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Expert Report Maps Out Transformation of NJ’s Troubled Nursing Home Industry
New Jersey needs a better-coordinated system to monitor the state’s nursing homes, additional enforcement muscle to regulate the industry and new tools to enhance transparency, according to an expert report released Wednesday.
Nursing homes themselves, whose residents accounted for one in four of the state’s COVID-19 deaths, need additional funding to hire more staff and pay better wages, greater transparency around facility ownership and more state involvement when it comes to infection control protocols, the report also notes.
Gov. Phil Murphy welcomed the findings from consultants with Manatt Health and committed to spending at least $10 million in federal funding to implement changes. The state is already seeking to better coordinate how it responds to nursing home issues under the pandemic, one of the experts’ most urgent suggestions.
‘A call to do better’ — Murphy
“Their recommendations outline how long-term care facilities can move forward with confidence to reopen for new residents and visitors, and how they can best address mitigation, protection, and resiliency against future outbreaks,” Murphy said at his daily media briefing on Wednesday. “It is a call for all of us to do better — better communication, better support for staff and residents, better monitoring, better coordination between the state and facilities.”
The state hired the group in early May as the number of COVID-19 cases and related deaths continued to mount at skilled nursing facilities, which serve nearly 46,000 elderly and medically compromised individuals who are particularly vulnerable to the novel coronavirus. Manatt Health was paid $500,000 for this work several weeks later.
The experts’ findings come exactly three months after New Jersey identified its first case of COVID-19 and as the Murphy administration faces growing questions about its coronavirus response at nursing homes and other long-term care facilities, as well as prisons and other group residences where the virus can spread easily. Public health leaders have criticized state officials for not instituting more rigorous testing at these sites, and the New Jersey Legislature is forming a bipartisan task force to examine the administration’s response.
“It could not possibly come at a more vital time,” Murphy said of the report, “with recommendations we can put in place now to enhance our current mitigation efforts, and others that will help ensure a stronger, more robust, and more centralized response when the next pandemic comes.”
More than 162,000 New Jerseyans have now been diagnosed with COVID-19, including nearly 11,900 who have died (according to official figures). Residents and staff at long-term care facilities — which include nursing homes, assisted living and residential hospitals — make up at least one in every five cases identified and 42% of the lab-confirmed fatalities, according to state figures. Several states, including Pennsylvania and Connecticut, have seen a greater share of deaths from long-term care, the report noted.
Manatt’s 100-page report — produced by a team led by industry veterans Cindy Mann, a former Obama administration official, and Carol Raphael, who worked with AARP and the Visiting Nurse Service of New York — includes recommendations for the next three months and beyond. Many are designed to address concerns that have plagued nursing homes for decades: a workforce constrained by low pay and limited opportunities; chronic underfunding of the system; and, at some facilities, a poor track record in controlling infection.
“We need a long-term vision that truly learns the lessons of the last two years — the tragedy at Wanaque that should have been the wake-up call and the tragedy we are now in,” said Milly Silva, executive vice president of 1199SEIU United Healthcare Workers East, which represents some 8,000 nursing home workers in New Jersey and has been a vocal advocate for long-term care during the pandemic.
Tragedy at Wanaque
An adenovirus outbreak in the fall of 2018 at the Wanaque Center for Nursing and Rehabilitation — which contributed to the death of 11 young people and sickened some three-dozen others — led to a series of reforms designed to improve infection control protocols at residential health facilities.
In its report, Manatt acknowledges the inherent challenges for these long-term-care facilities, including outdated layouts that put three or four residents in one room, the inherent vulnerabilities of the residents and the staff that serve them and a nationwide shortage of protective equipment for workers, test kits and other resources. In addition, the state — and region — was particularly hard-hit by the coronavirus, with New Jersey reporting 9% of the nation’s COVID-19 cases as of early June, while representing just 3% of the U.S. population, it notes.
“(A)s deep-seated and long-standing as this situation is, we will directly and aggressively confront this challenge, alongside the many good actors in the long-term-care industry,” Murphy said at his briefing, noting the majority of owners and managers are “good people who want to do the right thing” for residents, staff and families. “Together, we will make New Jersey a national leader and national model,” he added.
Representatives for the nursing home industry welcomed the report — praising its comprehensive and long-term view — and pledged to work collaboratively with state officials to improve care for residents. Evelyn Liebman, advocacy director for AARP New Jersey, called it an important roadmap for elder care, but also underscored the importance of implementing the changes outlined in the paper.
“Now is where the rubber meets the road,” Liebman said. “If the last months have taught us anything, this is not a report that can sit on the shelf. We all have a stake in ensuring these recommendations are implemented with deliberate speed.”
The Manatt report, which was produced in about three weeks, involved video and phone conversations with at least 50 stakeholders, Murphy said, including industry representatives, labor leaders, consumer advocates and others. The experts contacted a “sampling” of facilities but did not visit any in person, citing state stay-at-home orders. State and federal inspectors have conducted in-person reviews in recent weeks.
Mann and Raphael organized their recommendations in four categories: strengthening the state’s emergency response capacity; stabilizing facilities and the workforce; increasing transparency and accountability; and improving quality and resiliency over time.
“There’s a lot to unpack in this report,” state Department of Health Commissioner Judy Persichilli said. “These workers and the residents who call these facilities their home need a system that supports the culture of quality, care and of course prevention of infection.”
Some of the key points include:
Strengthen emergency response capacity
- Create a consolidated statewide entity to respond to long-term care emergencies, similar to the emergency operations center in place for broader health or police crises;
- Ensure clear emergency plans are in place in advance to address staffing shortages, family communication, relocating residents if needed and other situations;
- Create a unified web-based dashboard to help stakeholders track long-term care needs and the response.
Stabilize facilities and the workforce
- Enhance wages for nursing-home workers, many of whom earn close to minimum wage;
- Ensure these workers have paid sick leave and opportunities for professional growth;
- Consider boosting Medicaid reimbursements for nursing-home care, or providing relief payments — something Persichilli said the state might do with federal funding.
Increase accountability and transparency in the industry
- Better tracking of nursing-home ownership: Three out of four are for-profit entities;
- Higher penalties for regulatory violations; revoking licenses of repeat offenders;
- Regular inspections and increased oversight;
- Medical-loss ratios, or other requirements to ensure additional funding goes to residential care, not into an owner’s pocket;
- Publicly available nursing-home report cards.
Create a more resilient, higher quality system
- Greater state control and input on infection control at facilities;
- Better coordination among public agencies regulating the industry;
- Establish “Governor’s Task Force on Transforming New Jersey’s LTC Delivery System.”