Do No Harm?

On August 25, 2020, the Centers for Medicare & Medicaid Services (CMS) issued a 22-page document to guide state surveyors in the process of assessing compliance with new testing guidelines for long-term care (LTC). Among the highlights:

  • Testing Options: 1) Rapid point-of-care (POC) testing devices with a CLIA Certificate of Waiver or 2) through an arrangement with an offsite laboratory with rapid reporting of results (e.g., within 48 hours).
  • Testing Frequency: Based on 1) Community COVID-19 Activity Level Community, 2) COVID-19 County Positivity Rate in the past week, 3) Symptomatic resident/staff, 4) Outbreak. Varies from monthly to twice a week.
  • Testing Refusal: Guidance for Policies and Procedures if staff or residents refuse testing.
  • Noncompliance related to this new requirement will be cited with the new tag F886. 

The agency also introduced a 202-page memo on the Interim Final Rule for Comment (IFC) outlining the revised regulations to strengthen CMS’ ability to enforce LTC reporting of COVID-19 information, to establish a new testing requirement, and to create new requirements for hospitals and laboratory testing and reporting. Again, testing of residents is mandated to protect them from the infection and to keep them from harm. 

Theoretically, the frailest of our elders are at the highest risk for contracting COVID-19, and they often are the most likely to be uncooperative with the testing because it is extremely uncomfortable, they do not understand the procedure, and they are being approached by someone in PPE which makes the person unrecognizable and frightening.

Our Case: Patsy’s response to testing: “I’m 93 years old and you’re so much younger, and this hurts. Why did you do this to me? Stop it!” And then she burst into tears.

The Society for Post-Acute and Long-Term Care (AMDA) on May 18, 2020, addressed this concern in their policy statement: COVID-19 Testing Strategies Should Be Tailored to the Clinical Situation. Their criteria for universal testing is five-fold: 

  1. Testing must be readily available. 
  2. It must be completed in a timely manner by qualified people. 
  3. Have low false-negative or false-positive rates. 
  4. Impose a low physical or emotional burden on the resident
  5. Be appropriately reimbursed. 

In spite of the wisdom of the AMDA guidance, states continued to push forward on universal testing; and the August 25th guidance from CMS does not accommodate the AMDA guidance. The CMS guidance is well-intentioned. However it was not developed by experts in geriatric medicine or those with experience in the nursing home environment, and it does not take into consideration the physical and emotional burden imposed on the residents being tested. 

To inflict discomfort on the frailest residents, the ones we wish to protect, is unacceptable. Until retail stores, restaurants and bars are closed, mandated masking is imposed, social distancing enforced, staff are tested weekly, and social gatherings restricted, it is unfair to ask the frail elderly to pay a greater price to reduce COVID’s spread by traumatizing them with repeated nasopharyngeal swabs, and PPE- clad staff. We can do better by our frail elders.

Our Case: When the next round of routine testing was scheduled, Patsy, who was asymptomatic, was allowed to refuse the testing after explaining the reason for the testing and offering the option of less invasive testing. Had she been symptomatic or outbreak testing was called for she would have been placed on Transmission-Based Precautions (TBP) until the criteria for discontinuing TBP have been met. This option meets the guidance of 42 CFR § 483.10(c)(6), offers a person-centered approach when explaining, and upholds the essence of “doing no harm”.

Contact us to learn more about frailty and its impact on care in the nursing home population.