Infection control procedures in senior living have come under intense scrutiny during the coronavirus pandemic.
With the immediate crisis and response in the rearview mirror, providers are now turning to keeping their communities safe for the long haul, and are applying the lessons learned responding to the virus as states across the country gradually reopens.
Tighter infection control procedures will be paramount moving forward, because the virus shows no signs of being eliminated and new Covid-19 hotspots are emerging in states that were not initially impacted by the virus or were slow to implement shutdowns. Fourteen states and Puerto Rico recently recorded their highest seven-day averages of new Covid-19 cases since the pandemic started, according to Washington Post data analysis.
Additionally, providers must ensure that communities are in compliance with federal and state infection control guidelines. Those state protocols, however, vary widely, according to a May report from The Journal of Post-Acute and Long-Term Care Medicine (JAMDA). Thirty-two states list infection control as a training component for staff in residential care and assisted living facilities, but the requirements vary by state.
Ten states include language in their infection control policies specifically surrounding epidemics and reporting disease outbreaks to state and local public health departments. Six states directly reference general resident isolation practices for communicable diseases within their infection control policies, and only Massachusetts and Oregon have pandemic preparedness included in their infection control guidelines.
Having responded quickly to the pandemic, Asbury Communities plans on maintaining vigilance for the foreseeable future, Senior Vice President of Health Care Services and Operations Henry Moehring told Senior Housing News. The Frederick, Maryland-based nonprofit operator operates eight CCRCs in Maryland, Pennsylvania and Tennessee.
“[Our] vigilance is still very strong and needs to be strong,’” he said.
Denver-based Solera Senior Living recently enlisted a third-party partner to help draft and implement infection control policies, with an eye toward balancing resident safety and engagement.
Maintaining the basics
Asbury responded quickly to the pandemic because it was able to adapt its communicable disease outbreak plan, which includes guidelines for isolating one or more residents testing positive for a virus, identifies residents and caregivers who have been in close contact with those infected, and institutes protocols for securing entry points, community areas and shared amenities.
Asbury aggressively communicated the need to practice social distancing, proper hand washing, the importance of wearing masks and especially staying at home to its residents and staff.
This has resulted in positive results around compliance with procedures, as well as an increase in self-regulation among frontline staff on proper wearing of personal protective equipment (PPE).
“As time has gone by and the states are relaxing some of their restrictions, we find we still have stringent guidelines from CMS around skilled nursing appropriately, [as well as] around assisted living, and we continue to to hold those barriers up pretty high to protect those residents that are the most vulnerable,” Moehring said.
Protocols such as hand washing have always been an important part of infection protocols, and will certainly continue to be prioritized going forward, Pathway Health Director of Education Sue LaGrange told SHN. Based in Lake Elmo, Minnesota, Pathway Health provides management and consulting services to clients in the long-term and post-acute care industries.
What has changed since the pandemic disrupted the industry are some of the directions for optimizing PPE, due to supply and demand imbalances.
“Some facilities have been able to access an adequate supply of PPE, [but] there are still facilities that are using alternatives because when this pandemic started, they started with conventional [safety equipment], and then went to contingency, and then went to crisis,” LaGrange said.
Asbury is ensuring that all of its communities have adequate PPE stock. Last year, the operator hired Jeremy Leonard as its supply chain program director. He sits in on Asbury’s daily system-wide Covid Call which is the Covid leadership team at the home office and the community leadership teams, gauging what each facility needs in PPE, tracking down suppliers, and shifting inventory between communities if necessary to ensure proper levels.
In its focus on maintaining greater PPE stockpiles going forward, Asbury is not alone. Louisville, Kentucky-based Atria Senior Living — which operates 216 communities — has even secured a warehouse to serve as a distribution hub.
Asbury is also storing specific medical equipment across its buildings, based on use and need, and is cleaning and disinfecting equipment according to CDC and manufacturers’ guidelines. This ensures rapid deployment when needed, and minimizes the risk of cross-contamination.
As the pandemic has settled into a period of relative stability, Asbury has been able to obtain new medical supplies, which will be vital for testing residents, staff and visitors moving forward.
Choosing what to reopen
Reopening protocols, like infection control procedures, also vary widely by state. As a result, providers will err on the side of caution when relaxing access restrictions, and determining what amenities will reopen. Facility lockdowns have exacerbated feelings of isolation and loneliness among senior housing residents these past few months, and providers are cognizant that communal amenities, dining and other group outings are as much social endeavors as functional. Walking a line between wellness and health is critical moving forward.
Asbury is practicing social distancing with its residents for group activities as the pandemic persists, and has limited dining to room service. As more states progress with their reopening plans, the provider is partnering with foodservice vendor, Sodexo, on a review of its dining operations to determine how to reopen dining rooms in a safe manner. The provider has also switched to HEPA filters in its HVAC systems, in hopes of reducing the transmission of viruses through air ducts.
“We’re looking at the layout of our dining rooms, the [feasibility of] buffets. In the short term, you probably won’t see them again, just because of the risk,” Moehring said.
In addition, Asbury is ramping up testing of staff, residents and essential visitors to establish baselines of its communities’ exposures to the virus, which will in turn inform the decisions on what parts of its campuses to reopen.
“We’ve seen success with things like outdoor activities [and] exercise programs where you’re limiting the group, people are wearing masks and you have them physically spaced out. Those are the things that we can build on,” he said.
Working with a third party
Other providers are turning to third parties to ramp up their infection control protocols. Solera Senior Living enlisted the services of a group, The Covid Consultants, a group of infectious disease doctors and nurses based out of Rose Medical Center in the company’s home base of Denver, Solera CEO Adam Kaplan said during a recent appearance on SHN TALKS.
The Covid Consultants conducts site visits of businesses, assesses weaknesses and pain points in a building and operations, establishes guidance for safe reopenings, executes the plan and follows up with clients to update the plans with new CDC and state guidance as it becomes available.
For Solera, outsourcing infection control allows the provider to turn its attention to other pressing issues, and helps to strengthen the company’s culture. Additionally, having a dedicated infection control company on hand helps build trust between the provider, its residents and families that their well-being and safety is top priority.
“We’re senior housing leaders, but we’re not infection control experts. At some point, we’ve got to get beyond spending 90% of our time and energy on infection control. That was a decision that I think was a very smart, prudent one, and one that I had done earlier,” Kaplan said.
In one example of how Covid Consultants has helped, Kaplan described a visitor questionnaire that Solera has been using, based on CDC recommendations. On that form, visitors were being asked whether they had recently traveled to or been in an area considered high-risk for Covid-19. This is a vague question, the Covid Consultant reviewer noted, saying that in her opinion, everywhere is high risk for the coronavirus at the moment.
So, she responded “yes” to that question, and therefore would have been barred from entering the Solera building.
“That’s an example of something where the CDC had good intentions, but now things have changed, and we just need to modify this form to provide more clarity,” Kaplan said.
Another benefit of working with a third-party expert could potentially be in protecting senior living providers from litigation. This was not on Kaplan’s mind when Solera began working with The Covid Consultants, but Kaplan already has seen insurance costs go up, and he believes that the threat of litigation related to Covid-19 is real. Working with respected third-party infection control experts could reasonably reassure residents, families and others.
“I think being able to say, we’ve engaged a third party, this is their expertise, this is how they’ve advised us — I think that will provide a little more validity,” Kaplan said.
For all these reasons, he thinks that securing third-party infection control partners will become much more commonplace within senior living.
“If this was not a lasting change, I would be shocked,” he said.
Infection protocols continue to evolve as more information about Covid-19 is learned from the CDC, state and local public health departments.
On a federal level, the Environmental Protection Agency (EPA) updated its List N of approved disinfectants that meet the agency’s criteria against SARS-CoV-2 — the virus that causes Covid-19.
This list is essential for providers to revisit frequently, in order to find replacement disinfectants due to vendor shortages, LaGrange told SHN. This can be the difference between proper disinfecting of items such as reusable dining supplies or medical equipment.
“[These] chemicals have been reviewed to make sure that they’re meeting the requirements needed for reducing the spread of Covid-19,” she said.
Asbury is maintaining consistency in its clinical education program. Director of Clinical Education Martha Gurzick oversees education for clinical staff all across the system, ensuring that guidelines are uniform across the portfolio. If tweaks do need to be made to conform with a campus’ physical limitations, those changes can be made between Gurzick and local leadership.
“The materials are prepared. It’s not something that each community has to draft or download,” Moehring said.
Asbury’s campuses are staffed with designated “infection preventionists” — registered nurses serving as conduits between Gurzick’s office and frontline staff to ensure that appropriate equipment is on hand and is used appropriately, across the campuses and all shifts. They also work with the clinical team at the system level so that Asbury’s infection control protocols are consistent.
Nursing staffs across Asbury’s campuses have taken the lead in implementing infection controls. Each community participates in the company’s Nurse Practice Council, run by Gurzick and Vice President of Clinical Excellence Skip Margot. The Council reviews protocols and communicates changes and updates to associates on the front line.
“They are managing the front line and they do it very well. It’s about the relationship that that leader or manager has with those associates,” Moehring said.