Nursing homes have been a focal point in the fight against COVID-19. While the challenges of protecting vulnerable and elderly nursing home residents against an unknown and often silently transmitted disease are significant, the pandemic has made existing problems within the long-term care community even more readily apparent. Poor quality of care, insufficient staffing, and questionable administrative practices among small and large facilities have been noted.

Yet another problem – the practice of admitting confirmed COVID-19 patients as hospitals overflowed. This was a problem, particularly in facilities which had poor infection control practices and staffing deficits before COVID-19 arrived.

A recent report by ProPublica focuses on how these issues have played out at the New Jersey-based CareOne chain. According to ProPublica, CareOne, which is among the largest nursing home chains in New Jersey, offered to take COVID-confirmed residents from another local care facility, St. Joseph’s Senior Home.

Following a difficult and disruptive transfer process of almost 90 residents from St. Joseph’s, CareOne would go on to have the highest rate of COVID-19 deaths among long-term care facilities in New Jersey. While nursing home deaths related to COVID-19 are high across the state of New Jersey – 6,800 at the writing of this article – CareOne still stands out.

Some figures to consider: The chain’s facilities had an infection rate of 56% when the rate statewide was 38%. Their death rate for certified beds was 17% compared to 10% statewide. In May, CareOne’s infection rate was almost twice the overall rate in New Jersey: one for every 2.2 beds had a COVID-infected patient compared to one for every 3.8 beds across the rest of the state.

Despite this, CareOne has played a major role in responding to COVID-19 in New Jersey. After the transfer of patients from St. Joseph’s, the state granted CareOne a license to provide more than 700 beds to care for COVID patients following their hospital discharge.

Classifying residents as “short term” leads to decline in quality of care

Quality of care isn’t a new concern for nursing home watchdog groups, and it’s not a new concern for critics of CareOne. CareOne has been the subject of lawsuits in past years over failure to meet nursing home care standards.

However, CareOne’s response was surprising. While lawsuits alleging failure to care for residents isn’t uncommon, CareOne claimed that they didn’t actually have to meet industry standards for their short-term residents.

Short-term stays tend to be for patients undergoing rehab or convalescing following surgery, but in the spring and summer of 2020, the flow of these patients has been replaced by COVID-19 hospital discharges.

While New Jersey, like many other states, has extended immunity for liability to nursing homes and extended care facilities, the tactics historically used by CareOne demonstrate a history of legal maneuvering around industry standards. Immunity ensures a lack of accountability. This is a major concern for patients and their loved ones.

Prioritizing returns over residents

To some degree, CareOne taking on additional patients, was beyond their control. The state of New Jersey issued an order on March 31 requiring all long-term care facilities to accept discharged but stable COVID-19 patients. Patients had to be accepted even if they were still testing positive for the disease and they weren’t allowed to be tested prior to admittance.

Even if facilities did have the option to turn patients away, the State provides significant financial incentives to take them. Facilities were eligible to receive funds on a per-patient basis from the more lucrative Medicare rather than Medicaid. Moreover, facilities that were licensed by the state could be reimbursed for all reasonable costs through both the Federal Emergency Management Agency (FEMA) or emergency compensation boards appointed by New Jersey governor, Phil Murphy.

Systemic problems at work

While CareOne demonstrates a range of problematic issues in its response to COVID-19, it’s far from the only care facility that does. The shocking death toll among New Jersey nursing home residents as a result of COVID-19 prompted the state to form an independent assessment of the facilities and their regulatory overseers in May.

Led by consulting group Manatt Health, the report released in June painted the picture of a system unprepared for the pandemic and unprepared to oversee a response.

As the report noted: “Under-resourced state agencies did not have sufficient staff to deploy to facilities and conduct meaningful oversight prior to COVID-19…COVID-19 didn’t create the problem–it exacerbated the long-standing, underlying systemic issues affecting nursing home care in New Jersey.”

The quality of care in nursing homes is more important than ever in the COVID era. Accountability is, too.