As the state struggled to help nursing homes, counties stepped in to fill the gaps

As coronavirus cases appeared in nursing homes across the region, the Bucks County Health Department recommended that the staff in the county’s facilities use masks — a guideline issued before the state’s advisory. The county also provided tests to nursing homes, distributed protective supplies, and assigned staffers to monitor homes with outbreaks.

When the coronavirus swept through Montgomery County’s nursing homes, county leaders asked the state Department of Health for help — but when the state could promise only phone follow-ups, the local Health Department deployed teams to visit hot spots in person.

Pennsylvania’s nursing homes are licensed and inspected by the state, but as COVID-19 took hold, county governments got involved. They learned that nursing homes had taken a backseat to hospitals when it came to getting personal protective equipment, that staff at some facilities were not trained in containment protocols, and that many facilities, while accustomed to dealing with seasonal flu, were unprepared to weather the extended outbreak of a pandemic.

“The state, early on, was intent on helping. But their idea of helping was often sending a memo, without any human follow-up," said David Damsker, director of the Bucks County Health Department. "I don’t blame anyone for not having the resources, but maybe they shouldn’t be regulating these places if they don’t have enough people to do it.”

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Department of Health spokesperson Nate Wardle said the state is assisting its close to 2,000 nursing and other long-term-care facilities by working with local health-care coalitions, the medical reserve corps, and other state agencies. He said staff have conducted site visits to investigate safety concerns, and this month, the federal Centers for Disease Control and Prevention started sending teams to some homes.

“We know that disease outbreaks in congregate care settings are particularly challenging,” he said in an email. “In many cases, by the time we are made aware of an outbreak, a wide number of exposures may have already occurred.”

Local governments in the Philadelphia region have been particularly responsive to the needs of nursing homes, said Zachary Shamberg, president and CEO of the Pennsylvania Health Care Association, which represents more than 400 long-term-care facilities.

“Absent support from Harrisburg, we think it’s fantastic that county health departments are stepping up,” he said. “If we could replicate what we’re seeing in the southeast part of the state everywhere, we would.”

A state announcement last week that nursing homes with COVID-19 cases should begin testing all residents and staff has led some facilities to again ask for guidance. The move would help contain the spread by identifying asymptomatic patients, but carrying it out would require more supplies and staff than many nursing homes have.

Deaths in nursing homes and assisted-living facilities account for more than two-thirds of coronavirus-related fatalities in the state, with the highest number of deaths occurring at homes in Philadelphia, Montgomery, Bucks, and Delaware Counties. More than 13,000 cases have been reported.

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Even as nursing homes banned visitors, screened staff, and began serving meals in residents’ rooms, the virus crept in, due in part to staff members who showed no symptoms and spread it unknowingly.

“It was clear in Pennsylvania that our focus was 100% on hospitals, and that made sense,” Shamberg said. “But the minute the surge didn’t happen, the state should have directed all additional care and attention to these homes.”

The state had a plan to deploy quick-strike teams that would train nursing home staff on infection prevention. But county leaders said the state Health Department has heavily relied on phone consultations done by ECRI, a health-care research institute hired last month.

As COVID-19 took root in nursing homes, staff members grew desperate for masks, gowns, and test kits, said Ruth Cole, director of clinical services for the Montgomery County Health Department, and EMS crews were dispatched to the same homes multiple times a day. She believed some homes needed more than phone calls.

Montgomery County Commissioners Chair Val Arkoosh, a physician, said nursing homes weren’t even on her radar at the start of the outbreak.

“We were working under the assumption that their needs would be met through the Department of Health,” she said. “Once they said, ‘We’re not in a position to provide in-person visits,’ we said, ‘OK, we’re going to have to figure this out ourselves.’ ”

The county has sent six two-person strike teams to dozens of facilities to help with disease control protocols and PPE requests. The county must ask permission before visiting, but Arkoosh said once it’s made clear that the teams are there to help, they are greeted with relief.

Counties without health departments have struggled to get information and supplies. Delaware County, which has been assisted by Chester County’s Health Department since March, has the region’s highest rate of infection. One Broomall nursing home has lost more than 40 residents to COVID-19, and staffing shortages prompted the National Guard to deploy medics.

“It has been very difficult to navigate assisting our nursing homes," said Delaware County Councilwoman Christine Reuther. "We do not have great visibility into what’s going on in these homes, and we need to be careful not to be the regulators, because we don’t have that authority.”

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In Philadelphia, the city Public Health Department has regularly taken the lead in nursing home outbreaks. It has a team of workers trained in infectious disease that reached out to homes in February about how to handle sick patients and screen employees for symptoms.

Even with those preparations, COVID-19 spread rapidly through Philadelphia’s nursing homes. Steve Alles, director of the health department’s disease control division, said many homes aren’t equipped to train employees in containment strategies, such as how to fit-test masks or disinfect PPE without contaminating themselves.

“The work of infection control in a nursing home takes a highly skilled person who has worked in infectious disease control, and nursing homes don’t usually have robust infection control teams," he said. “They don’t have the resources."

Wardle acknowledged the state’s financial challenges, noting that Pennsylvania ranks among the lowest in the nation in terms of public health funding.

“Training on PPE is something that we have been working on during this crisis, but it is correct to say many nursing home staff members likely had not been trained on how to properly wear PPE prior to COVID-19,” he said.

Wardle said the Health Department has sent guidelines to nursing homes about how to roll out universal testing. The state has testing swabs from the federal government to use, and the Health Department and National Guard are working on finding labs to process them.

For many facilities, the idea of testing all employees is panic-inducing, since it could further strain staff levels. Damsker, of Bucks County, said his department will help nursing homes develop a plan.

Overall, he said, the situation in Bucks has improved. Nursing home staff who became ill have recovered and returned to work. In the event of future outbreaks, he believes homes will be able to group the sick together, and separate infected staff from those who haven’t had the virus.

“Once we reopen, we may have another flareup,” he said. “But we’ll be better able to extinguish it.”