NACo Brief: Nursing Homes & COVID-19
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Background
Now more than ever, counties are making significant investments in health and human services while also providing critical services to protect and enhance the lives of our nation's vulnerable populations.
COVID-19 had a devastating impact on long-term care environments in the early days of the pandemic. These facilities house older adults and individuals with underlying chronic conditions who are more susceptible to severe complications from COVID-19 illness. In addition, serving this population comes with challenges relating to staffing, PPE, resident transfers and co-horting.In March of 2020, the Centers for Medicare and Medicaid Services (CMS) reported that 127 of the nation's 15,000 nursing homes had at least one resident who tested positive for COVID-19, and the Kaiser Family Foundation reported that in total, approximately one-third of all US deaths from COVID-19 occurred among residents and staff at long-term care facilities.
Counties are on the front lines protecting our communities – especially those citizens that are most vulnerable – from the threat of coronavirus. The concentration of COVID-19 cases and deaths in nursing homes significantly impacts both counties and our residents.
Nationally, counties own and operate 824 skilled nursing facilities and nursing homes.
This brief is a resource for counties on federal guidance, policies, data and local best practices relating to COVID-19 outbreaks and ongoing infection control measures in long-term care facilities.
Skilled Nursing Facility (SNFs) | These facilities provide senior care, meal preparation, and non-medical assistance, but also have specialized staff such as speech-language pathologists, rehabilitation specialists, audiologists, among others. Skilled nursing care is typically provided for rehabilitation patients that do not require long-term care services. This type of care is also referred to as post-acute care, in that it typically is provided following an emergency hospital stay. |
Nursing Home | These facilities also provide care to residents with the presences of certified nurses, meal preparation, and non-medical assistant like bathing; however, they lack the on-site licensed medical practitioners of a skilled nursing facility. Nursing home facilities are also known as long term care (LTC) or extended care facilities (ECF). They provide more permanent care, as oppose to the more transient nature of skilled nursing facilities, however nursing homes and SNFs can be combined. |
Key UpdatesNACo made several key updates to this brief to reflect the changing landscape of COVID-19 prevention and mitigation efforts in long-term care environments, including:
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Data
County-owned or supported nursing homes across the US.
Figure 1. Number of Nursing Homes. (Source: NACo Analysis of U.S. Department of Health & Human Services Data)
Figure 2. County Supported Nursing Homes. (Source: NACo Analysis of U.S. Department of Health & Human Services Data)
- Counties own and operate 449 nursing homes and directly support 758 nursing homes across the US.
- 41 out of the 48 states with county governments (85 percent), plus the District of Columbia, have at least one county-owned or county-supported nursing home.
- Indiana and Texas each have over 100 county-owned or supported nursing homes
- As of 2019, there are 14,871 nursing homes located in counties across the US with 1.26 million residents.
Rates of COVID-19 Vaccination in Long-Term Care Facilities
Nursing and Residential Care Facilities Employment Data (In Thousands)
Figure 3. Number of People With at Least One Dose in Long-Term Care Facilities. Source: CDC COVID Data Tracker. https://covid.cdc.gov/covid-data-tracker/#vaccinations-ltc
Change in Nursing and Residential Care Facilities Employment Data (In Thousands)
Figure 4. Number of Fully Vaccinated People in Long-Term Care Facilities. Source: CDC COVID Data Tracker. https://covid.cdc.gov/covid-data-tracker/#vaccinations-ltc
From December 2020 – April 2021, the US has fully vaccinated 1.4 million residents in long-term care facilities (LTCFs) and over 1 million LTCF staff
COVID-19 Cases and Death Rates in Long-Term Care Facilities since December 2020
Kentucky | -35% |
New Hampshire | -19% |
California | -14% |
Connecticut | -14% |
South Carolina | -12% |
Source: KFF analysis of state reports, state dashboards, press releases, press conferences, official state data from news reports, and the COVID Tracking Project. State population data is from 2019 US Census Bureau Estimates
- CDC reports that since COVID-19 vaccinations began in mid-December 2020, the number of COVID-19 deaths in LTCFs in all states declined by 89 percent as of April 2021
- New cases in LTCFs dropped by 92 percent between December 2020 and April 2021
Staffing trends in long-term care facilities
Figure 5. Nursing and Residential Care Facilities Employment Data (In Thousands). Source: Altarum analysis of monthly BLS Current Employment Statistics data. https://altarum.org/sites/default/files/uploaded-publication-files/SHSS-Labor-Brief_May_2021.pdf
Figure 6. Nursing and Residential Care Facilities Employment Data (In Thousands). Source: Altarum analysis of monthly BLS Current Employment Statistics data. https://altarum.org/sites/default/files/uploaded-publication-files/SHSS-Labor-Brief_May_2021.pdf
According to the Bureau of Labor Statistics, employment numbers in nursing and residential care facilities continues to fall, down 340,000 jobs since February 2020.
Overview of Federal Guidance
Since the start of the COVID-19 pandemic, there has been a flurry of administrative guidance and regulatory actions to address the spread of the virus in high-risk congregate living environments, particularly in skilled nursing facilities (SNFs) and nursing homes. Below is a comprehensive summary of the federal guidance, regulatory actions and resources aimed at mitigating and stopping the spread of COVID-19 in these settings as of this brief's date of publication. Providers and facilities should also consult with their local and state health departments for updates and further guidance.
Vaccinate long-term care residents and staff
Residents of long-term care facilities (LTCF) are at increased risk of infection and severe illness from COVID-19. As such, the Centers for Disease Control and Prevention (CDC) recommends that all LTCF residents be vaccinated against COVID-19. Given LTCF health care personnel's (HCP) essential role in fighting the COVID-19 pandemic and their increased risk of getting COVID-19 and spreading it to their patients, CDC also recommends that HCP be vaccinated against COVID-19.
To ensure access to the COVID-19 vaccine, CDC established the Pharmacy Partnership for Long-Term Care Program. The program provides end-to-end management of the COVID-19 vaccination process, including cold chain management, on-site vaccinations and fulfillment of reporting requirements, to facilitate safe vaccination while reducing the burden on LTCFs and jurisdictional health departments. Both LTCF residents and staff were eligible to receive a vaccine through the program
While the program has now ended, facilities may continue working with their federal pharmacy partner or another provider to provide COVID-19 vaccines. States are also working to ensure that LTCFs that did not enroll in the Pharmacy Partnership can receive the vaccine through local health departments or other methods.
Further, in March 2021, the federal government began providing a direct allocation to long-term care (LTC) pharmacies participating in the Federal Retail Pharmacy Program. A list of LTC pharmacies currently enrolled in this program is available here. These weekly allocations continue to increase as more supply becomes available.
To continue receiving the COVID-19 vaccine, CDC recommends LTCFs administrators and clinical leadership consider the following options:
- LTCF staff should contact their facility's current LTC pharmacy to see if they are enrolled to provide the COVID-19 vaccine through their state or territory.
- LTC pharmacies that are not enrolled to provide the COVID-19 vaccine with the state or territory or through the Federal Retail Pharmacy Program can visit their state immunization program website to view options for becoming a COVID-19 vaccination provider.
LTCFs becoming COVID-19 vaccination providers would be responsible for vaccine ordering, storage, handling and administration. They would also be responsible for reporting supply and vaccine administration information to their state.
The federal government has also provided guidance on communicating and building confidence around the COVID-19 vaccine with LTCF residents and their families and staff. When preparing staff for vaccination, the CDC recommends emphasizing that COVID-19 vaccination will save lives, encouraging open communication to address concerns and questions transparently, informing staff of their options to receive the vaccine and providing consistent and impactful messages about vaccine safety and effectiveness.
When preparing residents for vaccination, the CDC recommends engaging in effective COVID-19 conversations to understand residents' concerns and questions, answering questions around vaccine consent and explaining that anyone who receives the vaccine will be given an Emergency Use Authorization (EUA) fact sheet before vaccination and discussing expectations around changes to visitation policies and other infection and prevention control practices after the vaccine.
Other Key Resources for COVID-19 Vaccination in Nursing Homes:
- Importance of COVID-19 vaccination for residents of long-term care facilities
- Communication resources for COVID-19 vaccines
- Preparing staff for COVID-19 vaccination
- Preparing residents for COVID-19 vaccination
- COVID-19 Vaccine Communication and Confidence Checklist
- COVID-19 Vaccine Safety in Long-Term Care Facilities
Use federal resources to review, assemble and strengthen strategic plans and procedures for emergency preparedness and infection prevention and control.
Prior to the current public health emergency, Medicare and Medicaid-participating long-term care facilities have been required by law to establish and maintain infection prevention and control programs designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections.
During the COVID-19 pandemic, the Centers for Disease Control and Prevention (CDC) recommends that nursing home and long-term care facilities review their infection prevention and control policies and procedures for safety precautions, to protect both residents and staff. The agency has released and updated a guidance framework entitled, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes. Some of the recommendations made within this document can be modified in response to COVID-19 vaccinations. These modifications can be viewed in CDC's Updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 vaccination.The key concepts of this guidance (as of May 20, 2021) are as follows:
- As regular practices resume and facilities begin to relax restrictions, nursing homes must sustain core IPC practices and remain vigilant for COVID-19 infection among residents and HCP to prevent spread and protect residents and HCP from severe illnesses, hospitalizations and death.
- Isolate symptomatic patients as soon as possible by placing patients with suspected or confirmed COVID-19 in private rooms with the door closed and private bathrooms where possible.
- Protect healthcare personnel by providing necessary personal protective equipment (PPE), cohorting patients with COVID-19 and limiting the number of staff that provide care for infected patients.
Other Key Resources for Addressing COVID-19 in Nursing Homes:
- CDC's Infection Prevention and Control Assessment Tool for Nursing Homes Preparing for COVID-19
- CDC's COVID-10 Preparedness Checklist for Nursing Homes and other Long-Term Care Settings
- CMS' COVID-19 Focused Survey for Nursing Homes (zip file)
Spotlight Resource: The Federal Long-Term Care (LTC) Ombudsman ProgramAuthorized by the Older Americans Act and administered by the Administration on Aging (AoA), the federal Long-Term Care (LTC) Ombudsman program operates in every state and the District of Columbia. State Ombudsmen—typically located in State Units on Aging—designate staff and thousands of volunteers statewide as representatives to directly serve residents of nursing homes, board and care homes and assisted living facilities, addressing complaints and advocating for improvements in the long-term care system. LTC Ombudsman duties include visiting residents regularly, addressing and resolving quality of care and safety issues, training staff, families and residents on resident’s rights and abuse prevention, helping prevent inappropriate evictions and more. Guidance from the AoA details the important role that LTC Ombudsman programs can play in emergency planning and response. These model policies and procedures:
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Adhere to standard federal guidelines on staff protocols, resident co-horting, screening of residents and healthcare professionals, and implementing visitation restrictions.
Within its guidance for protection prevention and control measures in healthcare settings, the CDC outlined specific actions to protect staff and residents from the spread of the infection. Below is a summary of these measures as of May 20, 2021.
Infection Prevention & Control Program |
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Educate Residents, HCP and Visitors on COVID-19 |
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Reporting COVID-19 Outbreaks |
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Vaccinations |
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Source Control |
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Visitation |
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Personal Protective Equipment |
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Communal Activities & Areas |
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Testing |
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Evaluating & Managing HCP |
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Evaluating & Managing Residents |
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Cohorting of Residents with COVID-19 |
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Resident Intake and Transfer |
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New Challenge: Long Term Care Workforce ShortagesWhile recent jobs numbers show a number of industries recovering from pandemic job loss, nursing home and residential care facilities have continued to see a steady decline. According data from the Bureau of Labor Statistics, nursing home employment fell by 7.4% from March to April 2021, making April the 15th consecutive month of job loss for this sector that is down 338,000 jobs since peak employment numbers in February 2020. According to the American Health Care Association (AHCA) workforce recruitment and retention has been a persistent challenge for long term care providers due to the ongoing shortage of trained caregivers for critical roles, which may be contributing to the slow job recovery in this sector. |
Assess supply of personal protective equipment (PPE) and initiate measures to optimize current supply.
The CDC has stated that transmission from asymptomatic and pre-symptomatic residents of congregate living facilities with COVID-19 can occur in healthcare settings, particularly in geographic areas with moderate to substantial community transmission. Therefore, HCP working in LTCFs should use CDC-recommended personal protective equipment (PPE) throughout the facility.
While concerns over PPE shortages have diminished in recent months due to an increase in available supply, LTCFs should still maintain an accurate survey of their PPE and facilities are required to report their supply information to the National Healthcare Safety Network (NHSN) Long-term Facility (LTCF) COVID-19 Module weekly. Facilities should also use the NHSN LTCF COVID-19 Module to indicate critical PPE shortages (i.e., less than one week supply remaining). The American Health Care Association (ACHA) also recommends contacting your local healthcare coalition, state health department, local health department or local hospital(s) and health care providers in your area if running low on PPE.
PPE also helps protect health care professionals from potentially infectious patients and materials and toxic medications, and other potentially dangerous substances used in healthcare delivery. The agency has published guidelines for optimizing PPE supplies, with detailed descriptions on recommendations for eye protection, isolation gowns, gloves, facemasks, N95 Respirators, Powered Air Purifying Respirators, Elastomeric Respirators, and Ventilators.
The Personal Protective Equipment (PPE) Burn Rate Calculator is a spreadsheet-based model designed to help healthcare facilities plan and optimize PPE use during the COVID-19 pandemic. The tool calculates the average consumption rate, also known as the "burn rate," for each type of PPE entered in the spreadsheet. The information from the calculator can then be used to estimate how long PPE supplies will last, based on the average consumption rate, and can help facilities make order projections for future needs.
Other guidance published by the CDC includes providing supplies necessary to adhere to recommended infection prevention and control practices. This guidance contains the recommendation to place FDA-approved alcohol-based hand sanitizer with 60-95 percent alcohol in every resident room and other resident care and common areas. Unless hands are visibly dirty, hand sanitizer is generally preferable to soap and water in most clinical situations (including before and after touching a resident) due to evidence of better compliance.
The CDC also recommends that facilities make necessary PPE available in areas where resident care is provided and positing a trash can near the exit inside resident rooms to make it easy for staff to discard PPE before exiting the room or providing care for another resident in the same room.
Additionally, employers should select appropriate PPE and provide it to HCP per Occupational Safety and Health Administration (OSHA) PPE Standards. LTCFs should maintain supplies of facemasks, N95 or higher-level respirators, gowns, gloves and eye protection and implement an OSHA-compliant Respiratory Protection Program that includes medical evaluations, training and fit testing.
Nursing Home Oversight During COVID-19: The Role of State Survey Agencies (SSAs)CMS works in partnership with State Survey Agencies (SSAs) to oversee nursing homes. SSAs are responsible for state licensure and make annual visits to nursing homes participating in the Medicare and Medicaid program to ensure compliance with CMS’s health and safety requirements as well as state licensure requirements. SSAs also investigate and validate complaints made my individuals. While CMS suspended non-emergency inspections across the country earlier in the COVID-19 pandemic, in January 2021 SSAs were instructed to resume more routine surveys once a state had entered Phase 3 of the Nursing Home Reopening Guidance. Guidance on these inspections is available here. |
Ensure compliance with federal regulations on transparency and reporting.
The Centers for Disease Control and Prevention (CDC) and the Centers for Medicare and Medicaid Services (CMS) have implemented many regulatory actions since the start of the COVID-19 public health emergency to improve COVID-19 reporting and transparency in nursing homes. Below is a summary of reporting requirements around COVID-19 case and vaccination.
COVID-19 Case & Vaccination and Treatment Reporting Requirements
In May 2020, CMS released an interim final rule (IFR) entitled "Updating Requirements for Notification of Confirmed and Suspected COVID-19 Cases Among Residents and Staff in Nursing Homes." The IFR sets requirements for reporting new cases of COVDI-19. These reporting requirements are subject to existing federal privacy laws, including the 42 CFR Part 2 rule governing the confidentiality of patient health records.
Additionally, in May 2021, CMS published an interim final rule (IFR) entitled "COVID-19 Vaccine Immunization Requirements for Residents and Staff." The IFR establishes requirements around the COVID-19 vaccine in LTCFs, including reporting the vaccine status of residents and staff, each dose of the vaccine received, COVID-19 vaccination adverse events and therapeutics administered to residents for treatment of COVID-19.
Below is a summary of the reporting requirements:
What to Report | Who to Report To | When or How Frequently to Report |
| Weekly | |
The occurrence of either:
| Residents, their representatives, and families of those residing in the facility | 5 p.m. the next calendar day |
Links to Additional Federal Guidance:
Center for Medicare and Medicaid Services (CMS)
- Toolkit on State Actions to Mitigate COVID-19 Prevalence in Nursing Homes
- Nursing Home Reopening Guidance for State and Local Officials
- Nursing Home Visitation COVID-19 Memorandum
- LTCF Testing Requirements and Revised COVID-19 Focused Survey Tool
- Nursing Home Visitation
Centers for Disease Control and Prevention (CDC)
- Key Strategies to Prepare for COVID-19 in Long-Term Care Facilities (LTCFs)
- Updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccination
- Optimizing Supply of PPE and Other Equipment during Shortages
- Improve the Fit and Filtration of Your Mask to Reduce the Spread of COVID-19
- Strategies to mitigate Healthcare Personnel Staffing Shortages
Overview of Federal Legislation
Nursing Home Provisions in COVID-19 Packages | ||
Bill Number/Title | Summary | Date Passed |
Families First Coronavirus Response Act (PL 116-127) |
| Signed into law March 18, 2020 |
CARES Act (PL 116-136) |
| Signed into law March 27, 2020 |
Paycheck Protection Program and Health Care Enhancement Act (PL 116-139) |
| Signed into law April 24, 2020 |
Consolidated Appropriations Act of 2021 (PL 116-260) |
| Signed into law December 27, 2020 |
American Rescue Plan Act (P.L. 117-2) |
| Signed into law March 11, 2021 |
Standalone Nursing Home and Long-Term Care Facility COVID-19 Bills | |||
Bill Number/Title | Sponsor | Summary | Status |
Quality Care for Nursing Home Residents and Workers During COVID-19 Act (S. 317) | Sen. Cory Booker (D-N.J.), Sen. Richard Blumenthal (D-Conn.) |
| Introduced on February 12, 2021, and referred to the Senate Finance Committee |
Quality Care for Nursing Home Residents and Workers During COVID-19 and Beyond Act (HR 598) | Reps. Jan Schakowsky (D-Ill.), Mark Takano (D-Calif.) |
| Introduced on January 28, 2021, and referred to the House Ways Means and Energy & Commerce Committees |
COVID-19 Nursing Home Protection Act of 2021 (S. 333) | Sens. Bob Casey (D-Pa.), Raphael Warnock (D-Ga.), Sheldon Whitehouse (D-R.I.), Cory Booker (D-N.J.), Maria Cantwell (D-Wash.), Bob Menendez (D-N.J.), Jeanne Shaheen (D-N.H.), Tina Smith (D-Minn.), Amy Klobuchar (D-Minn.), Tammy Duckworth (D-Ill.), Chris Van Hollen (D-Md.), Sherrod Brown (D-Ohio), Catherine Cortez Masto (D-Nev.), Jack Reed (D-R.I), Mazie Hirono (D-Hawaii), Maggie Hassan (D-N.H.) |
| Introduced on February 22, 2021, and referred to the Senate Finance Committee |
PROTECT Long Term Care Facilities Act (HR 844) | Reps. Mikie Sherrill (D-N.J.), Bill Pascrell (D-N.J.), Donald Payne (D-N.J.), Albio Sires (D-N.J), Judy Chu (D-Calif.), Jimmy Panetta (D-Calif.), Daniel Kildee (D-Mich.) |
| Introduced on February 4, 2021, and referred to the House Energy & Commerce and Ways & Means committees |
County Best Practice Examples
Fairfax County, Va. | To prevent large-scale outbreaks in its long-term care facilities, the county has a response plan in place if one positive case in a facility is detected. The county dispatches a rapid response team to provide training on appropriate personal protective use and general infection prevention practices. Additionally, the county assigns a public health nurse to lead an investigation and provide recommendations when necessary. |
Los Angeles County, Calif. | The county uses a four-pronged approach to increase vaccinations in its facilities: Policy & Procedure, People, Culture, and Materials. The county recommends holding regular services to provide information on the vaccines and answer any questions. Additionally, the county recommends empowering a diverse group of vaccine champions to share their vaccine experiences and encourages the community to show compassion to people still considering whether to get vaccinated. |
Multnomah County, Ore. | The county advises its long-term care facilities to make broad preparations for when they encounter a positive test. The county recommends that the facilities develop a Continuity of Operations Plan to respond to an outbreak. Additionally, they recommend determining which staff members would care for patients and training personnel to perform essential functions. If a facility encounters a positive test, they require them to test all residents, facility staff and associated staff within three days. |
Franklin County, Ohio | Franklin County provides weekly updates on positive case counts among residents and staff in all long-term care facilities in the county. The data, which are easily accessible on the county's website, include cumulative totals as well. |
Oakland County, Mich. | The county produced a two-page document with relevant guidelines, action steps, and links that overview how its long-term care facilities had been responding to the pandemic. The document includes procedures for handling visitors, managing outbreaks, and educating staff about COVID-19. |
Federal Advocacy MessagesSupport policy solutions that help build a strong long-term care workforce. The nursing home and long-term care sector have had persistent challenges with workforce recruitment and retention, an issue only exacerbated by the COVID-19 pandemic, which disproportionately impacted these facilities. According to the Bureau of Labor Statistics data, nursing home employment fell by 7.4 percent from March to April 2021, making April the 15th consecutive month of job loss for this sector, which is down 338,000 jobs since peak employment numbers in February 2020. County recovery depends on partnerships at the federal level that will establish a strong health care workforce in long-term care in nursing environments to provide the highest level of care to our most vulnerable residents. Support legislation that enhances federal aid for skilled nursing and long-term care facility COVID-19 response efforts. Given the tremendous impact that COVID-19 has had on congregate living facilities, counties need congressional support for legislation that enhances federal aid for skilled nursing and long-term care facilities in subsequent COVID-19 packages. Without the tools to effectively manage the spread of the disease in these facilities – including adequate personal protective equipment (PPE), funding for testing, medical supplies and staffing support – counties cannot effectively protect their residents and assist in helping our nation recover from this pandemic. |
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