Post-Acute Care & Nursing Facilities

There is a common saying in healthcare – “if it isn’t documented, it didn’t happen.” In the healthcare industry, and particularly in the long-term care (“LTC”) sector, clinical and operational documentation has long been critical for purposes of ensuring appropriate patient care and demonstrating compliance with the myriad regulatory requirements imposed by the Centers for Medicare & Medicaid Services (“CMS”), as well as state licensing and Medicaid agencies.

COVID-19 clearly presents unique challenges to LTC facilities. Although infection control and emergency planning protocols are not new to LTC facilities, the rapidly changing landscape of guidance issued by federal, state, and local regulatory bodies relating to COVID-19 has placed LTC facilities in a position where they must implement, and simultaneously communicate to staff, residents, and resident family members, new or updated clinical and operational protocols on a daily, if not hourly, basis. Given the urgency in ensuring appropriate protocols are in place, there is often an emphasis on action, as opposed to documenting the actions taken.

On April 7, 2020, the U.S. District Court for the Western District of Arkansas granted summary judgment in favor of the U.S. Department of Health and Human Services (“DHHS”) in the closely-watched Northport case. In this case, certain nursing facility industry plaintiffs challenged the enforceability of the most recent iteration of the Centers for Medicare & Medicaid Services’ (“CMS”) rule governing the use of pre-dispute arbitration agreements with residents in long-term care (“LTC”) facilities that participate in the Medicare or Medicaid programs. In finding for the government, the Northport court held that the rule was a valid exercise of CMS’s authority under the Administrative Procedures Act (“APA”), was adopted in accordance with federal procedural rules, and does not conflict with the Federal Arbitration Act (“FAA”).

On April 2, 2020, at the direction of the president, CMS issued additional guidance [https://go.cms.gov/2V1QBdM] regarding the mitigation of the spread of COVID-19 in the country’s nursing facilities. The guidance was apparently issued in response to recent onsite observations by CMS and CDC experts in nursing facilities. In short, the guidance addresses five key issues:

On March 24, 2020, the Wisconsin Department of Health Services (DHS) prepared correspondence to the Center for Medicare and Medicaid Services (CMS) seeking waivers of certain Medicaid requirements pursuant to Section 1135 of the Social Security Act (42 U.S.C. § 1320b-5) due to the COVID-19 pandemic. The correspondence to CMS was shared on March 24, 2020 with the Wisconsin Legislature Joint Committee on Finance seeking their approval to submit the Section 1135 Waiver to CMS. The letter to CMS prepared by DHS states that Wisconsin is implementing all the blanket waivers issued by CMS on March 13, 2020 in Medicare, Medicaid and the Children’s Health Insurance Program (CHIP), to the extent applicable.

Since February 6, 2020, the Centers for Medicare and Medicaid  (CMS) issued official Coronavirus (COVID-19) guidance for health care providers in all care settings to implement in an effort to control the rate of COVID-19 transmission. However, a special focus is on nursing facilities because these facilities house the country’s population most susceptible to COVID-19. In the CDC’s March 18, 2020 Morbidity and Mortality Weekly Report (MMWR), the agency highlights the COVID-19 outbreak at a nursing home in King County, Seattle, Washington, in which 81 of the 130 residents (62%) contracted COVID-19, and 49 of those residents were hospitalized. The median age of the infected residents was 81 years old. To date, 80% of deaths related to COVID-19 are of persons 65 years old or greater.  Therefore, it is imperative nursing homes take drastic measures to reduce the risk of severe illness or death associated with COVID-19. Husch Blackwell’s answers to the Frequently Asked Questions below follow the current CDC and CMS guidance which outlines these drastic measures.

On March 20, 2020, the Texas Health and Human Services Commission issued Provider Letter 20-23, providing clear guidance to Texas’ assisted living communities on how to reduce the risk of the spread of COVID-19. Finding that; “…COVID-19 presents a significant health and safety risk to ALF residents” and that “the best method of protecting [residents] from infection is to keep the infection out of the facility”, the provider letter adopts guidelines that are similar to those put in place several days ago for nursing facilities. Significantly, the letter determines that; “[a] resident’s right to visitation can be restricted in order to protect the health and safety of residents”.

These are extraordinary times. COVID-19, or the novel coronavirus, has disrupted the life of every American and every business. Hospices are no exception. In fact, they are on the frontlines, responsible for providing care to the elderly, a population extremely susceptible to COVID-19. The Husch Blackwell Hospice Team is fundamentally a group of problem solvers,…

The CDC’s latest Morbidity and Mortality Weekly Report released Wednesday, March 18, 2020, reiterated that both residents and the workforce of long term care facilities remain most vulnerable to the exposure and spread of COVID-19.  According to the Report, “[s]ubstantial morbidity and mortality might be averted if all long-term care facilities take steps now to prevent exposure of their residents to COVID-19. The underlying health conditions and advanced age of many long-term care facility residents and the shared location of patients in one facility places these persons at risk for severe morbidity and death.”

In the wake of the COVID-19 global pandemic declaration, hospice providers are faced with the difficult conundrum of ensuring the continuity of care for their vulnerable patients while attempting to comply with the recent CDC and CMS guidelines regarding post-acute care facilities’ lock-down procedures. There is no question the intentions of long-term care facilities are well-meaning in an effort to protect its residents who are most susceptible to COVID-19 complications.[1] However, these precautionary measures put residents receiving hospice services at risk of missing supportive treatment and important care planning.  The American Health Care Association (AHCA) and National Center for Assisted Living (NCAL) derived its skilled nursing facility visitor restriction recommendations from the CMS revised guidance issued March 9, 2020, and hospice providers should take note of these recommendations to ensure they are not prohibited from caring for their patients.

Courts recognize the complication that exists when determining what constitutes actionable harassment where a healthcare employee is a caretaker for a patient with diminished capacity. The Fifth Circuit Court of Appeals recently reviewed this issue in a Title VII case that highlights the risks posed to employers in the healthcare and social assistance industries by patient harassment and violence: Gardner v. CLC of Pascagoula, LLC, No. 17-60072 (February 6, 2019). In Gardner, the Fifth Circuit explained the risks to healthcare employers when it reversed summary judgment on a nurse assistant’s claim for hostile work environment and retaliation, holding that a genuine dispute of material fact existed as to whether an assisted living facility took reasonable precautions to prevent sexual harassment and physical violence by a resident.

Background

Gardner was a Certified Nursing Assistant employed at the Plaza Community Living Center, an assisted living facility, and “often worked with patients who were either physically combative or sexually aggressive.” Gardner had been assigned to work with a patient who had been diagnosed with multiple “physical and mental illnesses,” and had a reputation for groping female employees, as well as a history of violent and sexual behavior toward both patients and staff at the facility. Gardner alleged that she put up with propositioning and sexual assault by the patient on a regular basis, but that when she complained to the administrator at the facility, she was told to “put [her] big girl panties on and go back to work.”