Coronavirus Commission for Safety and Quality in Nursing Homes Commission Final Report September 2020 Approved for Public Release; Distribution Unlimited 20-2378. © 2020 The MITRE Corporation. All Rights Reserved. Commission Final Report NOTICE This document was produced for the U. S. Government under Contract Number 75FCMC19F0012, and is subject to Federal Acquisition Regulation Clause 52.227-14, Rights in Data-General. No other use other than that granted to the U. S. Government, or to those acting on behalf of the U. S. Government under that Clause is authorized without the express written permission of The MITRE Corporation. For further information, please contact The MITRE Corporation, Contracts Management Office, 7515 Colshire Drive, McLean, VA 22102-7539, (703) 983-6000. Approved for Public Release; Distribution Unlimited 20-2378. © 2020 The MITRE Corporation. All Rights Reserved. Commission Final Report Coronavirus Commission for Safety and Quality in Nursing Homes Morgan Jane Katz, MD, MHS Assistant Professor of Medicine, Johns Hopkins Commission Members University, Maryland Roya Agahi, RN, MS HCM, WCC Beverley L. Laubert, MA Chief Nursing Officer, CareRite, New York State Long-Term Care Ombudsman, State Department of Aging, Ohio Lisa M. Brown, PhD, ABPP Professor of Psychology, Rosie D. Lyles, MD, MHA, MSc, FACA Palo Alto University, California Director of Clinical Affairs, Medline Industries, Mark Burket Illinois CEO, Platte Health Center Avera, South Dakota Jeannee Parker Martin, MPH, BSN, RN Eric M. Carlson, JD President and CEO, LeadingAge California Directing Attorney, Justice in Aging, California G. Adam Mayle, CHFM, CHC, CHE (does not endorse this report) Administrative Director of Facilities, Memorial Michelle Dionne-Vahalik, DNP, RN Healthcare System, Florida Associate Commissioner, State Health and Human David A. Nace, MD, MPH, CMD Services Commission, Texas President, AMDA –The Society for Post-Acute and Debra Fournier, MSB, BSN, RN-BC, Long-Term Care Medicine, Pennsylvania LNHA, CHC, CPHQ Lori Porter, LNHA, CNA Chief Operations Officer, Veterans’ Homes, Maine CEO, National Association of Health Care Assistants, Missouri Terry T. Fulmer, PhD, RN, FAAN President, The John A. Hartford Foundation, Neil Pruitt, Jr., MBA, MHA, LNHA New York Chairman and CEO, PruittHealth, Inc., Georgia Candace S. Goehring, MN, RN Penelope Ann Shaw, PhD Director, State Department of Social and Health Nursing Home Resident and Advocate, Braintree Services, Aging and Long-Term Support Manor Healthcare, Massachusetts Administration, Washington Lori O. Smetanka, JD David C. Grabowski, PhD Executive Director, National Consumer Voice for Professor of Healthcare Policy, Harvard University, Quality Long-Term Care, Maryland Massachusetts Janet Snipes, LNHA Camille Rochelle Jordan, RN, BSN, MSN, Executive Director, Holly Heights Nursing Home, APRN, FNP-C, CDP Colorado Senior Vice President of Clinical Operations & Innovations, Signature Healthcare, Kentucky Patricia W. Stone, PhD, MPH, FAAN, RN, CIC Jessica Kalender-Rich, MD, CMD, AGSF, Professor of Health Policy in Nursing, Columbia FAAHPM, FACP University, New York Medical Director, Post-Acute Care, University of Kansas Health System, Kansas Dallas Taylor, BSN, RN Director of Nursing, Eliza Bryant Village, Ohio Marshall Barry Kapp, JD, MPH Professor Emeritus of Law, Florida State University, Florida Approved for Public Release; Distribution Unlimited 20-2378. © 2020 The MITRE Corporation. All Rights Reserved. Commission Final Report Table of Contents Executive Summary ........................................................................................................ iii Principal Recommendations ............................................................................................... vii 1 Introduction .................................................................................................... 1 2 Background .................................................................................................... 6 2.1 CMS and State Regulation of Nursing Homes .................................................... 6 2.2 SARS-CoV-2 Exposure, Spread, and Mitigation in Nursing Homes ...................... 8 2.3 COVID-19 and Nursing Home Data .................................................................. 9 2.4 Systemic Problems in Long-Term Care ............................................................ 11 2.5 Guiding Principles in Relation to Safety and Quality of Nursing Home Residents ................................................................................ 12 3 Themes, Recommendations, Action Steps, and Analysis .................................... 18 3.1 Testing and Screening .................................................................................... 19 3.2 Equipment and PPE ....................................................................................... 24 3.3 Cohorting ..................................................................................................... 28 3.4 Visitation ...................................................................................................... 32 3.5 Communication ............................................................................................. 38 3.6 Workforce Ecosystem: Stopgaps for Resident Safety ........................................ 41 3.7 Workforce Ecosystem: Strategic Reinforcement .............................................. 48 3.8 Technical Assistance and Quality Improvement ............................................... 53 3.9 Facilities ....................................................................................................... 56 3.10 Nursing Home Data ....................................................................................... 60 4 Securing the Future of Long-Term Care ........................................................... 65 4.1 Strategic Workforce Planning ......................................................................... 65 4.2 Interoperable Data, Real-Time Predictive Modeling, and Communications Technology.......................................................................... 65 4.3 Facility Planning and Renovations ................................................................... 66 4.4 Payment Reform ............................................................................................ 66 4.5 Overall: Resident-Driven Care and Shared Decision-Making ............................. 67 Appendix A: Definition of Acronyms and Terms in Report ......................................A-1 Approved for Public Release; Distribution Unlimited 20-2378. © 2020 The MITRE Corporation. All Rights Reserved. i Commission Final Report Appendix B: Selection of Commission Members ....................................................B-1 Appendix C: Findings and Evidence for Recommendations and Action Steps ........... C-1 Appendix D: List of CMS Actions to Date ............................................................ D-1 Appendix E: Public Input Summary ......................................................................E-1 Appendix F: Commission Charter ......................................................................... F-1 Appendix G: Commission Memorandum of Short-Term Recommendations – July 17, 2020 ................................................................................. G-1 Appendix H: Nursing Home COVID-19 Data Limitations ...................................... H-1 Appendix I: Commission Recommendations Overview Presentation – August 14, 2020 ............................................................................. I-1 Approved for Public Release; Distribution Unlimited 20-2378. © 2020 The MITRE Corporation. All Rights Reserved. ii Commission Final Report Executive Summary The global outbreak of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) constitutes a public health emergency unlike any in living memory. The transmission characteristics of COVID-19—the disease the virus causes in the human body—result in brisk community spread. Moreover, the recovery trajectory for those who survive the initial acute attack of the virus remains to be seen. The scientific community’s understanding of the virus and development of effective treatments for COVID-19 is nascent. Nursing homes have emerged as prime hotspots for COVID-19 outbreaks. In the United States, nursing-home residents and staff represent only 8% of COVID-19 cases, yet bear 41% of COVID-19 deaths based on data reported August 13.1 Beyond experiencing the ravages of the disease itself, residents have been traumatized by the impact of nursing homes restricting visitors and curtailing group activities in an effort to mitigate spread of this virus. The resulting physical and mental harm—and increased vulnerabilities—to residents is common knowledge and troubling. Furthermore, the pandemic’s spread in these institutions has exposed and exacerbated long-standing, underlying challenges in this care setting. For example, dynamics of the U.S. federal system—where public health, emergency management, health services, and long-term care authorities function at federal, state, and local levels—have resulted in a patchwork approach to infection prevention and control that many believe has contributed to our nation’s inability to contain the spread of the virus. Purpose of the Commission and This Report The Centers for Medicare & Medicaid Services (CMS) tasked MITRE, the operator of the CMS Alliance to Modernize Healthcare (Health FFRDC), with an urgent