Report to the Legislature
Epidemic Disease
Preparedness and
Response for Long-
Term Care Facilities
December 2021
SHB 1218 (2021)
Jointly prepared by:
Washington State
Department of Social
and Health Services
(DSHS) &
Washington State
Department of Health
(DOH)
To request this document in another format, call 1-800-525-0127. Deaf or hard of hearing
customers, please call 711 (Washington Relay) or email civil.rights@doh.wa.gov.
For more information or additional copies of this report:
Amy Abbott
Residential Care Services
Washington State Department of Social and Health Services
360.725.2489
amy.abbott@dshs.wa.gov
Carolyn Ham
Office of Communicable Disease Epidemiology
Washington State Department of Health
360.878.7906
Umair Shah, MD, MPH
Secretary of Health
Don Clintsman,
Interim Secretary, Department of Social and Health Services
Contents
Executive Summary ......................................................................................................................... 1
Introduction .................................................................................................................................... 2
Authorizing Legislation ............................................................................................................ 2
Methodology ........................................................................................................................... 3
Summary of Best Practices and Lessons Learned Identified by Stakeholders ....................... 4
The COVID-19 Public Health Emergency ................................................................................. 4
Specific Issues to Care Delivery During COVID-19 .......................................................................... 7
Visitation Policies .................................................................................................................... 7
Timely and Adequate Access to Personal Protective Equipment (PPE) ............................... 10
Infection Control Practices .................................................................................................... 13
Rapid and Accurate Testing .................................................................................................. 16
Staffing .................................................................................................................................. 18
Continuing Care Retirement Communities ........................................................................... 20
Emergency and Epidemic Preparedness ............................................................................... 21
Communication, Guidance, and Regulatory Conflicts .................................................................. 24
Conclusion and Next Steps ........................................................................................................... 29
Appendices .................................................................................................................................... 31
Appendix A. List of SHB 1218 Stakeholder Workgroup Members ........................................ 31
Appendix B. Public Health Language .................................................................................... 33
Appendix C. The Complexities of the Long-Term Care System ............................................ 35
Appendix D. Funding Streams in the Long-Term Care System ............................................. 39
WASHINGTON STATE DEPARTMENT OF HEALTH AND
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Executive Summary
Substitute House Bill 1218; Chapter 159, Laws of 2021 (SHB 1218) was adopted on May 3, 2021,
to improve the health, safety, and quality of life for residents in long-term care (LTC) facilities.
This legislation requires the Department of Health (DOH) and the Department of Social and
Health Services (DSHS), along with key partners, to jointly develop a report and guidelines on
epidemic disease preparedness and response for licensed and certified LTC settings. A draft
report is due to the legislature by Dec. 1, 2021. The final report is due July 1, 2022.
This first draft report focuses on the specific issues faced by licensed and certified LTC settings
in Washington state during the COVID-19 pandemic and identifies associated needs as required
by SHB 1218. It begins to identify major challenges, best practices, and lessons learned about
containment and mitigation strategies for controlling the spread of the infectious agent.
The major issues identified and discussed in this report are grouped by topic. Within each topic
area, the two departments and stakeholder representatives identified the key challenges to
providing services in licensed and certified LTC settings, as well as the LTC system’s needs to
address those challenges. The topics include:
• Visitation policies that balance the psychosocial and physical health of LTC residents.
• Timely and adequate access to personal protective equipment (PPE) and other infection
control supplies.
• Admission and discharge policies and standards.
• Rapid and accurate testing to identify infectious disease outbreaks for resident
cohorting and treatment; contact tracing purposes; and protecting the health and well-
being of residents and employees.
• Communication, guidance, and regulatory conflicts.
• Ongoing staffing challenges in LTC facilities.
• Emergency and epidemic preparedness in LTC facilities.
The future needs identified in this report are specific to each topic area; however, there are
some common themes across each area. These include cross-sector education; funding and
access to resources; communication improvements; and increased consideration of behavioral
health.
DOH and DSHS will continue to work with the stakeholder workgroup to finalize this report and
develop guidelines that build upon the needs identified to date. These guidelines will consider
federal rules, the variety of involved provider and facility types, and available resources for
infection control. A timeline for implementation and a process to maintain and update the
guidelines will be included in the guidelines development process.
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Introduction
Authorizing Legislation
Substitute House Bill 1218; Chapter 159, Laws of 2021, (SHB 1218) was adopted on May 3,
2021, to improve the health, safety, and quality of life for residents in long-term care facilities.
This draft report addresses Section 30 of the bill, which requires the Washington State
Department of Health (DOH) and the Washington State Department of Social and Health
Services (DSHS) to jointly develop a report and guidelines on epidemic disease preparedness
and response for long-term care facilities, with input and consultation from interested
stakeholders, including but not limited to: local health jurisdictions (LHJs), advocates for
consumers of long-term care, LTC facility provider associations, and the Office of the State
Long-Term Care Ombuds (see Appendix A for a complete list).
SHB 1218 directs DOH and DSHS to develop a report and guidelines on the following timeline:
• Submit a draft report and guidelines on COVID-19 to the Healthcare Committees of the
legislature by Dec. 1, 2021.
• Submit a final report and guidelines on COVID-19 to the legislature by July 1, 2022.
• Beginning Dec. 1, 2022, and annually thereafter, review the report and any
corresponding guidelines to make necessary changes and add information about any
emerging epidemic of public health concern.
This draft report addresses priority areas identified in SHB 1218:
• Visitation policies that balance the psychosocial and physical health of residents.
• Timely and adequate access to personal protective equipment (PPE) and other
infection-control supplies so that LTC facility employees are prioritized for distribution
in the event of supply shortages.
• Admission and discharge policies and standards.
• Rapid and accurate testing to identify infection outbreaks for resident cohorting and
treatment, contact tracing purposes, and protecting the health and well-being of
residents and employees.
Also included in this draft report are topics identified by our stakeholders as areas of interest or
concern, including preliminary considerations of communication, emergency guidance conflict,
and staffing challenges at long-term care facilities; as well as appendices detailing the
complexities of the LTC system and describing LTC funding streams.
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Methodology
DOH and DSHS convened a stakeholder workgroup comprised of representatives from advocacy
organizations, professional associations, health care coalitions, local health jurisdictions (LHJs),
the state Long-Term Care Ombuds, state government, long-term care consumers, and other
interested stakeholders. The group had six virtual meetings from July through September 2021
to share experiences and lessons learned during the COVID-19 pandemic to inform
development of this draft report. Individual interviews and small group discussions with
stakeholders were organized to gather additional information. While participants in the group
committed to the process and were actively engaged, identifying lessons learned was less clear-
cut than initially anticipated due to significant challenges with the rise of the Delta variant and
the resultant fifth wave of COVID-19 infections. Identifying lessons learned through COVID-19
will be an ongoing process as the pandemic and associated response continue to evolve.
DOH and DSHS will continue to engage stakeholders to further develop the report and
guidelines on COVID-19, so they can be finalized and submitted to the legislature by July 1,
2022. We will reconvene the stakeholder group in early 2022, providing us the opportunity to
collaborate on the guidelines and address additional responsibilities identified in SHB 1218:
• Ensure that any corresponding federal rules and guidelines take precedence over the
state guidelines.
• Avoid conflict between federal requirements and state guidelines.
• Develop a timeline for implementing the guidelines and a process for communicating
the guidelines to LTC facilities, LHJs, and other interested stakeholders in a clear and
timely manner.
• Consider options for targeting available resources towards infection control when
epidemic disease outbreaks occur in LTC facilities.
• Establish methods to ensure that epidemic preparedness and response guidelines are
consistently applied across all local health jurisdictions and LTC facilities in Washington
state (which may include recommendations to the Legislature for any needed statutory
changes).
• Develop a process for maintaining and updating epidemic preparedness and response
guidelines as necessary.
• Ensure appropriate considerations for each unique provider type.
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Summary of Best Practices and Lessons Learned Identified by
Stakeholders
DOH and DSHS gathered and organized stakeholder comments to identify future best practices
and lessons learned associated with each focus area in this report, as well as some overarching
needs. These are listed and described at the end of each section. Common themes include:
Education. Several areas of conflict and confusion experienced by stakeholders during the
COVID-19 pandemic can be mitigated through education. Local health jurisdictions (LHJs) and
state leadership would benefit from information on the complexities of the LTC system. Long-
term care facility administrators and other LTC stakeholders need clarity on the role of the LHJ
in a public health emergency. Long-term care facility operators and staff need education on
foundational emergency preparedness principles.
Policies that consider behavioral health. The behavioral health impacts of the pandemic were a
common topic of discussion among stakeholders. Behavioral health supports are needed for
LTC facility staff and residents experiencing anxiety and depression as a result of COVID-19 and
its societal impacts. Future LTC guidance and resulting LTC facility policies restricting resident
visitation during an epidemic need to take residents’ emotional well-being into account.
Funding and access to resources. Many pain points identified by stakeholders can be traced
back to limited funding and resources. Stakeholders shared that LTC facilities need funding
support to reduce staffing challenges as well as improved access to resources, including testing
materials and PPE. See Appendix D for a description of LTC funding streams.
Communication. Stakeholders identified many areas in which improved communication would
result in improved preparedness and a more efficient emergency response, particularly in
situations where guidance is changing rapidly.
The COVID-19 Public Health Emergency
Nationwide Public Health Emergencies
The secretary of the federal Department of Health and Human Services (HHS), under section
319 of the Public Health Service Act, can determine that:
a) A disease or disorder presents a [national] public health emergency (PHE); or
b) That a public health emergency, including significant outbreaks of infectious disease or
bioterrorist attacks, otherwise exists.
According to HHS, there have been 29 nationwide PHEs since 2009. This number includes the
initial events and various renewals over time. Examples of diseases prompting a PHE include
H1N1 flu, the opioid crisis, Zika, and most recently the COVID-19 (SARS CoV-2) pandemic. The
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declaration of a PHE indicates the situation has become emergent (unusual, unforeseen,
unpredictable) and the potential harm to health may overwhelm a community’s ability to
address the emergency. All health care delivery systems have struggled and continue to
struggle under the weight of the PHE during the COVID-19 pandemic. The LTC system, in
particular, has been severely impacted.
Epidemic/Pandemic in Washington State
According to a DOH report on COVID-19 and the LTC system (published Sept. 14, 2021), 4
percent of the state’s cases (22,872) and 40 percent of deaths (2,811) were either associated
with or likely associated with LTC facility settings (such as skilled nursing facilities, assisted living
facilities, and adult family homes). These cases included residents, employees, and visitors. Not
all were exposed at the LTC facility—many had visited multiple locations during their exposure
period, and some may have visited a LTC facility after disease onset.
Figure 1 below in blue shows the LTC facility-associated cases over time. Figure 2 in orange
shows the LTC-associated deaths over time.
Figure 1. Long-Term Care Cases Over Time in Washington State
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Figure 2. Long-Term Care-Associated Deaths Over Time in Washington State
The remainder of the report describes challenges faced by the LTC system, barriers that were
part of the provider experience, trauma experienced by LTC facility residents, and
communication challenges between providers and government entities. From these
experiences also came lessons learned. At the time of writing this draft report, the state is still
in the grips of the COVID-19 epidemic/pandemic. More will be learned over time by all involved
in the LTC system.
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Specific Issues to Care Delivery During COVID-19
Visitation Policies
The CDC confirmed the first case of COVID-19 in Washington on Jan. 20, 2020. At that time,
testing for COVID-19 was done according to limited case definitions that were primarily focused
on foreign travel. The extent to which the COVID-19 virus was circulating in the community was
largely unknown until a substantial outbreak at a LTC facility in King County, Washington, was
identified on Feb. 28, 2020.
A joint investigation by the Washington State Department of Health and Public Health-Seattle
and King County was the first to describe how the combination of residents’ advanced age,
chronic underlying health conditions, and living in congregate settings enables COVID-19 to
transmit easily between residents, staff, and visitors and cause significant mortality.
By March 18, 2020, there were 167 confirmed cases of COVID-19 that could be traced back to
Facility A in the diagram below. Facility A had approximately 130 residents being cared for by
170 staff members. One of the early revelations in the investigation was an apparent
connection between the spread of the disease and the movements of staff and residents
between facilities.
Figure 3. Timeline Showing Long-Term Care Facilities in King County with One or More
Confirmed Cases of COVID-19 from Epidemiology of Covid-19 in a Long-Term Care Facility in
King County, Washington, McMichael et al., 2020
Early in the COVID-19 epidemic, before the actual mode of transmission was identified (how the
pathogen moves from an infected person to a non-infected person), it was clear that
movement across facilities was potentially dangerous to staff, residents, and visitors. Of the 167
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COVID-19 cases that were traced back to Facility A, 35 individuals died, including 34 residents
and one visitor.
As COVID-19 outbreaks escalated in in Washington and nationwide, LTC facilities took steps to
keep infected residents, staff, and visitors away from those who had not been infected.
Following guidance from national, state, and local public health authorities, LTC facilities put in
place enhanced infection-control practices, changed their admission and discharge policies, and
implemented visitation restrictions. While the visitation restrictions were important to protect
long-term care residents, these resulted in negative, unintended consequences for some.
IDENTIFIED CHALLENGES:
Unintended consequences of restrictive visitation policies. The early days of the COVID-19
pandemic were a difficult and confusing time for the LTC industry. Visitation guidance varied
greatly, especially at the beginning of the pandemic when scientists were still trying to
understand the transmission modalities of the virus. For most LTC settings, there was a span of
time when no visitors were allowed. Even regulatory agency field staff did not visit facilities for
surveys, apart from complaint investigations that included allegations of abuse and harm, and
CMS-mandated infection control surveys.
In addition to restrictions on families and other visitors, some professional service providers
were denied access to LTC facilities:
• Hospice providers whose end-of-life services would normally include physician or
medical services, pharmacy services for pain management, nursing services, spiritual
care, social work, and bereavement support were denied access. Even when some of
the restrictions to visitation were lessened, hospice providers continued to report being
told only the hospice nurse would be allowed to visit the facility, denying residents the
full array of end-of-life care.
• Home health services (which include skilled nursing, physical therapy, occupational
therapy, and other therapeutic services) and home care services providers were unable
to access their patients who resided in various LTC facility types.
• The LTC Ombuds Program, authorized as a health oversight agency, was denied access
to LTC facilities. Ombuds act as resident advocates, authorized to perform complaint
intake and early resolutions at the facility level. Much of their work is done through
personal contact and via the trust formed through this contact. LTC Ombuds staff can
become a significant part of a resident’s support system. In the absence of personal
contact, the LTC Ombuds program undertook a massive postcard campaign to keep in
touch with residents. As in many other businesses, the Ombuds Program attempted to
substitute technology for direct contact but this was not always successful. According to
the LTC Ombuds, the program itself suffered a significant attrition of volunteer staff
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during the pandemic. This was due to the inability to meet face-to-face with the
residents. For some, the face-to-face interaction was the most appealing part of the
volunteer role.
• The Office of Developmental Disabilities (DD) Ombuds provides advocate services to
persons with intellectual and developmental disabilities. They also work on resolving
individual/client complaints in a variety of settings. Their complaint system is designed
to work by phone and online. According to DD Ombuds staff, their most productive
method—prior to the COVID-19 pandemic—was making in-person visits to their clients’
places of residence. Visitation restrictions made this impossible.
o DD Ombuds staff stated that social isolation was a big problem for this
population, as many did not have access to internet services.
o The DD Ombuds staff noted the nature of the complaints changed during the
COVID-19 pandemic. There were allegations by some that the restrictions they
received did not match what they understood about the virus. DD Ombuds staff
stated, “Our folks had no choices given to them.” For example, a DD client
complying with physical distancing and wearing a mask might be told they were
not allowed to visit the same places the general public could visit, like the
grocery store.
Continuing trauma. Many articles have been written addressing the significant mental health
impacts to LTC residents who were subjected to prolonged confinement in their rooms. The LTC
residents participating in our stakeholder group shared their personal experiences that
confirmed the difficulty of this time for them. The experiences, emotions, and concerns voiced
by residents during the workgroup include:
• Feelings of isolation, fear, and worry for their fellow residents.
• Feelings of grief and loss for their friends in the facility who died from COVID-19.
• One account of the suicide of a fellow resident.
• Difficulty witnessing the physical decline of residents who were restricted to their rooms
and could no longer walk in the hallways, which for many was their primary form of
exercise.
• Observing residents with dementia who experienced further cognitive decline.
• Observing a resident who cried daily at the facility front door, asking to be let out.
• Feeling a sense of fear that the caregivers they trusted and often had good relationships
with were now a possible source of the virus.
• An overall sense of the loss of ability to “live a life worth living.”
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IDENTIFIED NEEDS:
Visitation policies that consider resident mental health. Prolonged isolation, even for the best
of reasons, can be harmful to the well-being of a LTC resident. Guidance and LTC facility policies
and procedures are needed that allow for social interaction, physical activity, and access to
family and others significant to the resident’s mental health and well-being. Some LTC facilities
successfully implemented alternative approaches to visitation, including establishment of
outdoor spaces for visitation and remote options using tablets.
Access for Hospice, Home Health and LTC/DD Ombuds. LTC policies and procedures are
needed that allow for the delivery of these services and alternative ways of communicating
with residents. The use of PPE and infection control training should be part of the protocol.
Increased access to behavioral health services. Behavioral health support is needed for
residents and staff who survived the COVID-19 pandemic and are displaying symptoms of
adjustment difficulties (comparable to Post Traumatic Stress Disorder-PTSD) or other
anxiety/depression disorders. If this is not an area of expertise of the LTC provider, they will
need additional behavioral health training and/or resources.
Updated policies. Visitation policies will need to be kept current according to the LTC facility
type and the appropriate regulatory entity’s guidance.
Timely and Adequate Access to Personal Protective Equipment (PPE)
While Washington maintains a state PPE stockpile (known as “the backstop”), requests for PPE
(e.g., masks, respirators, gowns, gloves, and eye protection) early in the pandemic far outpaced
the state’s ability to source and fulfill orders. State leadership developed prioritization
guidelines for PPE distribution, but initial guidelines did not include LTC in the first prioritization
tier with hospitals and other medical or medical-adjacent facilities, resulting in LTC facilities not
being able to access this resource early in the pandemic.
Ultimately, stakeholders worked with leadership to revise the prioritization guidelines to
include LTC in the first prioritization tier. Additional supports were made available at the county
level: requests for PPE from the state supply are routed through county-level emergency
management agencies and passed to the state if the county is unable to fulfill the request.
Some counties were able to acquire a relatively stable supply of PPE early in the pandemic and
support LTC facilities in their jurisdiction.
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IDENTIFIED CHALLENGES:
Supply chain shortages. At the beginning of the COVID-19 pandemic, shortages of PPE (masks,
respirators, gowns, gloves, and eye protection) were a major challenge across the medical
industry, including for LTC facilities and services of all types. The sharp increase in demand from
both health care and non-health care consumers was further complicated by substantial price
increases, supply chain shortages, and goods that did not meet safety standards; these all
contributed to LTC facilities’ initial struggles to obtain adequate supplies of PPE.
Also in high demand were other supplies essential to infection control protocols, such as hand
sanitizer and cleaning supplies. These were necessary for the protection of residents and staff
and to remain in compliance with infection prevention guidelines. These issues were
particularly problematic for adult family homes (AFHs). Large facilities such as hospitals, skilled
nursing facilities (SNF), and assisted living facilities (ALF) typically purchase their goods from
medical supply companies. Smaller LTC facilities, such as AFHs, typically use “big box” stores to
purchase goods such as cleaning supplies. When the panic-buying of the general public emptied
the shelves of grocery stores of all sizes, AFH providers had no way to access these supplies.
Since medical supply companies sell in large volumes, this was problematic for AFH owners
because:
• An individual AFH owner is unlikely to be able to afford the quantity they would have to
purchase from a medical supply company.
• Even if affordable, an individual AFH operator may not have the capacity to store large-
volume supplies.
Cleaning and disinfectant supplies come with strict manufacturer instructions for use (IFU),
guidance that must be followed for the product to be effective in killing viruses, molds, and
bacteria. The most common directive in an IFU is that the product should not be used beyond a
designated expiration date. Cleaning and disinfectant supplies purchased in large volumes by a
small facility are likely to expire before these can be used in their entirety.
Larger LTC facilities explored contracts with international producers to meet needs for
increased PPE with varying results: some orders placed through international suppliers were
redirected to the federal stockpile upon arrival in the United States while others were
continuously delayed. Smaller LTC facility types such as AFHs, which typically rely on public-
facing bulk suppliers, did not have direct access to manufacturers or medical suppliers, creating
additional barriers to PPE access for these facility types.
Finding the variety of PPE needed to satisfy infection control guidelines remains a challenge.
For example, a facility needs to stock a variety of sizes of gloves and gowns to meet staff needs
and infection control requirements, but suppliers may only have gloves and gowns available in
one size. While the supply chain for many materials has stabilized as of the writing of this
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report, new state and federal testing mandates are creating shortages once again: some
facilities are currently reporting a four- to six-week wait for testing supplies necessary for
outbreak identification.
Opportunity costs. Early in the pandemic, LTC operators were impacted by heightened
opportunity costs, in which time spent securing the necessary quantities and varieties of PPE is
time not spent providing care to residents or completing other tasks. LTC operators of all sizes
report that working to secure required PPE was the equivalent of a full-time position at the
beginning of the pandemic and is again becoming a time burden with shortages and delays
resulting from new mandates. Smaller operators are particularly affected.
Early in the pandemic, LTC facilities needed to dedicate time to respirator medical evaluations
and fit testing for staff. Fit testing is a 20- to 30-minute procedure to ensure a proper seal
between a respirator face piece (including disposable respirators, like N95 masks) and an
individual’s face. Respirator medical evaluations determine whether it is safe for individual
health care workers to use respirators. Workers complete a medical questionnaire to help
identify potential health issues with respirator use in a work setting. Some LTC facility types had
not previously used N95s or other respirators in their settings and had to establish fit testing
procedures for the first time, while other facilities that had previously done fit testing based on
specific brands of respirators needed to repeat the process quickly due to receiving unfamiliar
types of respirators from a supplier or the state backstop. DOH recommends that only large
facilities/agencies conduct their own fit testing due to the significant time commitment
required to learn to conduct a fit test. As of the writing of this report, DOH is providing free
online respirator medical clearance for fit testing to a wide variety of LTC types, in addition to
having engaged fit testing vendors perform free respirator fit testing in each county in
Washington.
Cost and quality concerns. In response to increased demand, costs for PPE increased sharply at
the start of the COVID-19 pandemic with some LTC facilities reporting up to 35 percent
increases in cost for supplies such as masks, gloves, and hand sanitizer. Some supplies received
from the federal or state emergency stockpiles were not usable or did not meet the
requirements of infection control guidelines. Even without cost inflation, the sheer quantity of
PPE needed to meet requirements are cost prohibitive on a long-term basis. For example, some
larger facilities are using 300-400 gowns per day, which is not covered by current
reimbursement rates and not financially sustainable.
IDENTIFIED NEEDS:
Protections against price gouging. Request legislation from the Office of the Attorney General
(Senate Bill 5191, 2021 Legislative Session) was intended to cap price increases on needed
supplies to 10 percent during a state of emergency, but this legislation ultimately did not pass.
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Washington remains one of 14 states without legislation that expressly prohibits price gouging
during an emergency.
Governmental supply. While county- and state-level emergency PPE provisions were eventually
made available to LTC facilities, stakeholders report that having this support earlier and in
greater quantity will be essential in future crises. Creating a streamlined process to access state
stocks of PPE should also be considered, as the process varied by county and was not always
intuitive.
Creative options for smaller facilities to access resources. Smaller LTC facility types such as
adult family homes do not have access to the bulk suppliers used by hospitals and larger LTC
facility types. Creative options for these facilities to access PPE (such as the formation of
coalitions in which smaller facilities join together to order and divide large quantities of PPE and
infection control supplies) should be considered alongside regulatory solutions.
Infection Control Practices
Infection control was the main topic of two of the stakeholder meetings. Some of the issues
raised will be addressed in more detail in other sections of this report.
Discussions with the stakeholder group revealed common challenges across provider types.
Examples include:
• Difficulty obtaining personal protective equipment (PPE).
• Difficulty obtaining infection control supplies such as hand sanitizer, disinfectants, and
other cleaning supplies.
• Conflicting guidance from public health and regulatory entities.
• Concern that onsite visits from regulatory entities raised anxiety and created additional
staff burden during an already stressful time for staff.
• Confusion between providers and public health authorities regarding who was
responsible for contact tracing.
• Difficulty with testing of staff and residents for COVID-19 due to:
o Short supply of testing materials in the early days of the pandemic.
o Long turnaround times for results at the beginning of the pandemic, making it
difficult to make decisions about strategies such as cohorting (keeping residents
together who have been confirmed to have the same disease process).
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o Lack of appropriately credentialed or trained staff (such as a nurse) to perform
the testing, particularly an issue for the adult family home operators who do not
include nursing staff in their regular staffing model.
• Difficulty in following guidance for creating COVID-specific sections of a residential
facility due to staffing shortages.
• Difficulty finding the best method for meeting quality of life standards while also
implementing needed infection control strategies such as isolation and quarantine.
DOH to assist LTC providers with the unique challenges of COVID-19.
Some of these guidance documents include:
• Interim Guidance for Long-Term Care: Transferring Between LTC and other Healthcare
settings
• Contingency Strategies for PPE Use During the COVID-19 Pandemic
• Respirator and PPE Guidance for Long-Term Care
• Testing in Long-Term Care Facilities
• Risk Assessment for Resident/Clients After Community Visits
Lessons Learned and Best Practices for Infection Control
At the time of this writing, Washington and the nation are in the fifth wave of increased COVID-
19 infections. It is difficult to look back and draw conclusions when the situation is changing
almost daily. However, insights shared by our stakeholder group may be useful for future
planning. These include:
• Community-based settings, such as supported living, found local drive-through test sites
useful as some facilities are too small to receive local health jurisdiction (LHJ) support.
• Supported living services accomplished cohorting by moving clients who had tested
negative for COVID-19 to an extended-stay hotel and keeping those who had tested
positive in their home.
o However, providers noted it was challenging to staff both environments on a
24/7 basis.
• Some residential facilities carried out rapid construction (such as adding doors to
hallways) to create COVID-specific wings. From the resident perspective, these actions
were more effective.
• Adult family homes were rarely able to cohort negative and positive residents due to
the facilities’ small size. Positive residents were moved to COVID-positive facilities.
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o If the staff of the adult family home tested positive in sufficient numbers to
compromise care, all residents were moved to alternative facilities until the staff
recovered and could return to work.
• When residents met discharge criteria, many were able to go into transitional settings
funded by the Federal Emergency Management Agency (FEMA).
• Many LTC facilities strengthened communication practices by establishing channels of
regular information sharing (i.e., virtual town halls, telephone conferences, e-
newsletters), and stakeholders reported that these measures greatly reduced anxiety
among resident family members.
Admission and Discharge Policies
One of the overarching themes in infection control continues to be the challenge of providing
adequate staffing to care for LTC residents and those receiving LTC services. A LTC facility may
have unoccupied beds, but may not have the staffing available to admit additional residents.
Hospital discharge planners searching for a suitable location for a patient to continue their
recovery may turn to home health as an alternative, but community-based providers may also
have staffing shortages. Our stakeholder group identified the following issues associated with
discharging patients from hospital settings:
• In Eastern Washington, many patients required complex care (including behavioral
health care) and specialized equipment that was not always readily available.
• State- and FEMA-supported strike teams (who helped fill staffing gaps in LTC facilities)
provided much-needed assistance. During the stakeholder meetings, there was a
perception that this support is becoming more limited.
• Stakeholders from SNF and ALF raised concerns about closing dedicated COVID-19 units,
for which funding ended in June 2021.
• The Developmental Disability Ombuds from the stakeholder group noted that it is often
difficult for their clients to find placement after hospitalization. The organization created
a document in December 2018 to highlight the problem, titled “Stuck in the Hospital.”
This problem worsened during the COVID-19 pandemic.
IDENTIFIED NEEDS:
Decision-making tools. A “decision tree” may make it easier for providers to make admission
and discharge decisions during an outbreak. Stakeholders suggested this tool might alleviate
confusion, especially when guidance is changing rapidly.
Systematic approaches to advance directives. One stakeholder provided the group with an
article on “An Advance Care Planning Long-Term Care Initiative in Response to COVID-19” that
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explores a systematic approach to advance directives that might include “Do Not Hospitalize”
orders which could give the resident or family an opportunity to choose, in advance of need,
whether they wish to remain in the facility for the duration of their care for COVID-19.
Increased waiver clarity and tracking. Some regulations in RCW or WAC were waived during
the pandemic to help facilitate health care in the new COVID-19 environment. Some
stakeholders thought these waivers were useful, but difficult to track. We will explore this topic
further in the final version of this report.
Funding support. Stakeholders spoke of continued advocacy to maintain funding that they
stated was critical to maintaining a stable workforce, particularly funding to improve staffing
and wage support.
Improved discharge processes. Discharge problems were present prior to the pandemic for
residents with chronic or serious mental illness, individuals with dementia, residents with short-
term skilled nursing stays who were previously unhoused, and others. Stakeholders expressed
the need for consistent discharge planning practices to improve the ongoing well-being and
safety of residents.
COVID-19 supports. Dedicated COVID-19 units and transitional care units are an ongoing need
and will remain critical as long as the pandemic continues.
Staffing supports. Rapid-response staffing teams provided by DSHS filled a critical gap and are
needed on an ongoing basis.
Rapid and Accurate Testing
Washington has a statewide COVID-19 testing strategy based on the principle that testing is a
critical and essential part of the overall response to COVID-19. Identifying those infected by or
exposed to SARS-C0V-2 is necessary in responding to and stopping the spread of infection. The
testing strategy calls for the assurance of available testing resources (e.g., specimen collection
kits); in-state lab capacity to quickly and efficiently process test kits; and staffing support for
testing efforts in settings operated by health care facilities, LHJs, and other organizations and
agencies. Testing recommendations are updated as needed and follow the best available
scientific guidance. Equitable and widespread access to testing with rapid turnaround times for
results is a top priority.
Washington’s statewide testing strategy prioritizes people displaying symptoms of COVID-19,
close contacts of infected persons, and people in congregate settings where there are
confirmed positive cases. In addition, the state’s testing efforts work to reach populations
disproportionately impacted by COVID-19, including people with lower incomes, people of
color, immigrant and refugee communities, and older adults.
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There are two kinds of tests to determine if a person is positive, or has COVID-19 at the time of
the test: polymerase chain reaction (PCR) tests and antigen tests. The PCR test is a molecular
test sent to a lab that looks for virus-related genetic material in a specimen collected from an
individual; turnaround time to receive results from a PCR test is usually 24 to 72 hours. Antigen
tests look for certain proteins that are part of the virus and return results in around 15 minutes.
DOH has provided testing supplies and resources to a number of LTC facilities across the state
and continues to work to ensure that staff in congregate LTC settings have access to convenient
testing.
IDENTIFIED CHALLENGES:
Testing unavailable early in the pandemic. When testing for COVID-19 began in early February
2020, criteria for testing was limited to those displaying symptoms who had recently traveled to
known outbreak areas in China or had prolonged exposure to a known COVID-19 case. Initially,
the only test kit designed for SARS-CoV-2 approved by the U.S. Food and Drug Administration
(FDA) and available in the United States was developed and distributed by the CDC. Samples
needed to be sent back to the CDC in Atlanta for testing, with results taking at least three to
five days to be returned. FDA Emergency Use Authorization rules made it difficult for state and
hospital laboratories to develop their own test kits even as accuracy issues were discovered
with the first version of the CDC test. This gradual ramp-up of testing capabilities significantly
delayed outbreak identification in LTC and other settings early in the pandemic.
In March 2020, the FDA relaxed its rules around the development of COVID-19 diagnostic
testing, and state and local labs slowly gained the capability and capacity to conduct their own
tests. Criteria for testing broadened over time, but test kit supply shortages and lab delays in
the first few months of the pandemic continued to limit rapid outbreak identification in all
settings, including LTC.
As of the writing of this report, rapid tests are now available for use in LTC settings to quickly
identify new COVID-19 cases among LTC staff and residents. However, the current surge in
cases due to the Delta variant and new testing mandates at the federal level are again causing
concern about testing supply shortages.
Many LTC types need external support for testing. Early in the pandemic, LTC facility types that
do not include nurses as part of their regular staff relied on LHJs to provide testing support, but
high demand on LHJs and limited testing resources resulted in long delays before testing
processes could be established. Home- and community-based LTC settings were largely left on
their own to identify available resources. Many were able to use community testing resources
(e.g., drive-through testing sites), which became easier later in the pandemic as those resources
became more widely available. Depending on the type of test, some facilities were required to
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obtain a Clinical Laboratory Improvement Amendments (CLIA) waiver to perform testing, which
can be a difficult process for small facilities.
Cohorting processes were difficult to establish without access to rapid and accurate testing.
Cohorting, or grouping together patients who test positive for COVID-19 in a single physical
area within a facility, is a recommended infection-control strategy. Cohorting allows dedicated
staff to work with only COVID-19-positive residents to prevent spreading the virus across
facilities, and can extend the use of certain PPE such as masks and eye protection when
supplies are limited as they often were early in the pandemic. To successfully cohort positive
residents, facilities need to know who (staff or resident) is positive in order to assign staff and
residents to appropriate areas of a facility. In the absence of rapid and accurate testing,
facilities instead had to use isolation and quarantine measures to prevent the spread of the
virus among residents early in the pandemic. Residents were restricted to their own rooms or
living spaces, which reduced exposure risk but resulted in increased anxiety among residents
and may have contributed to increased risk for other negative health outcomes in the long
term.
IDENTIFIED NEEDS:
Rapid distribution of testing resources. For future epidemic planning, stakeholders indicated
that producing and distributing rapid tests as quickly as possible will be critical to early
outbreak identification.
Staffing
Washington state is experiencing severe staffing shortages across LTC facility types. According
to CMS data compiled by the American Association of Retired Persons (AARP), 56.5 percent of
Washington skilled nursing facilities reported a shortage of direct care workers in August 2021.
While staffing shortages across LTC facilities existed before the pandemic, the situation has
grown more serious since the beginning of 2020. In the second week of September 2021, 102
out of 200 skilled nursing facilities in Washington reported staffing shortages in a weekly
National Healthcare Safety Network (NHSN) report, compared to 68 in late January 2021
(NHSN, 2021). Nationally, 73 percent of nursing homes and 59 percent of assisted living
communities say their facility’s overall workforce has declined since 2020, according to an
industry group survey.
IDENTIFIED CHALLENGES:
Multiple factors contributing to staffing shortages. Staffing shortages have worsened during
the pandemic. Medicaid reimbursement rates are calculated based on cost data that are up to
four years old, resulting in rates that do not match current-time costs of care. A general worker
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shortage across all industries and a steep increase in wages across all sectors has left LTC
facilities, particularly skilled nursing facilities, in a difficult financial position as they raise wages
to compete with hospitals and entry-level positions outside the health care sector. Enhanced
Federal Medical Assistance Percentage (FMAP) funds are temporarily providing a rate increase
to both SNF and AFH, with some organizations using the added funds to support increased staff
wages, but these add-on funds will expire on Dec. 31, 2021. Many communities, particularly in
rural areas, find that even with increased wages there is a reduced pool of applicants for jobs.
See Appendix D for a description of LTC funding streams.
Stakeholders shared that workers in all LTC settings in Washington have been “on the front
lines” of the pandemic since the beginning with little opportunity for rest, resulting in
widespread staff burnout and exhaustion. Staff have worked extra hours to make up for
personnel shortages and have had to quickly learn and implement new safety protocols while
taking on additional duties, such as bringing meals to patient rooms in facilities that have closed
dining areas due to COVID-19 outbreaks. Many LTC residents received some percentage of their
physical care from family members prior to the COVID-19 pandemic; visitation restrictions
implemented early in the pandemic meant that staff were providing all care for all residents as
family members were not allowed to enter facilities.
In August 2021, Gov. Inslee issued an emergency proclamation mandating that long-term care
workers be fully vaccinated against COVID-19 by Oct. 18. Some stakeholders have expressed
concern about the requirement, saying that the mandate has resulted in staff departures
among workers who do not wish to get the vaccine (direct care, ancillary, and administrative).
Staffing shortages create ripple effects. Personnel shortages impact admissions to LTC
facilities. Hospital systems across the state, facing their own staffing shortages, are working to
transfer patients to LTC settings as quickly as is appropriate, but some LTC facilities cannot
currently admit new residents due to staffing shortages, even if beds or rooms are available.
These delays create hospital backlogs, taking hospital beds away from others who may need
them.
In a recent survey of AFHs, 30 percent of respondents reported empty beds because of staffing
shortages. Many AFHs across the state have indicated that the ongoing staffing shortages may
lead to closures, which would displace residents and add additional stress to the LTC system.
Staffing shortages make it challenging for facilities to follow recommended infection control
practices, such as cohorting. Cohorting, or grouping together patients who test positive for
COVID-19 in a single physical area within a facility, is a recommended infection control strategy
during outbreaks. Cohorting allows dedicated staff to work with only COVID-19-positive
residents to prevent spreading the virus within the facility. Facilities experiencing personnel
shortages have found it challenging to keep staff assigned to one specific part of a facility as
shifting resident needs require frequent revisions to staff schedules and assignments to ensure
all areas of a facility are appropriately covered.
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Unique infection control challenges. A major challenge related to contact tracing in LTC
settings is the potential for cross-contamination by staff working in multiple facilities or
residences. This has been a particular challenge in supported living (SL) settings. Due to limited
hours and low pay, staff often work for multiple SL agencies. Tracking COVID-19 exposure
across homes and SL agencies in the event of an outbreak remains a challenge throughout the
pandemic.
IDENTIFIED NEEDS:
Relief staff and settings. LTC facilities need additional support to provide rest and time off to
staff and to fill in the gaps left by personnel shortages. Stakeholders report that programs like
the Rapid Response Crisis Staffing teams deployed by DSHS have been extremely helpful
throughout the pandemic. Dedicated COVID-19 units (to which residents testing positive for
COVID-19 can temporarily be transferred to receive appropriate care) are another highly
beneficial support to short-staffed facilities.
Mechanism to trace staff across multiple agencies. Stakeholders report that a statewide
system to track employees who work across multiple SL agencies and LTC facilities for contact
tracing purposes will be extremely helpful during future epidemics.
Continuing Care Retirement Communities
Continuing care retirement communities (CCRCs) provide residents multiple levels of care on a
single campus, with many offering independent living, assisted living, and skilled nursing. While
the assisted living and skilled nursing services provided by a CCRC are licensed and regulated,
the independent living sections of a facility function like individual private residences and are
not subject to the same regulatory oversight. In Washington state, a CCRC must be registered
as such with DSHS to be able to refer to itself in promotional or marketing materials as a CCRC.
As of the writing of this report, there are 23 registered CCRCs in Washington, but there are also
many facilities not formally registered as CCRCs that mimic the CCRC model and offer a
spectrum of care services in addition to independent living.
Because CCRCs include independent living clients as well as residents who receive services in
settings licensed and regulated by the state, the application of COVID-19-specific guidance was,
at times, challenging and confusing for CCRC operators. Stakeholders report that early in the
pandemic some CCRCs applied visitation restriction guidance uniformly across facility
campuses, even in situations where independent living clients live in separate buildings from
residents living in licensed settings, despite the guidance only being intended to apply to the
regulated areas of the facility. In some cases, spouses may live at the same CCRC, with one
spouse residing in independent living while the other spouse lives in an assisted living or skilled
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nursing setting. Many CCRCs followed infection control practices that restricted movement
between parts of the campus; stakeholders shared that this sometimes resulted in spouses
being kept apart for prolonged periods of time.
CCRC operators also experienced challenges around applying guidance to spaces and amenities
shared by independent living clients and residents receiving licensed care services, such as
dining facilities, gyms or fitness centers, and pools. CCRCs had to determine if these specific
spaces on a campus should follow LTC facility-specific guidance or if community guidance
(intended for commercial businesses open to the public) applied.
Finally, local health jurisdictions interpreting guidance at the county level often did not
understand the difference between CCRCs and other types of LTC facilities, which created
challenges as LHJs worked to interpret and issue LTC guidance at the county level.
IDENTIFIED NEEDS:
Clear guidance that considers the CCRC setting. CCRCs need more clarity and support to apply
guidance across facilities with different levels of care where not all residents may be subject to
the same restrictions or recommendations. Stakeholders also identified the need for specific
exceptions to visitation guidance that allow spouses residing on the same campus to visit one
another, even during periods when facilities may be restricting resident movement between
areas.
Education for LHJs about the LTC system is included as a requirement of SHB 1218 section 19;
this education should include information about the CCRC model and how LTC guidance may
only apply to portions of a CCRC campus.
Emergency and Epidemic Preparedness
Early Identification
The Washington State Department of Health (DOH) and the Washington State Department of
Social and Health Services (DSHS) first met with the SHB 1218 stakeholder group on July 6,
2021. As participants shared their experiences with the COVID-19 pandemic, several themes
emerged. An initial stakeholder comment of “We weren’t ready” was echoed by others in the
group. Another comment was that emergency preparedness was hard for those who had never
done it before. The diversity of experiences in preparedness and stakeholder concerns reflected
the complexity of the LTC system itself. There was one point of agreement: “We can do better.”
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The Challenge and the Approach
One of the challenges (and opportunities) of SHB 1218 is the spectrum of LTC providers covered
by the bill. Facility types vary from large facilities with multiple levels of care to individual
residences caring for two to six people. LTC services take place both inside these structures and
in a variety of other settings including private homes. There is no one-size-fits-all approach to
preparedness plans for a wide variety of providers. However, discussions with stakeholders
with expertise in emergency preparedness revealed there are common elements to
preparedness that can be adapted to each provider’s unique situation. To help familiarize the
other stakeholders with these, the SHB 1218 team devoted the Sept. 15, 2021, meeting to
emergency/epidemic preparedness, presented in a town hall format. Stakeholders with
expertise in emergency preparedness and response served as panelists. The format allowed for
shared knowledge, perspectives, and experiences, plus audience questions/answers.
Traditional Emergency Preparedness versus Epidemic Preparedness
The expert panel talked about elements of preparedness common across most formal plans.
The following components are critical to include in both traditional preparedness (natural
disasters like earthquakes, hurricanes, floods, fires), and epidemic preparedness planning:
1. An initial assessment of potential hazards (sometimes referred to as an all-hazard
assessment).
2. The development of policies and procedures that are specific to the identified risk.
3. The development of a communication plan.
4. Training, testing, and evaluation of the plan (including after-action reporting).
There are other companion attributes to preparedness planning that cross all types of
emergencies. These include:
• The importance of relationship-building within and outside of an organization, including
those with emergency response expertise, relationships with public health, and
potential partnerships that may serve as resources during the actual emergency.
• The importance of building staff resiliency into the plan (to reduce the likelihood of
psychological harm and burnout as a consequence of the emergency).
• Willingness to embrace the planning process.
• Willingness to share failures and lessons learned with others so they can learn from your
experiences.
The panelists also identified areas where epidemic preparedness/response is significantly
different from traditional emergency preparedness planning. These include:
• Traditional preparedness is designed to manage acute and localized issues. An epidemic
response is more widespread and has regional impacts across many sectors (e.g., the
impact of COVID-19 on the supply chain for necessary goods).
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• Epidemic responses must be persistent and adapt to waves and surges of the disease.
The periods in between waves are where planning and restoring/restocking efforts can
take place.
• Staffing must be done with the possibility of a long-term response in mind.
• An epidemic is considered a low-frequency, high-consequence event. This means that
response plans must be tested frequently (for example, as often as fire drills).
Preparedness for one type of emergency will help preparedness with other emergency types.
For example, plans for continuing operations when staff are out can be used if there is flooding
or a disease outbreak. Co-occurring emergency events have been pervasive throughout the
COVID-19 pandemic. During the pandemic, there have been major hurricanes, large-scale forest
fires, heat waves, and flooding. Following infection control best practices is more difficult when
these natural disasters force people together in congregate settings for shelter.
Training Recommendations
The panelists recommended that at least one person in each LTC organization receive Incident
Command Systems Training to familiarize themselves with the system that serves as the
nationwide response structure for a variety of organizations, including health care facilities.
Another recommended training technique was the creation of checklists that can be used
during the emergency. As one panelist stated, “It can be easier to teach people to remember to
look at a checklist with exact instructions and contact information of who to call for further
guidance.” These checklists can serve as templates so they can be modified for different
emergency events.
An excellent resource for planning, particularly for those who are new to the process, is the
Community Emergency Response Training (CERT). One of the key elements of this program is
personal preparedness, the idea being that the more an individual employee is prepared at
their own home and with their own families, the sooner they will be able to be part of their
organization’s response.
The organization’s communication plan should include staff training in how to achieve a
common message. The panelists advised that training should include advance notice of
decisions that may be made outside of their organization’s control and the possible impact this
may have on the services they provide. An example might be the authority the local health
jurisdiction has during a public health emergency. It can also be useful for outside partners to
participate in staff training. The partner can share how their organization functions and the role
they play during an emergency or epidemic response. During these trainings, partners and staff
should discuss available backup resources if a partner organization is unable to respond to the
emergency. Forming partnerships prior to an emergency is ideal and can improve emergency
response since all partners know each other and understand one another’s role.
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Resident and Family Involvement
Residents, clients, and their families should be aware of the emergency/epidemic plan. One
stakeholder, who is a current LTC resident, told the group that it is important for residents and
their families to be able to ask questions of those who manage facilities about the plan, such as
“Do you have a plan, what is it? Are you aware of resources that are available to help you do
emergency planning?”
IDENTIFIED NEEDS:
Funding. Funding is needed for emergency/epidemic preparedness. Many education resources
may be free, but there will still be costs associated with the time it takes to train staff, test the
plan, and evaluate the plan on a regular basis.
Access to resources. More clarity is needed to identify and understand what external
organizations are available as resources to the preparedness process. Stakeholders commented
that it would be helpful to have a repository of preparedness plans they could adapt to their
individual LTC organization.
• The expert panel provided the following resources, though there is still a need for a
more comprehensive repository that applies specifically to the Washington state
setting:
o https://repository.netecweb.org/files/theme_uploads/LTCPPEEducationFinalRev
9.13.2021.pdf
o https://repository.netecweb.org/exhibits/show/ncov/ncov
Special consideration of adult family homes. There are approximately 3,500 adult family
homes across Washington. As individual small businesses, they are often isolated and may have
difficulty accessing resources for emergency preparedness. Further planning on how to help
this particular provider type is needed.
Behavioral health support. Providers need additional support to reduce the stress and trauma
of the COVID-19 response. A stakeholder suggested that additional training is needed in
“Psychological First Aid” as a means of assisting with staff resilience and recovery.
Communication, Guidance, and Regulatory Conflicts
Washington state has a decentralized governmental public health system characterized by local
control and partnerships. State law gives primary responsibility for the health and safety of
Washington residents to 35 local health jurisdictions (LHJs) representing Washington’s 39
counties. Each county legislative authority establishes a local board of health which “shall have
supervision over all matters pertaining to the preservation of the life and health of the people
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within its jurisdiction.” Local boards of health are made up of majority elected officials and
approve the budgets, programs, and policies of local public health agencies. During the COVID-
19 pandemic, information and guidance was issued to LTC facilities via federal (CDC, the
Centers for Medicare and Medicaid Services - CMS), state (DOH, DSHS, the Governor’s Office),
and local-level (LHJ) authorities and regulatory bodies, which sometimes resulted in confusion
and guidance conflicts.
IDENTIFIED CHALLENGES:
Initial guidance lacked understanding of LTC. Stakeholders conveyed that early state-level
decisions about emergency guidance seemed to be made without thorough consideration of
the complexity of LTC. Many LHJs interpreting and applying guidance at the county level may
have lacked this understanding, particularly in smaller counties with fewer staff members or
counties with high LHJ staff turnover. Some counties initially tried to apply LTC guidance
uniformly across all LTC types without an understanding of the different models, rules, and
regulatory bodies at play.
Rapid guidance changes were confusing. In discussions with stakeholders, LHJs reported that
due to the ever-evolving nature of the pandemic, guidance issued by the CDC and state
agencies changed quickly and often and it was not immediately clear what was changing in
updated guidance. Guidance would be interpreted and applied differently from county to
county, creating challenges for LTC operators with facilities in multiple counties whose
administrators were working to keep track of the updates and ensure facilities in all counties
had the resources needed to follow protocols. Stakeholders report that communication
confusion abounded early in the pandemic, with LHJs being unsure who to call at the state level
for assistance in guidance interpretation and LTC administrators being unsure who to call at the
state level or at LHJs for clarification and assistance with guidance implementation. Many LTC
operators developed strong relationships with LHJs, resulting in faster response times later in
the pandemic. However, stakeholders report that LHJ recommendations often come via phone
discussion and not in writing, which can later become a problem if a facility needs to show
documentation to regulators as to why something was done a certain way.
From a resident perspective, some LTC residents report being unaware of even the basics of
issued guidance, including what guidance their specific facility was implementing and where
that guidance was coming from, particularly in cases where the respective LHJ was
implementing more restrictive guidance than the state.
Guidance conflicts. The stakeholder group was asked to complete a survey on regulatory
mismatch, or instances in which regulations and guidance received from local, state, or federal
agencies seemed to contradict each other. This survey was also shared with LTC association
members. The survey received 80 responses from the LTC community.
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The survey inquired about the source of regulatory mismatch and respondents were asked to
select all applicable answers. The most popular answers were that:
• LHJ guidance differed from DSHS guidance (19 percent).
• State regulators gave different advice or guidance than the applicable LHJ (17 percent).
• CDC guidance differed from a proclamation from the governor (17 percent) or from LHJ
guidance (17 percent).
Figure 4
Respondents were asked where they went to resolve regulatory or guidance conflicts and asked
to select all applicable answers. The most popular answers were that they called their LHJ (18
percent), called DOH (17 percent), or called their professional association (15 percent).
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Figure 5
Respondents were asked about the typical timeframe for guidance conflict resolution. One to
three days was the most popular answer (39 percent), but many respondents reported longer
time frames (four to seven days, or 15 days to one month were also popular answers), and
some respondents indicated that some guidance conflicts impacting their facilities are still
unresolved.
Figure 6
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Respondents were asked to share whose guidance they ultimately followed, and why. Many
respondents said they followed the most restrictive guidance issued in the event of regulatory
mismatch, as it felt like the safest option for staff and residents. Some respondents indicated
that they followed the guidance issued by their state regulatory body (DOH or DSHS) while
others said they followed LHJ guidance due to an understanding that the LHJ is the final
authority. Many respondents shared that in instances of regulatory mismatch, they felt caught
between the involved entities and that a clear communication plan or avenue for guidance
conflict resolution would have been helpful.
Respondents were asked to describe the most common scenarios they faced with regard to
regulatory mismatch during the pandemic. They described feeling like the CDC, Governor’s
Office, DOH, DSHS, and LHJs did not work to align guidance before issuing, and that providers
had to spend significant time trying to reconcile differences with lengthy delays in response
time, particularly early in the pandemic. Other respondents described scenarios in which
guidance changed multiple times within a short time period, necessitating the rapid writing and
re-writing of facility policies by administrators to reflect new protocols which in turn created
confusion for staff and residents. Many respondents described experiencing confusion over
who had final authority, particularly when trying to get guidance for residential providers who
have varying licensing and certification requirements.
IDENTIFIED NEEDS:
Education for all parties. A common theme that arose during discussions with stakeholders
around guidance conflicts and communication challenges was the need for education for all
involved parties. LHJs need to understand the complexities of the LTC system to effectively
issue guidance and provide support to LTC operators within their jurisdiction; section 19 of SHB
1218 requires DSHS and DOH to provide this type of training. In addition, LTC operators need
training on how emergency guidance is issued and who to contact when resolving guidance
conflicts. State leadership involved in the development of emergency guidance needs to
understand the major players in the LTC system and know who should be involved in decision
making early in a public health emergency.
Relationship building. All stakeholders reported that having strong relationships across sectors
was critical for information sharing and guidance clarification. LTC facilities with established
relationships with state- and county-level authorities and LHJs with established relationships
with state agencies better understood who to call for answers and information early in the
pandemic. Developing and maintaining these relationships before an emergency arises is
critical for effective communication during a crisis.
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Strengthened communication. Stakeholders emphasized that having a streamlined plan for
communication and guidance conflict resolution would be helpful when clarifying future
regulatory discrepancies. Weekly LTC Q&A calls facilitated by DOH, with panelists from DSHS,
LTC associations, LHJs, and others provide the opportunity for LTC providers to ask clarifying
questions about guidance and receive advice; stakeholders report that these calls have been
helpful.
LTC residents and family members need plain talk materials explaining guidance being followed
by their specific facility and how that guidance will impact the delivery of care and services.
Interpreters, including deaf and ASL interpreters, need to be considered essential personnel to
ensure that all residents are receiving communications.
Many LTC facilities set up regular internet teleconferencing calls (e.g., Zoom webinars) or
established processes for sending frequent e-newsletters to share updated information on
restrictions and safety measures with resident family members; this had the effect of easing
their anxieties while also reducing burden on LTC staff who were fielding a high volume of
phone calls early in the pandemic when visitation restrictions were first implemented.
Conclusion and Next Steps
The LTC community faced significant challenges during the COVID-19 pandemic. As of the
writing of this report, the rise of the Delta variant and the resultant fifth wave of infections
continues to stress the LTC system. DOH and DSHS have worked with LTC stakeholders to
understand barriers and challenges, as well as identify lessons learned, best practices, and
future needs. This learning will be ongoing as the pandemic continues to evolve.
DOH and DSHS will continue to work with the SHB 1218 stakeholder workgroup to finalize this
report and develop guidelines that build upon the needs identified to date. These guidelines
will consider federal rules, the variety of involved provider and facility types, and available
resources for infection control. A timeline for implementation and a process to maintain and
update the guidelines will be included in the guidelines development process.
As required by Section 30 of the law, by July 1, 2022, DOH and DSHS shall finalize the report and
guidelines on COVID-19 and provide the report to the healthcare committees of the legislature.
As this process looks toward ways to prepare for the next epidemic, we share a common hope
that through collaboration, more lives can be saved.
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Appendices
Appendix A. List of SHB 1218 Stakeholder Workgroup Members
Christa Arguinchona, Providence Sacred Heart Medical Center
Sandra Assasnik, Washington State Hospital Association
Heidi Audette, Department of Veterans Affairs
Doris Barret, Developmental Disabilities Administration
Sharla Bode, Washington Home Care Association
Carolyn Cartwright, REDi Healthcare Coalition
Harp Cheema, Whatcom County Health Department
Kim Conner, Washington State Independent Living Council
Karen Cordero, Adult Family Home Council
Robin Dale, Washington Health Care Association
Julietta Davidson, Developmental Disabilities Administration
Leslie Emerick, Washington State Hospice & Palliative Care Organization
Linda Fairbank, Department of Veterans Affairs
John Ficker, Adult Family Home Council
Brad Forbes, Alzheimer's Association
Amy Freeman, LTC Ombuds
Alan Frey, Kitsap Home Care Services
Donna Goodwin, Home Care Association of WA
Amal Grabinski, Provail Supported Living
Peter Graham, DSHS Aging and Long-term Support Administration
Saif Hakim, Developmental Disabilities Administration
Kelly Hampton, Developmental Disabilities Administration
Barb Hansen, Washington State Hospice & Palliative Care Organization
Chad Higman, Puget Sound Regional Services
Laura Hofmann, LeadingAge WA
Todd Holloway, Center for Independence
Patricia Hunter, LTC Ombuds
Angeles Ize, Benton-Franklin Health District
Jacqueline Kinley, Unified Care Systems
James Lewis, Public Health Seattle-King County
Larissa Lewis, WA DOH
Scott Livengood, Alpha Supported Living
Danielle Love, Whatcom County Health Department
Cathy Maccaul, AARP
Elena Madrid, Washington Health Care Association
Barbara McMullen, State Fire Marshal's Office
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Vicki McNealley, Washington Health Care Association
Dylan Montgomery, State Fire Marshal's Office
Deb Murphy, LeadingAge WA
Dana Nguyen, Clark County Public Health
Travis Nichols, WA DOH
Jeremy Norden-Paul, Washington State Developmental Disabilities Council
Alyssa Odegaard, LeadingAge WA
Susan Pelaez, Northwest Healthcare Response Network
Sara Podczervinski, WA DOH
Cassie Prather, Spokane Regional Health District
Drew Pratt, Spokane Regional Health District
Sabine Preyss, Washington Society for Post-Acute and Long-Term Care Medicine
Aaron Resnick, Northwest Healthcare Response Network
Lisa Robbe, Developmental Disability Ombuds
Betty Schwieterman, Developmental Disability Ombuds
Katherine Seibel, National Alliance on Mental Illness
Noah Seidel, Developmental Disability Ombuds
Brianna Smith, Comagine Health
Melanie Smith, LTC Ombuds
Lauri St. Ours, Washington Health Care Association
Christina Wells, Developmental Disabilities Administration
Annette, LTC resident
Judah, Resident family member
Julia, LTC resident
Katrina, Resident family member
Randi, LTC resident
Susan, LTC resident
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Appendix B. Public Health Language
Throughout this report, we use terminology that is part of public health language. The Centers
for Disease Control and Prevention (CDC) provides definitions of common public health
terminology. This section of the report refers to general public health terminology and is not
specific to how these concepts were applied in LTC. Due to the needs of LTC providers and
residents, public health interventions were tailored to this population during the COVID-19
response. In later areas of the report, we discuss how these elements were adapted to the LTC
setting during the pandemic.
In this report, there are descriptions of stakeholder experiences with containment and
mitigation strategies. Containment strategies are used early on in an outbreak to prevent the
spread of disease and include (but are not limited to):
• Rapid identification;
• Infection control measures;
• Coordinated response between health care facilities;
• Continued assessment and screening until spread is controlled.
Mitigation strategies, used when containment is unsuccessful, follow these guiding principles
from the Centers for Disease Control and Prevention:
• Mitigation efforts aim to reduce the rate at which someone infected comes in contact
with someone not infected or reduce the likelihood of infection if there is contact.
• Decision-making by public health officials is based on the level of community spread of
the disease and will differ from one community to the next.
• Certain settings in a community with vulnerable populations are high-risk environments
for disease transmission. These include congregate settings (living in close quarters) like
LTC facilities, correctional facilities, and homeless shelters.
• Two mitigation strategies are isolation and quarantine. Although the two terms sound
similar in nature, CDC provides definitions useful in distinguishing between the two
strategies:
• Isolation separates sick people with a contagious disease from people who are
not sick.
• Quarantine separates and restricts the movement of people who were exposed
to a contagious disease to see if they become sick.
Alerting people who may have been exposed is done through a process known as contact
tracing. This is typically done by the local health jurisdiction (LHJ) but can also be done by other
entities with appropriate training. Contact tracing is beneficial because it:
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• Will let people know they may have been exposed to COVID-19 and should monitor
their health for symptoms of COVID-19.
• Helps people who may have been exposed to COVID-19 get tested.
• Provides instructions on how to self-quarantine if it is confirmed they had sufficient
close contact to be at risk of becoming ill or to self-isolate if they develop a COVID-19
infection. “Close contact” is defined as being within 6 feet of an infected person for a
cumulative total of 15 minutes or more in a 24-hour period.
The Many Names for Disease Occurrence
There are several words that describe infection-related events. It starts with an index case,
which means the first instance of a patient coming to the attention of health authorities. As the
number of cases grows, there may be groupings of cases that have certain things in common
like a shared geography or worksite. For COVID-19, a collection of two or more confirmed cases
among workers within 14 days is considered a cluster. Another term that is used for a similar
event is outbreak. According to the CDC, an outbreak “indicates a potentially extensive
transmission within a setting or organization.” The progression from index case to outbreak can
happen very quickly.
For a Washington state LTC facility, the interim outbreak definition is as follows:
• Licensed or certified long-term care setting-acquired COVID-19 infection in a resident.
• COVID-19 infection in health care workers (HCWs) who were on-site in the long-term
care facility or agency at any time during their infectious period OR during their
exposure period and have no other known or more likely exposure source.
Between August 2020 and September 2021, the federal Centers for Medicare & Medicaid
Services (CMS) required testing in nursing homes if a single new case of COVID-19 was
identified in any HCW or any long-term care facility-acquired COVID-19 infection in a resident.
This guidance was updated Sept. 10, 2021, and was adopted by Washington state on Sept. 30 to
include a focus on unit-based testing instead of facility-wide testing.
As the number of cases grows and exceeds that which may be expected, an epidemic may be in
progress. Once the cases with common disease presentation occur in widespread areas, across
country boundaries and involving multiple continents, the disease has reached pandemic
proportions.
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Appendix C. The Complexities of the Long-Term Care System
The LTC system in Washington state is a complex system designed to enable vulnerable adults
to meet their physical, mental, and social needs, goals, and preferences. The state Legislature
has declared that residents in LTC facilities “should have a safe, clean, comfortable, and
homelike environment, allowing the resident to use his or her personal belongings to the extent
possible.” The COVID-19 pandemic highlighted the need for a common understanding among
public agencies of what services make up the LTC system.
To fully understand how this system works, it is best to start with the basic concept of "home."
When one residents in a nursing home or an assisted living facility, their assigned room or
apartment is considered their home. A wide variety of skilled medical services are provided in
these settings but within these walls, it is still their home. This is why in this report, the
recipients of long-term care services are referred to as residents (or clients) and not patients.
There is a great deal of supportive care being provided as a part of the LTC system. For
example:
• A person may live in their own assisted living apartment, but could be receiving nursing
services or physical therapy through a home health agency or hire a home care aide
from a home care agency, either short or long-term.
• A family may have decided that the best care for their loved one is in a smaller facility,
such as a licensed adult family home (AFH) where 1-6 residents live.
• A person with behavioral challenges may reside in a community setting, such as an
enhanced services facility.
• Persons with intellectual/developmental disabilities may live together in a rented
apartment while receiving supported living services.
A person in any or all of these living environments may need assistance with their activities of
daily living - ADLs (e.g., bathing, dressing, toileting).
There is one more common element to this network of services. In any of these environments,
any of the places the person calls home, it may become necessary to receive end-of-life care
from a state-licensed, Medicare-certified hospice provider.
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Figure 7. Long-Term Care System Components
Not only are there a wide variety of services available within the LTC system, these services are
also under the regulatory authority of multiple state and federal agencies. For example:
• Skilled Nursing Facilities/Nursing Homes: The Centers for Medicare and Medicaid
Services (CMS). CMS is the payment source for many LTC services, including nursing
facility services. In order to receive funds from CMS, an organization must comply with
certain Conditions of Participation (COPs). These COPs are performance standards of
care that are designed to bring about safe care and to restore the person to their
highest practicable level of functioning. Nursing facilities also follow state licensing
standards. DSHS conducts regular surveys, as well as complaint investigations, to assure
compliance with both state and federal standards.
• Assisted Living Facilities, Adult Family Homes, and Enhanced Services Facilities: These
are state-licensed facilities whose regulations are codified under RCW/WAC and
Home
Health
Private Duty
(with 1:1
Contract)
Home Care
(non-medical)
Hospice
Assisted Living
staff
Adult Family Home
staff (May live-in)
Supported Living
Services staff
DSHS-Paid
caregiver
Enhanced Services
Facility staff
Nursing Home
staff
SERVICES
PEOPLE
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monitored by DSHS. DSHS conducts regular licensing inspections for compliance with
state regulations and investigates complaints.
• Home Health and Hospice: Home health and hospice agencies are regulated by both
CMS and under state RCW/WAC rules. The Washington State Department of Health
(DOH) is responsible for regulatory oversight, performing survey services to verify
compliance with COPs and state licensing regulations and conducting complaint
investigations.
• Home Care: Home care agencies are state licensed and regulated by state laws and
rules. The Department of Health is responsible for regulatory oversight, survey services,
and investigating complaints relating to home care services. It is important to note:
o If a person hires an individual to perform home care duties and the business
relationship is only between the two parties, DOH has no jurisdiction or
authority in this scenario.
o If a person contracts with an individual provider (IP) paid through Medicaid to
provide support with ADLs, DSHS contracts with agencies that are the employer
of the IP and ensures that training requirements and certifications are met.
Other government entities that may become involved include the Centers for Disease Control
and Prevention (CDC), the Occupational and Safety and Health Administration (OSHA), and the
U.S. Department of Labor (DOL) or Washington State Department of Labor and Industry (L&I).
At the county level, it is the local health jurisdiction (LHJ) that holds local authority during a
public health emergency.
These entities may or may not communicate effectively with one another.
Even under the best circumstances, it can be difficult to maintain the balance between ensuring
that necessary LTC services are available and ensuring that those services are being provided in
a manner that meets regulatory standards designed to achieve safe care.
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Figure 8. Long-Term Care System Regulatory Oversight
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Appendix D. Funding Streams in the Long-Term Care System
There are a variety of mechanisms to pay for LTC services in Washington. The following is a list
of possible payor sources for LTC care. While we have tried to include as many situations as
possible, this is not an exhaustive list. It is common for these resources to be used in
combination, particularly those from non-governmental sources:
• Private Pay: Goods and services relating to LTC are paid for with personal assets,
savings, and/or investment income.
• Medicare: Eligibility is determined by the federal government. Typically this is age-
related, but can also be due to certain diagnoses. For example, a person in renal
(kidney) failure who requires dialysis can become a Medicare beneficiary at any age.
Medicare is not designed for ongoing, long-duration residential care, but may be the
primary payor of rehabilitative care that takes place in a LTC environment such as a
skilled nursing facility.
• Medicaid: The federal government sets the guidelines for eligibility, but each state
operates its own program. States utilize these funds for long-duration residential
support in a variety of settings, which may include the provision of services in the
beneficiary’s own home. Funds may be used to pay for services in a nursing facility or in
home and community-based settings (HCBS), such as adult family homes, assisted living
facilities, or enhanced services facilities. Because each state develops their own
programs, benefits can vary greatly from state to state.
• Veterans Benefits: Eligibility is determined by the federal government and tied to the
person’s military service record.
• Employer-Based or Corporate (Private Pay) Health Insurance: This form of insurance
may be the primary payor for initial treatment of diseases and/or injuries, but typically
has very limited benefits for LTC.
• Long-Term Care Insurance: The consumer pays premiums with their own funds for
insurance benefits purchased in advance of need. Once a person has a debilitating
condition, they are highly unlikely to be qualified to participate by the insurer. If the
person is approved to receive benefits by the insurer, LTC insurance benefits can be
used in the beneficiary’s own home, in a nursing home/skilled nursing facility , in an
assisted living facility or in an adult day health setting.
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Figure 9. Long-Term Care System Payment Sources
Medicaid Funding and the COVID-19 Pandemic
Federal Medical Assistance Percentage (FMAP) – Due to the rapid spread and high mortality of
COVID-19, a nationwide public health emergency was declared by the Health and Human
Services Secretary on Jan. 31, 2020. Federal legislation, in the forms of the Families First
Coronavirus Response Act and the Coronavirus Aid Relief and Economic Security (CARES) Act,
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provided funding support to help states cope with the dual burden of increased health care
costs and the economic downturn resulting from the effects of the pandemic.
In Washington, Medicaid funding is typically structured as a 50/50 split (with some small
variations among programs) between state and federal dollars. Federal relief packages changed
this split, creating Enhanced Federal Medical Assistance Percentages (FMAP) funds, which
shifted the split to a higher amount of federal dollars and a lower amount of state dollars.
Washington invested most of the additional federal match funds back into the Medicaid rates.
For example, Washington used the Enhanced FMAP funds to provide both skilled nursing
facilities and adult family homes with a temporary add-on increase to their daily rates.
The Enhanced FMAP funds are scheduled to continue through Dec. 31, 2021. There are
scheduled funding increases to some LTC settings during 2022, but these are not equivalent to
what the Enhanced FMAP funds have provided during the COVID-19 pandemic. There will be a
six-month gap in funding between when the Enhanced FMAP add-on funds expire on Dec. 31,
2021, and when other Washington state legislature-approved rate increases are available on
July 1, 2022.
Stakeholders expressed concern about this gap in add-on funding. One stakeholder shared that
these funds were being used to support increased staff wages in some organizations. There
were no requirements placed on providers as to how they could use the additional funds. The
additional funding was intended to offset a variety of costs related to the pandemic, including
the purchase of PPE, hiring of additional staff, and equipment purchases, to name a few
examples.
Long-Term Care and Future Funding Possibilities
House Bill 1087 (Chapter 363, Laws of 2019) established the Long-Term Services and Supports
(LTSS) Trust program, also known as the WA Cares Fund. This program is a first-in-the-nation,
state-funded long-term care insurance. This program was modified by SHB 1323 in 2021.
Beginning in January 2022, employers are required to collect premiums through payroll
deductions at the rate of $0.58 per $100 earnings. There is no income cap for this contribution.
There is no employer contribution required. The first benefits of the program will begin Jan. 1,
2025. An eligible individual is entitled to a lifetime benefit of $36,500 for long-term services and
support, which the state will pay to LTC service providers on behalf of the individual.
The federal American Rescue Act of 2021 was signed into law on March 11, 2021. Section 9817
of the act provides states with a temporary 10 percent increase to FMAP for certain Medicaid
expenditures for home and community-based services (HCBS). This 10 percent funding can be
used over a 4-year period and cannot be used to offset state budget shortfalls. Washington has
applied for this additional funding and, at the time of this writing, is awaiting approval from
CMS.
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The federal Care at Home Act was introduced on July 29, 2021. This act would provide older
adults with up to 30 days of expanded skilled services, post-hospitalization, in their own homes
(as opposed to institutional care). Potential implications of this bill would be cost savings to
Medicare and increased ability for hospitals to discharge to home. Difficulty with discharges
from hospital care has been an ongoing problem during the COVID-19 pandemic.
