As the state is again hit with a rash of COVID-19 outbreaks at long-term care facilities, advocates say the virus’ spread is not a surprise – and it is made worse by longstanding issues with staffing and infection control in Kansas nursing homes.


It is no secret that nursing homes and other congregate care facilities are at a higher risk for the virus to spread owing to an older population, often with underlying health conditions, assembled together in close quarters.


But case counts are ticking up across Kansas, meaning that staff are at a higher risk of bringing the virus with them as they head to work after a trip to the grocery store or picking up a child from school.


And the rise in cases comes as residents and their families are increasingly distressed over not being able to visit with each other after months of isolation.


Combating the virus will simultaneously be more difficult for those facilities due to burnt out staff members and, increasingly, financial strain from federal testing requirements.


Many of these issues, advocates say, existed prior to COVID-19 and will complicate how long-term care facilities continue to respond to the virus.


"When something like COVID-19 comes along it lays bare the inadequacies that are already there and identifiable and that we just kind of bump along with most of the time," said Mitzi McFatrich, executive director for Kansas Advocates for Better Care.


Outbreaks raise questions over infection control


The Kansas Department of Health and Environment currently reports 250 clusters associated with long-term care, accounting for more than 2,800 cases of COVID-19. Fifteen of those facilities have more than 10 infections.


Rep. Susan Concannon, R-Beloit, said that many of them are in areas which thought they had weathered the worst of the pandemic already, pointing to an outbreak at a facility in her Ottawa County district.


"These are the issues and things we thought were coming last spring," she said. "And now with ... a second wave, those are the issues that we got a little bit complacent and now are bubbling up."


AndBe Home in Norton County gained national attention when it announced Monday that 10 residents at the facility had died from the virus, with all of the 52 other residents infected.


A Center for Medicare and Medicaid Services inspection in May sounded the alarm that the facility’s COVID-19 prevention planning "revealed lack of action and education to prevent the spread of COVID-19" within Andbe, although it appears the facility quickly addressed the deficiencies within 24 hours of the findings.


The CMS report noted that the facility wasn’t mandating that employees wear masks and that only a minority of workers were doing so in hallways and common areas.


"The facility staff lacked appropriate facemask covering for source control while in the facility, COVID-19 infection control staff education, and a COVID-19 policy to prevent the potential spread of the disease placing all 63 residents in the facility in immediate jeopardy," the CMS report said.


AndBe was not alone. At least five other Kansas facilities had their COVID-19 protocols deemed insufficient by CMS since between May and September.


But Sue Schuster, who works for the state’s Office of the Long Term Care Ombudsmen as a regional advocate for residents and families in northeast Kansas, said that reports of facilities disregarding infection control protocols persist.


Families will see staff or residents not wearing masks while looking in for a socially distant visit and report it, Schuster said. It is a sign that staff and residents in nursing homes, just as in society as a whole, may be experiencing pandemic fatigue, she noted.


"I think people are tired," she said. "I think people feel like they have done everything they are supposed to do and they feel like it is just us in here and we might have been exposed to each other but we are in a bubble and we are safe."


But facilities were frequently cited for not having proper measures in place to stop the spread of infections, even before the pandemic.


CMS data from 2017-19 compiled by Kansas Advocates for Better Care shows 117 facilities were deemed deficient for having and maintaining an infection control plan.


Much of this has been due to understaffing.


"What this virus has done to shine a very ugly light on how poor we were already doing in terms of providing adequate staff and making sure that good infection control practices are in place," McFatrich said.


Long-term staffing issues worsen during pandemic


Attracting staff was difficult in the long-term care sector even before the pandemic. Going back as far as 2001, organizations nationally were sounding the alarm that a shortage of qualified personnel was brewing.


A survey from an industry trade group last year showed the problem has deepened, with 75% of nursing directors in long-term care deeming staffing shortages to be their top challenge. Sixty-three percent surveyed say they do not have enough staff to properly care for residents.


That was before staffers started becoming infected with COVID-19.


"They're finding more asymptomatic people, which is a good thing that we are finding that out before residents become infected," said Barbara Hickert, the state’s long-term care ombudsmen. "But then that that's one less staff member that's able to work now for a period of time, and so they're stretched a lot thinner than they were before."


Volunteers from local schools are less likely to work at their nursing home over fears it might impact their ability to go to classes in-person or play sports. Staffers on the fence about their jobs may be pushed to leave by requirements that they undergo frequent testing.


And especially in rural areas, where work is more plentiful, facilities are reporting that more workers believe the precautions aren’t worth the hassle.


"I can go down the road to McDonald’s and get paid $15-an-hour and not have to worry about testing," Holly Noble, a representative from the Kansas Adult Care Executives Association, told lawmakers last month.


Kansas statute requires nursing homes have enough staff to meet the needs of residents, a vague standard that "doesn’t have a lot of meaning," Hickert said.


And while nursing homes once again have to submit payroll records to the federal government to guarantee staffing ratios are being met, that information is not yet public.


Other states have taken on novel solutions to attempt to tackle staff shortages, something advocates believe Kansas should also consider.


That includes Ohio’s strategy of having regional teams that can be called upon to provide additional support and testing when a facility is in need. That is supplemented by separate "strike teams" that can bolster infection control if an outbreak occurs.


Kansas facilities that are running low on staff have merely been getting waivers from the state to continue to operate as usual, McFatrich said.


"I think that's a recipe for disaster," she said.


Visitation, financial problems loom


And fewer staff members also makes it harder for facilities to cope with and set up visits between residents and their families. That has been a top priority for those fearing that isolation has caused a deterioration in mental and physical health for those living in long-term care.


But despite new CMS guidance aiming to allow in-person visits to begin, they are keyed to a county’s COVID-19 positivity rate. Facilities in areas with higher rates of infection will be more limited in when they can allow visitors in.


Other states have gotten creative here, as well. Minnesota and other states have authorized a family member to in effect be deputized as a caregiver, allowing them to enter a nursing home to help pitch in and help a loved one eat or be more comfortable.


But ultimately all visits are halted when a facility has a COVID-19 case, meaning that families often wind up frustrated


"You're just about to get to your 14 days or your 28 days and then boom, somebody else has been infected, so we started that all over again," Schuster said. "And it's just they just wait longer and longer to be able to get in there and see their family members."


An existential threat is facing nursing homes, as well: the prospect of financial ruin.


This has been made worse by financial burdens from testing staff, something which has to happen as often as twice a week.


And a host of uncertainties exist, such as whether federal Paycheck Protection Program loans will be forgiven or not.


Flu season also brings new issues, including a renewed demand for personal protective equipment, which some homes are still having trouble accessing.


And there is the worst-case scenario: a home having to be taken over by the state, a process known as receivership.


Those in the long-term care industry fear the pandemic will reverse a years-long decline in the number of facilities that have been in receivership.


"Many adult care homes in Kansas are unsure of their long-term ability to operate and provide care for their residents," Noble said. "We feel like sitting ducks just waiting for the other shoe to drop."


If the industry is able to re-emerge from the pandemic, some say it is a chance to re-imagine the future of long-term care.


Experts say that COVID-19 relief funds can be used to train more potential staff in colleges and trade schools.


And Hickert pointed to experiments in other states, where nursing homes are not designed in the way most Kansans are used to, but instead employ a series of smaller buildings with dedicated staff for each.


Called the greenhouse model, the thinking is that this improves infection control while also empowering residents.


COVID-19 might make more people open to such a concept, she said.


"There's always going to be a need for congregate living arrangements and long-term care," she said. "But how they look could be different."