Nursing homes are pushing back on recent Covid-19 vaccine reporting requirements that they say are confusing to follow and overwhelming for their already limited staff as they struggle to thwart new outbreaks.
A Biden administration rule requires long-term care facilities to report the vaccination status of their residents and staff on a weekly basis to the Centers for Disease Control and Prevention’s National Healthcare Safety Network (NHSN). The requirements illustrate a conflict for facilities that are facing financial troubles but are key to stemming the pandemic.
The federal Medicare agency says the rule (RIN 0938-AU57) will help monitor vaccine uptake as well as identify facilities in need of additional resources. But frustration has been building after some facilities reported receiving notices of noncompliance—even though they said they’ve submitted the data.
The complexities of the system leave room for error as well as take up time that staff could otherwise be spending taking care of patients, according to LeadingAge, a group representing more than 5,000 nonprofit aging services providers.
“This reporting each week is being done by staff who are desperately needed to be providing care for residents. This is a real challenge,” Jodi Eyigor, director of nursing home quality and policy at LeadingAge, said. “They just keep getting hit with more and more requirements, and now there’s this added layer of complexity and confusion.”
Nursing homes and other long-term care facilities are especially vulnerable to Covid-19 outbreaks. As of July 11, nursing homes reported nearly 660,000 confirmed cases among residents. More than 81% of residents and 58% of staff are vaccinated nationwide.
Facilities that don’t meet the new reporting requirements face a $1,000 penalty for the first occurrence. That penalty increases by $500 for each additional instance of noncompliance, according to the Centers for Medicare & Medicaid Services. Enforcement of the rule was set to begin June 14, and the CMS is making the reported facility-specific vaccination information publicly available.
The time commitment to report the data could be an issue, particularly as nursing homes face extra care responsibilities as well as staffing shortages and turnover.
Nursing homes have had to provide a “higher level of care due to changing guidelines” to prevent Covid-19 outbreaks, Eyigor said. “It’s requiring the people that you do have to do even more work on a smaller resources budget. People are stretched really thin.”
‘No Opportunity to Correct’
Long-term facilities were already required to report Covid-19 testing, cases, and mortality data to the NHSN before the new rule took effect in May. Less than 20% of nursing homes had sent vaccination data to the CDC under voluntary conditions, according to the rule.
“Data on vaccine uptake will be important to understanding the impact of vaccination on SARS-CoV-2 infections and transmission in nursing homes,” the CMS said in its rule. “This understanding, in turn, will help CDC make changes to guidance to better protect residents and staff in LTC facilities.”
But there are nursing homes that have tried to comply yet received reports of being noncompliant, Lisa Sanders, director of media relations at Leading Age, said. Several members said during the early weeks of reporting that they submitted the data—and had a screenshot to prove it—but the CMS wasn’t getting it, she said, noting that fewer providers may be having this problem now.
Sanders said facilities are being issued penalties for not submitting information on a given week, even before the data for that week as a whole is made publicly available. “Without seeing the data and with no explanation of the problem, it has been challenging to correct reporting issues,” she said. “We have reached out to CMS regarding this issue with no opportunity to correct.”
There’s two different modules to report the data in the NHSN—one for hospitals and one for long-term care—so it may be easy to report to the wrong one and miss out on a week of reporting, Eyigor said.
“It’s really not that clear, particularly for someone who is exhausted and having to go into the system and do all of this,” she said. “It can be easy to make a mistake and then the facility misses out on a week’s worth of reporting even if they have reported the data already.”
The CMS didn’t immediately respond to a request for comment on the facilities’ concerns.
‘Blood From a Stone’
The CMS estimated in May that it would take about 30 minutes per week for the additional reporting. Since then, more data elements have been added to each of the various reporting pathways, meaning it could take as long as two and a half hours to complete, Eyigor said.
Nursing home facilities may not have enough staff to both report this data and properly take care of their residents. Nursing homes in recent years have faced high turnover rates, and that’s likely only worsened during the pandemic.
A recent study published in Health Affairs, which used data from more than 15,000 U.S. nursing homes, found that nearly all direct-care staff at the typical facility left their jobs in 2017 and in 2018. High turnover rates can be linked to low compensation, poor working conditions, and few opportunities for advancement, the research found.
Staffing shortages only make it more difficult for facilities to meet new requirements while doing all that they can to combat the public health crisis, according to Eyigor.
“It’s not that nursing homes don’t want to comply with the reporting rule or don’t want to provide good care, they’re just doing too much,” she said. “They are trying so hard and yet you can’t squeeze blood from a stone.”
The rule applies to all long-term care facilities that receive Medicare or Medicaid. The CMS sought comment on the feasibility of extending the vaccination policy to other shared residences such as psychiatric hospitals, assisted living facilities, and group homes.
Disability Rights New York, a nonprofit advocacy group, said the rule is “an important step in recognizing and addressing the disproportionately high risk of infection and death for people with disabilities in congregate settings.” It also said it would like to see the rule expanded to all congregate care settings serving people with disabilities.
“Identifying trends and drawing conclusions is impossible without access to complete information,” DRNY wrote in a comment letter to the CMS. “We cannot prevail in the fight to control and limit infections and prevent deaths without accurate and comprehensive data.”
A group representing assisted living facilities, however, said it fears it would be “overly burdensome” for them to comply with the requirements given the threat of penalties.
Assisted living facilities haven’t received “anywhere near close” to the same amount of federal and state Covid-19 relief as other types of providers, yet they’ve suffered more than $30 billion in losses due to Covid-19 testing, cleaning, staffing needs, and low occupancy rates, Margie Zelenak, executive director of the Pennsylvania Assisted Living Association, said in a letter commenting on the rule. More reporting would only add to these losses.
“Many are still waiting for relief, and others have been inexplicably denied. As a result, nearly half are operating at a loss, and over half report that closures are imminent,” Zelenak said.
“Extending the IFC’s requirements to the assisted living industry, with serious penalties for noncompliance, would only exacerbate these problems for an industry that has been at the front lines caring for those most vulnerable to this deadly disease,” she said.