirement to ALFs as well. CMS will also require NFs to report COVID-19 cases directly to the CDC. Several states, including Alabama, Illinois, Georgia, and Florida, are making data on COVID-19 cases among LTC residents and employees publicly available.
Other states have issued additional requirements to further protect residents in NFs and ALFs. For example, governors in some states (such as Michigan) have issued executive orders protecting LTC residents from being evicted or involuntarily discharged in the event of an outstanding bill. Michigan also prohibits LTC facilities from using COVID-19 testing requirements or results to prohibit admission or readmission of a resident. A few states, such as Maryland, Georgia, and Florida, have called upon the national guard to help protect long-term care facility residents in their state.
With some governors recently announcing the relaxing of restrictions that aim to slow the spread of coronavirus infections, some state guidance issued for NFs and ALFs has expired or will soon expire (unless renewed). For example, Washington’s proclamation to prohibit LTC visitation expired on April 15, 2020, and executive orders issued by Georgia and Tennessee will expire on April 30, 2020. Other states, such as Arizona and North Carolina, have mandated that LTC guidance will expire upon termination of the state’s emergency declaration related to COVID-19.
The state-based patchwork regulatory approach shown in our analysis results in increased vulnerability to infection for some NF and ALF residents, depending on where they live. This situation mirrors a larger national trend in COVID-19 response in which some states have taken more aggressive actions than others, while the federal government assumes a “backup” role. This state-by-state approach to the COVID-19 pandemic may result in uneven rates of illness, hospitalizations, and mortality of long-term care facility residents and staff across the country.
To examine how states are regulating nursing facilities and assisted living facilities in response to the COVID-19 pandemic, we collected and analyzed state-issued guidance for NFs and ALFs for each of the 50 states and District of Columbia. This information was stored in a variety of different online locations, depending on the state: some regulatory guidance pertaining to long-term care facilities was stored on state-run websites dedicated to COVID-19-specific information and resources; some was stored on state Department of Health websites, some was stored on Governors’ websites, and some was stored on the websites of other state regulatory agencies, such as the Department of Human Services. State regulatory information was collected via Google keyword searches as well as targeted searches of government websites as listed above.
Regulatory information pertaining to NFs and/or ALFs was also conveyed in a variety of formats, including executive orders or press releases issued by state Governors’ offices, orders or guidance issued by state Public Health departments or other state regulatory agency (such as the Department of Human Services), or information or guidance appearing on state-run websites housing COVID-19-related information.
State regulatory information pertaining to NFs and ALFs was collected on a rolling basis via online search as detailed above between March 26 and April 20, 2020, and should be considered valid through April 20. Although best efforts were made, due to the wide variation in online location, presentation, and formatting of regulatory information pertaining to NFs and ALFs between states, it is possible that the research team inadvertently neglected to include some information, or was not aware of an update to information already collected. Some state regulatory guidance was directed to “long-term care” settings generally and either did not specify any particular type of facility or specified only one of the facility types discussed in this brief (in addition to “long-term care” settings generally). When that was the case, guidance was assumed to apply to both NFs and ALFs.