In this podcast, Daniel Sternthal, Shareholder, Baker Donelson, April Diaz, Vice President of Clinical Services, Marquis Companies, and Darrell Zurovec, General Counsel, Touchstone Communities, discuss how long term care facilities are dealing with the COVID-19 pandemic. The podcast discusses how facilities are dealing with pressing issues such as how to manage memory care units in light of the pandemic, how to minimize risk, staff issues, and navigating the patchwork of regulations from the federal, state, and local governments. From AHLA's Post-Acute and Long Term Services Practice Group.
To learn more about AHLA and the educational resources available to the health law community, visit americanhealthlaw.org.
In this podcast, Daniel Sternthal, Shareholder, Baker Donelson, April Diaz, Vice President of Clinical Services, Marquis Companies, and Darrell Zurovec, General Counsel, Touchstone Communities, discuss how long term care facilities are dealing with the COVID-19 pandemic. The podcast discusses how facilities are dealing with pressing issues such as how to manage memory care units in light of the pandemic, how to minimize risk, staff issues, and navigating the patchwork of regulations from the federal, state, and local governments. From AHLA's Post-Acute and Long Term Services Practice Group.
To learn more about AHLA and the educational resources available to the health law community, visit americanhealthlaw.org.
Hello, this is Daniel Sternthal and I am the chair of the Post-Acute Long-Term Services Practice Group at A H L A. And on behalf of the Practice Group, I want to thank you all for listening to our podcast, the title of which is COVID 19 a Boots on the Ground Conversation with General Counsel and VP of Clinical Services and Long-Term Care Facilities. And before we begin, I wanted to thank the folks at A H L A for putting this podcast together on such short notice. And most importantly, I especially want to thank our guests today, April Diaz. She is the VP of Clinical Services at the Marquee Companies, and Daryl Zer, who is General Counsel at Touchstone Communities for visiting with us today, uh, despite what I imagine for them, as with all of us, is an incredibly busy and challenging time. So for the next 30 minutes, we will dig into some of these issues related to Covid 19 in long-term care facilities. And I'm excited to get the perspective of two experts who look at issues, uh, from different angles, um, but are facing some real struggles today, uh, and talk about some of the immediate and urgent issues that long-term care providers are facing. And the goal is to dig into the covid related challenges from a resident's perspective, uh, dealing with staff members, uh, family members, and then identify best practices and challenges and how to manage the situation. Um, and just so you have a sense, you listeners have a sense of, uh, who we're gonna be hearing from. Uh, April is an rn. She's been with the Marky Company for about 16 years. And in her position, she is responsible for clinical system oversight and regulatory compliance, and she's based outta Portland. And the company I believe manages approximately or owns approximately 25 or so communities up in the Pacific Northwest and April. Please correct me if I'm, if I'm mischaracterizing and darl. Daniel,
Speaker 2:You're perfectly perfect. Good. Thank you.
Speaker 1:All right. Good deal. Thank you. And, and Darl is General Counsel at Touchstone Communities. He's based in Austin, Texas, um, and he's been with Touchstone for about three years. Touchstone has a similar number of communities in Texas. Um, and before, uh, joining Touchstone, Darryl has been, uh, a long-term care attorney for, if I had to guess, over 20 years.
Speaker 3:Yeah. Some something over 20 years. That's right.
Speaker 1:<laugh>,<laugh>. So thank you guys both for making time. Uh, we spoke, uh, as we were, were preparing for the webinar we spoke about a week ago, and we talked about the best way to organize it. And Daryl, you had a good suggestion of breaking this down into pre Covid world and post Covid world. And I imagine because y'all have so many communities between the two of you that you're, uh, in charge of and taking care of and focusing on, uh, you have a certain number of communities that fall into each one of those two categories. And so the idea is today to focus on those two worlds because the world view is very different from each one. Um, and I just want to touch base and, uh, and, and check in the, the last time we spoke, which was, I guess about a week ago, um, April, you had said that there was one community, um, at y'all's company that had, uh, positive test results for residents and employees. Uh, and, and Darryl, I think you had said that there was a resident who had been discharged from one of your communities, tested positive post-discharge, um, and that since then, there ha there's one community now where you're testing staff and residents. But I'm wondering, because so much changes so quickly, if y'all could tell us, you know, what are you dealing with today? Is that still accurate? What, you know, what, what does the world look like for you all, uh, as of today?
Speaker 2:Thanks. Uh, thanks, Daniel. Yeah, we, fortunately, knock on wood, at this point out of our 20, um, five facilities, both sniff and assisted living, we only have the one facility that we have positive residents. We have not had a knock, again,<laugh> crossing our fingers, a positive test from that facility in over a week. So we're hoping that that holds true. We have had now probably four facilities where we've had positive staff. Um, and little, little bit later when we talk about things that we have done to protect, fortunately, none of those facilities have we had any positive residents. And I think it comes down to some of the strategies that we've put in place, um, because it is very, um, high numbers in some of our, uh, counties in Oregon that we work in. And so those staff members were not surprised to see some positive staff members creep in.
Speaker 1:It's really all started, um, it seems like in the Pacific Pacific Northwest in terms of outbreaks in long-term care communities. And Darryl and I, and many of us that are probably participating in the listening to the podcast were at the long-term care and the law conference in San Antonio, just as this was, um, becoming a reality. Darryl, what, what are you seeing?
Speaker 3:Y Well, you know, here in Texas, um, we're still on the upward part of the, of the curve, uh, from a covid perspective. And so, you know, last week we had the one community that, that had a, a discharge resident who had tested positive. And as you said, Daniel, things move very quickly. So we now have a couple of facilities where we have had either staff members, uh, and, and generally speaking, it's been more staff members where they have, they have, uh, tested positive. Um, and we have had ano another community or two that has had a resident, uh, that has tested positive. And, and we don't have any current residents in-house. Uh, generally once they've tested positive, they're either testing positive, you know, because of the limitation on testing ability. They're testing positive after we discharge'em to the hospital, uh, after a change of condition. Um, and, uh, so, you know, we're not then j uh, so far we haven't had the situation where we're then remitting patients with. It's certainly not with an active covid diagnosis. So no known cases in house, but we are having some residents that are, that are, uh, coming positive. Now,
Speaker 1:It's interesting from, from what I'm hearing both of y'all say, uh, the staff is the, it seems like it's the harder, uh, group of folks to, uh, or maybe there's a greater risk that are harder to, to manage because they're, they're coming and going from the facility and interacting with folks. Uh, it's harder for y'all to control, um, their activities.
Speaker 3:Yeah, I think that's right. Um, you know, some of them work in multiple communities. Some of them work in a nursing facility and also work in a hospital, and there may be more exposure in that hospital. Uh, and, uh, but generally, yeah, yeah, they're, they're out there in the community living their lives. And, uh, so, you know, we're taking steps and we'll talk about this in more detail to, you know, screen them actively and, and, and do our best to make sure that, you know, we don't have folks coming into the community, uh, who are, are positive, um, you know, from our staff or, or vendors or, or what have you. But, uh, you know, it's, oh, uh, it's a continuing challenge.
Speaker 1:So think thinking about now from the perspective of pre covid and the communities that y'all are working with that haven't had an outbreak yet, if y'all could talk a little bit, and, and Darrell, I'll, I'll start with you. Uh, what steps have you found to be effective, or what steps are you taking to try to minimize the risk of an outbreak? And, and we're talking obviously beyond, you know, the guidance of cdc, the social distancing, the limiting the visitors, um, you know, assuming that those are, uh, as of now, uh, you know, commonplace, uh, across the country, uh, what are you seeing as being the most effective means to try to, to limit the outbreak and, and minimize the risk?
Speaker 3:Well, Daniel, I would say really all of that. I don't know that we have anything, uh, you know, a magic bullet that, that is different from the guidance that's out there. Uh, you know, we are screening all employees prior to each shift. Uh, we have a questionnaire that they have to go through and complete, and we've modified that, you know, we found that, you know, not all the folks who work at the community think this, you know, read, read the agree, read the, uh, screening tool the same way. And so, you know, someone says, well, I didn't know that. I should tell you if, you know, my wife tested positive yesterday. Well, you know, yeah, you should cuz see right here where it says<laugh>. So, you know, we've tried to modify that and make it more, you know, user friendly, uh, so that the staff can understand it. But we're screening folks. We're assessing residents multiple times a day, you know, cleaning mm-hmm.<affirmative>, uh, deep cleaning, high traffic areas within the building. Um, uh, you know, trying to work with, uh, actually, you know, limiting non-essential physician visits, especially outside the community. And, you know, we're, we're in touch with the attending physicians and or specialists. And if there is a visit, uh, you know, someone has a visit once a year to adjust their meds, well can we push that back, um, you know, by two months and see how things are going there. So we're trying to reduce some non-essential physician visits. Uh, we started drawing, uh, blood for lab draws with our own, uh, nursing staff. And, you know, rather than allowing the lab techs to enter the communities, um, trying to drill down deeper to find out where our staff are working. Are they working in other, you know, settings where they're, they might have, uh, exposure. Uh, and we are starting to get some traction now trying to use telehealth with some physicians. So, you know, it, it's a, you have to do it all and you have to keep doing it all and not get, um, you know, fatigued by the process. It's, it's something that, uh, not only do you have to keep doing it, but keep trying to think of new ways, you know, to improve and, and, you know, you know, come up with ways to, you know, limit the vector as it were.
Speaker 1:April, what, what does the, what does that issue look like for you?
Speaker 2:Yeah, I would absolutely agree with what Darrell said. Um, we're doing all of those things, obviously. Um, we know as a nation, starting that very first week of March, all the rollout of guidance after the Kirkland facility in Washington, um, came into the news. And our risk factors within our population became so obvious. Um, we actually began within our companies before the guidance, starting out all the restrictions and screening for cdc. The good news is obviously the guidance helped us because we were getting some pushback on restriction of visitors. Um, but we locked down on that. And, you know, in our conversations with the ombudsman, initially we had some struggles, um, that obviously went away once the guidance came in. So that has helped us greatly. The other thing is, like what Darrell mentioned as well is the constant need to make sure that the policies and protocols that we, that you write, um, it's not just verbal, but you've got something in writing that you're also nimble enough to keep those updated in communicating that with your facilities. Obviously trying to keep 25 facilities updated and on process without overwhelming them, we're gonna talk about that later, um, has been one of our biggest, um, areas that I've attempted to navigate. The other thing on what are we doing to decrease our outbreak is we as a company, after our first facility had their first positive test in March, uh, of 20 or March 27th was our first positive test. We realized maybe the impact of the asymptomatic person. Um, we had a key nurse who was assigned to our patient a who we happened to just test because she was the primary, she was positive. Um, and so she was completely and has been completely asymptomatic. We rolled out across all facilities that same day masks for all staff. Um, and so we did a lot of training with the ppe, but we very quickly put into place, um, the mask, um, strategy because we don't know what the asymptomatic carriers we, what we do know is because our facilities nationally have been, um, we called it a protective cocoon, is the only individuals like Darryl said, that are coming in like lab or floating staff. They're the ones that we have to protect our residents from. And the mask just adds that one extra layer in addition to the screening. And I do think for those couple facilities that we've seen in the last week, in particular in Oregon, where we've had positive staff, even though they were direct caregivers, I, I do believe the protection of that mask has, um, limited or prevented the spread of their positive asymptomatic period to our residents. Um, so we're holding tight to that. I do know PPE is a major struggle nationally. So we have some criteria within the hand being masks. How do you use them? How do we use our medical masks to make sure we're doing that? Um, and we've also set a very low threshold of if we have a resident who is presenting symptoms of when we put them in, uh, droplet precautions, um, we've seen very minor symptomology being what we've seen first. And so we're not waiting to true symptoms. And I think that also helps reduce some of the risk of spread. If we were to get a positive, our building that has a positive, we were able to keep that to 10 outta 60 residents. And I think it's cuz they moved very quickly mm-hmm.<affirmative>. But we also, as I said, we continuing having to change and respond to that change as we've learned more about covid and the risk factors.
Speaker 1:Right. And definitely moving target. Darrell, you had mentioned telemedicine in April. You, you didn't Oh, yes. I'm wondering, there's been so much in the, in the guidance about opening up telemedicine to facilitate care in particular in long-term care. And if y'all could take a minute, I'd love, love to hear what your experience is with it, uh, and and where you see that going.
Speaker 3:Go ahead, April. You're probably more closer to it than I am.
Speaker 2:Yeah, and I, I'm glad you brought that back up again. Cause I forgot to mention that we moved, uh, very quickly with telehealth probably starting that first week of March, and we figured we fig, um, we would waive the billing issue, but then now CMS has put the waivers up to help the billing. But we moved all of our practitioners to, um, our in-house practitioners to telehealth that first week via some iPads. And we've dedicated iPads for that. We've also now have done any of our wound care consultants, um, are doing it via iPad. So we very quickly limited the physical interchange to move it to technology interchange. And I truly think that we're gonna find that telehealth after we're all said and done, is one of those things that are gonna stick after Covid. It has been a, um, a well embraced platform both by residents and our providers, and it has worked really well in our communities in keeping our physicians and nurse practitioners being able to manage multiple buildings, but yet not going into multiple buildings to reduce the risk of spread between buildings if a case were to come up, um mm-hmm.<affirmative>, But we've had very good success with the telehealth.
Speaker 1:Darrell, do you wanna add to that? Any
Speaker 3:Legal concern? I, I think, I think we're we're, uh, earlier days. Um, so I don't, I don't have, uh, really anything substantive to add to that. It's a process that we're just starting out trying to pilot in a, in a couple of communities, and so we don't, you know, the, the jury's still out on, on how successful we're being with it, but we do, you know, the, the overall positive of limiting interaction, you know, from outside the, the facility, uh, you know, that in and of itself is a positive, but, uh, I don't have enough information right now on, you know, exactly how far we've been able to penetrate working with our, with our local practitioners.
Speaker 1:Right. So in, in terms of, uh, limiting the risk, you know, we've identified some issues and y'all have raised some, some good points. How do you take that knowledge? Because you, you, y'all have certain communities that are farther along and, and earlier along in the process. How do you take that knowledge, um, and prepare the staff at the various communities for the eventuality that there will, you know, in all likelihood be an outbreak, uh, either through, through a resident or a staff member as you guys are talking about, like, you know, how are you adjusting in particular? Um, and April, I'll start with you. How are you adjusting admissions, new admissions? What's that process looking like now? Um, are you denying, uh, admissions on new basis now? Are you, um, are you, that that guidance that just came out recently from, uh, cms, I, I think on Monday about transfers, uh, how, how, how is covid affecting that, that, uh, aspect of your job?
Speaker 2:And I think this is really going to be regionally based, um, in the Pacific Northwest. While we've had, um, some hotspots up here, um, in Oregon in particular, the acute care hospitals move very quickly at creating dedicated units within the acute care. Um, we don't have, knock on wood, the need at this point to create covid facilities in skilled. Um, and so have not applied the transfer you, uh, rules. But if we were to get an influx, like if we were in, so there's hard areas on the East coast, I think that CMSs um, flexibility on that is great in the fact of moving residents into safe environments. Um, with that said, though, for emitting of new residents, uh, our dhs um, and Oregon Health Authority has been pretty closely aligned in the fact that a covid healthy facility should not be taking a covid positive resident. And I think there's been other dialogues in other states that are different than that. And so we've used, um, for our new admits, um, the AMDA put out a screening tool that we actually had adopted and, and how do we screen hospital patients? We're not asking that a COVID test is done on all hospital admissions to snp that's not relevant or valid at this point, especially due to limitation of testing. But given certain risk factors, we might ask for that. Um, and just really focused in on those respiratory patients, the cardiac patients, any patient in the hospital that has some fee, low grade fevers even. Um, and looking at that now, with that said in the last week, most hospital systems now are starting to test every patient upon admission. And so we, most patients, were seeing that there has been a covid test completed, but we're also cautious that they've been in the hospital for 12 days. And if that COVID test was done on admission, it might be something to be looked at again. Um, and so it's just really focused approach on that. But we are not taking anyone that's covid positive, unless they've, they've proven to be negative, um, in a po infectious stage.
Speaker 3:And our process is, is similar. Our, our process is similar. We're not in introducing anyone, uh, who has covid or, or, uh, uh, doesn't meet the screening criteria into communities where, where we haven't had covid exposure, uh, or don't have any positive cases or suspected cases. So, uh, we also are, the Health and Human Services Commission in Texas has, uh, put out a, a screening tool that the hospitals complete. And, and it's got a decision matrix based on the, the CDC guidelines. Uh, and, and it, you know, has a decision tree where the hospital, it asks the hospital questions, have you done X? Have you done Y? And depending on the answers, they can either, either authorize to transfer the resident to a post-acute, um, setting or not. And, uh, the hospitals are meant to complete that and, and provided along with any transfers who, who do meet the criteria, uh, to be stepped down into a, a post-acute setting. Uh, and then we are also using sort of scrim similar screening on, uh, admissions from another, potential admissions from another sniff or from, uh, the community at large. Um, so we're, we're very similar in that regard. And then on those admissions that we do take, we are isolating those, those residents, uh, and treating them as a potential positive for 14 days. Um, trying to limit their interactions even more, uh, you know, so that we can, uh, you know, get past that incubation period.
Speaker 1:Uh, one of the issues that we touched on when we were preparing for the podcast was, uh, you know, working with all the residents and the family members, and there was a particular discussion about, about, uh, dementia residents. And I'm wondering April, if you could talk for a, a minute or two about, um, how y'all are handling, um, introducing preventative measures with a population that is, it's just really, really difficult to, to do that sort of thing.
Speaker 2:Yeah, this is definitely a challenge. We have in our portfolio, we have four memory care units. Um, and you know, the thing is that we've, from the beginning even said, we are going to do these protocols, these social distancing as much as we can in memory care, because there's the, the struggle that you can't necessarily, um, for someone who needs to be up and moving and wandering in memory care facility to be able to tell them they can't go out of their room or they can't mingle, is actually more stress producing, um, and anxiety provoking. And so we've done some things with adding some extra, um, support staff to those units where they help kind of redirect, um, residents from each other, um, different type of activities that, um, can be more engaging on a, um, individual basis or one-on-one, um, with a staff person versus social. Um, as we know, memory care can be very social. A lot of people do like to be around other people, but they don't understand. Now, it was interesting, our one facility that had, um, positive, the, the one positive that was off the main unit was within the memory care. And so the only thing I felt like staying, and I didn't say, but it felt like staying to that facility, good luck is, you know, we've got a memory care resident is positive covid, and this, this resident did not, like, he didn't feel that bad and he did not like to stay in his room. And he definitely didn't like the mask. We tried the bandana mm-hmm.<affirmative>, but we actually put a caregiver with an N 95 mask on the caregiver with this person during their waking hours to redirect constantly this person away from others. Um, in balancing that with the agitation, fortunately, uh, that person is now 14 days past his last symptom. And we didn't have any other resident in that memory care become positive, but it was really quite scary initially as it could become wildfire in a memory care facility. Some of our patients or residents in memory care, they actually liked the masks that our staff started using. And so<laugh>, we just let them wear the masks, um, if they liked them. Um, right. But some of our memory care residents with their dementia are actually scared of the masks. And so we're trying to find some balance in some masks that aren't fearful for somebody. Um, and so those are some of the challenges that we have. But creativity from your staff members, um, are, number one is, um, thinking of solutions to keep them distanced from each other cuz they won't, these residents won't stay in their rooms.
Speaker 1:Uh, another question that I had for you guys in, in, in terms of from the perspective of, uh, pre, pre covid communities is this, this flood of information, uh, you know, we feel it, um, you know, we're all working remotely now and so we're, we're probably working off smaller screens and we're used to, uh, and we're being inundated with guidance and information from so many sources. Uh, how, how are you guys managing that information so that it's not so much just noise, uh, but it's information that's actionable, um, and easy to implement on a community by community basis In April, if I'll I'll throw that one to you first.
Speaker 2:Yeah. This has been, um, a major process. We've brought most of the, all those decision making, um, an information filtering into our home office. So it's myself and our lead infection control preventionist consultant, um, who's amazing. And with our medical director for a company. So we actually brought in, you know, we're filtering through all of that massive information and, um, so deciding what is it that the facilities need, um, what's not overwhelming. Usually if we send something to the facility, if it's, you know, obviously education information, but if we roll out a policy, it's not just given a policy to them, it's, here's your policy and here's your action steps, what you need to do. Um, we've done a lot of coordination with our ops teams on that since the, I think March 3rd was our first webinar where we had all 25 facilities on Zoom. We've done one to two of those a week. Um, and if something major comes up, then we'll throw another one on. So it just allows the facilities, not only the dns uh, administrator of the facility, but their whole I d T team to be on the webinars at the same time. And so get the chance to get the information out. Here's specifically what we need you to do. Here's your, uh, flow charts that goes with the policy. People are visual, um, for when you need to do something, how you need to do it, and your notification process, um, both in clinical assessments but also in operational areas. Um, and that seems to have worked really well. And what we've heard from our facilities is just a relief for them to know they're gonna be given specific, um, action that needs to be done. They know that they can trust us and we're gonna do what we need to do. Um, but the standalone facilities is the pieces. You know, you think of organizations that are, they don't have a company that supports them or a standalone, and that's where they're gonna need some external resources to help them filter through this mass of information.
Speaker 1:Right. And, and a HLA has, uh, been a great resource for, uh, a lot of that guidance as well as the industry associations. Uh, Daryl, you, you kind of sit in in between as well, uh, you know, wearing a different hat. But if you could talk to us now and, and we're transitioning now, I guess, to, uh, communities that are dealing with, uh, covid, uh, outbreaks, uh, in particular, but how do you handle the messaging? Um, you're getting all this information coming in and you need to figure out a way to, you know, represent your client effectively, communicate transparently with, with the residents and the family members. Uh, how, how do you do that when you're dealing with so many communities at one time?
Speaker 3:Well, I mean, I think the key is just being as transparent as possible. Um, and, and it's, you know, we don't, we're not trying to push out the same message to all communities, uh, every day or to, to family members of, of every community every day. And so, you know, our focus in, in, you know, COVID in particular is, you know, if we have a, a resident who tests positive or staff member who tests positive, we try to very quickly notify every family member, um, you know, and when I say family member, I mean resident. If they have the, you know, cognitive, uh, ability to understand and, and or their family member and we get on the phone with them, uh, as quickly as we can, we have sort of, uh, you know, talking points for the administrators or social services to use as they go through and explain what's going on. Uh, you know, we, we would much prefer that they hear from us rather than seeing something on a Facebook post that somebody put up or hear a rumor mill or something like that. Uh, or hear things through the rumor mill, I should say. And we do the same thing with our, with our team members. And, you know, you can't always move as quickly as you would like. We've certainly had situations where, you know, uh, a compliance call comes in saying there are, you know, positive cases in our facility and they're hiding it from us. Well, no, we just, you were number 37 on the list to call<laugh> and you know, we're only on number 20. Uh, but you know, cuz you can't call everyone at at once. I mean, I think, uh, April you mentioned earlier that y'all have a, a text tree that goes out to, you know, to some, uh, of your, uh, employees where you can blast text everyone. Uh, we don't have that, that, uh, capability yet. So especially with families, we're relying on on individual phone contact to, to get out there and get the message and then, you know, but there's a balance to be struck as well where we're not exactly trying to overwhelm them with information. And so we're not, you know, if a, if a team member tests positive one week and, and then we have several other, you know, we do the risk assessment, uh, to determine who they've had contact with, et cetera. So we're doing additional tests that are pending once, if some of those additional tests come back pending. We're not necessarily reaching out and calling every family member again to say, you know, last week it was one team member, now it's five team members. Um, so we're not providing updates like that, but we do have a, a program in place that we call our guardian angels where we make regular phone calls to the, uh, families to just talk to them and, and give them an, uh, update on the status of, of their resident. And so on average, we've, we've, we're trying to make those calls twice a week, so it's, it's not the same message, you know, yes, we've had a positive, uh, test or that we're giving'em updates on the numbers, but once that initial notification comes out, we're making regular contact, uh, or at least trying to make regular contact with families to just talk to them one-on-one about, about, you know, their resident as opposed to what's going on. You know, and, and obviously we, you know, they'll ask questions that we have to answer, you know, do you have more cases, et cetera. Um, but the focus is on, you know, giving them an update as to what's going on with their, with their loved one.
Speaker 1:And are, are you finding that, uh, the family members that you're communicating with, are they, uh, are they understanding, uh, the situation or they, uh, panicking and, and, and, and, uh, ha ha having trouble accepting the situation and the information that y'all are sharing?
Speaker 3:Y yeah, overall, we haven't had a lot of negative feedback. I mean, I think the fact that this is, you know, when the, when the governor puts out a, uh, lockdown order and you've got, you know, the major metropolitan areas all under various forms of lockdown and even the rural areas, I mean, everyone pretty much has the message that this is serious. I mean, we did face some pushback, you know, back in, uh, the middle of March when we went to the no visitation policy. We were a little bit more stringent even than what the CMS guidelines were recommending. And we had a lot of pushback. And within a very short period of time, most of that's evaporated folks, folks understand. Um, you know, but like I said, you will get situations where someone in a smaller town, someone or, or you know, even a large town, someone finds something out on Facebook or in a small town, they find out, you know, that, uh, uh, someone's husband tested positive and that person is a nurse. And then they find out, well, that nurse also tested positive and, you know, why weren't we notified? And so, uh, you know, we are doing our best to be transparent and to get that notification out as quickly as we can. But, you know, every now and then you have somebody who's unhappy. But generally, I think the feedback's been pretty positive.
Speaker 1:Right. And, you know, akin to the, to the conversation and comment April that you made about managing, um, the, the information coming in. And, and Darrell, you had talked about, uh, you know, you know, governor's orders and executive orders. And when we spoke last week when we were planning to call Daryl, you had some really interesting insight in how, uh, you know, a highly regulated field is now even more regulated. Uh, but the differences, uh, in addition to federal and state regulators we're also now, um, interacting with local government and, uh, folks that maybe don't have as much background with the long-term care world. Uh, I was hoping you could take a minute and talk to us about your experiences there and if you've got any, um, advice or insights for folks that are dealing with the same situation.
Speaker 3:Yeah, sure. I mean, in, in general you have to, you know, you have, uh, state level, uh, orders that are coming out, executive orders, you know, municipal level executive orders, or maybe it's your county, you know, so you have all these additional layers. And as you said, the challenge, or one of the challenges is that, uh, those folks may not know what a nursing home is. They don't know the difference between a nursing facility and an assisted living facility, or they don't know, you know, which one they're, they're, they're talking about on a, on a given day. Um, in our particular case, we also have in Texas, these local health authorities, um, and the, the statutory structures kind of byzantine of as to whether they really report up through the state, um, department of Health Services. They're, but in many cases, they're fairly independent entities and they're, they're not bound, um, to follow CDC guidelines. Um, and they have very broad authority to issue what are called, um, public control orders. Um, and in some cases quarantine orders when, uh, they have reason to believe that there is, uh, an infectious, an outbreak of an infectious disease. And, you know, we certainly fall within, uh, within that, within those parameters. And they basically can order anything, uh, to, to be done that's in the best interest of preventing the outbreak or limiting the outbreak. So in the commu, the first community where we experienced, uh, a former resident who tested positive, the local health authority imposed an order that had, I think, almost two dozen separate, um, items, uh, or of specific requirements that we had to comply with. And most of them, frankly, we were doing anyways, they were consistent with CDC guidelines. Um, but some of them weren't. Um, they threw us a curve ball telling us that we couldn't have semi-private accommodations and had to serve residents all in private rooms, you know, to comply with that, we would've had to discharge 30 residents. Um, you know, fortunately they're reasonable people. And when we pointed that out to'em, uh, we were able to, you know, reach an accommodation. Um, but another issue that, that came up that we struggled with, quite frankly, is following CDC guidelines, we weren't using N 95 masks, um, uh, in that community. None of our staff members were using them, but they wouldn't lift this control order until we could demonstrate that we had a respiratory program that met OSHA standards, which required fit testing and medical clearance of all staff who might be required to use N 95 masks in the future. Um, and we kept trying to explain to them we're, we're not using these, why are you making us do this? And, you know, we eventually did, uh, come to a, an accommodation with them. But it's an interesting thing cuz the more I thought about it, and, and this may be something we were gonna cover, uh, before it, you know, in terms of sort of getting ready, uh, you know mm-hmm.<affirmative>, Inevitably in some sense, your nursing facility is going to have a, a COVID positive test. And so what what we've actually done is, is is taken that and tried, uh, taken the issue with the N 95 masks and, and, you know, incorporated a more proactive stance than we were originally taking. So we're working now in communities to start the, if you, if you actually follow the OSHA guidelines, you, you know, there's a medical clearance process, uh, and uh, then you have to do the actual fit testing mm-hmm.<affirmative>. So we're working proactively to have the medical clearance done at least for, you know, a key set of staff members and start working on the FIT testing or making sure we have that infrastructure in place. Cuz if you're sitting, if you're sitting there and you suddenly have 10 positive cases and you've gotta start using respirators and you're just then starting the process, it'll take you a week to two weeks to have people actually fit, tested, um, and medically cleared. So we're starting that process much earlier now. And, uh, while it was painful, uh, you know, it was the interaction with that local health authority, uh, that got us moving in that direction because they put it to the front of our mind by incorporating it into that, that, uh, local order.
Speaker 1:Right.<affirmative> that, that's good advice about, uh, getting ahead of that with the ppe. And obviously there's been a lot of discussion about, um, the supplies and PPE and, and, and getting access to them. Uh, and that was an issue, but I remember when you raised it, um, I don't think you would, it would even occur to you until you were actually faced with the issue for the, for the first time. So thank you for sharing that. Um, as, as a, as a final question I'd like to ask y'all, um, you know, we tried to cover pre and post covid issues. We tried to focus on dealing with resident challenges and, and staff challenges, um, and family members. Is there anything else that, uh, that y'all have noticed or observed? Has, has there been anything that, uh, that we didn't specifically focus on today that y'all think would be helpful to share with, uh, with the listeners of the, of the podcast? And, you know, I'm, I'm thinking about things like, uh, you know, what, what guidance has been most helpful or what has been the, the biggest challenge that you didn't anticipate? Uh, and there's something that I, I'm seeing more and more talk about online, uh, preparing for liability issues down the road and, and governor's orders that are providing immunity. I'm just wondering, like, where you're headed at. I don't wanna ask the proverbial question of, you know, what keeps you up at night? Cause I, I think there's a, a ton of issues, but if there's, do you have any final, uh, final points or comments that you could share with us? And, uh, April, I'll I'll pass it to you, give Darrell a chance to rest his voice.
Speaker 2:Yeah, I think, uh, and this is improving, but the, the availability of testing, um, is been significant. So, you know, it's initially the beginning of March, it was seven days out on some test results and the impact on the facility in Oregon, there's an executive order that as soon as you test a staff or a resident, um, you have no admission executive order applied, which makes sense, obviously if you're worried that you've got a covid infection. Um, but the testing delays are improving. We have some partnerships, again, we talk about alignment with some hospital health systems with now just doing covid testing with them for both employees and, um, residents for them to do. The covid are community, um, lab resources are still seven days out and it's not acceptable in timelines, but we also have some rural areas that are still stuck with the five to seven day timelines within their own hospital systems for testing or test availability. Um, and so people wonder, you know, when they look at numbers, I think we cannot, um, stress enough that you have to understand that your market area that you are as a provider, how are you gonna get the test if you need it, not when you need it. Think ahead. Um, who can you you partner with to make sure that you have, not only for residents, but your, your staff the quickest way to get a test. I'd be very cautious of scams. Um, we were attempting to find a way to test through the rapid testing and went down some rabbit holes and came back out saying, okay, this is not comfortable. This is not a valid test, but the scamming on test, um, manufacturers out there have to be understood. Um, but the testing delays itself. Um, our hospital systems have been great partners in that where our local lab resources were, um, just none of themselves handicapped. Nothing that they did intentionally, but they didn't have the ability to do it faster. Mm-hmm.<affirmative>, the other thing I think that must be looked at as you look at, you know, liability and legal is, uh, the reality is you will have, if you have covid, you'll probably experience a death of a resident. Um, and how do you think ahead and how you're going to manage that to both the staff and the families? How do you do it compassionately and honestly? Um, but also the press, you know, um, the press is very hot right now. We've seen the increased uptick of nursing home desks being a focus. Um, and they're very focused in the last week, in particular in Oregon on, um, reporting nursing home deaths. Um, so we did it in our communities have one person that passed away. Um, we actually think it was more related to the other comorbidities than the actual covid positive, but we've had to focus with the press and they just like to amplify that. And so how do we help our, um, communities, how do you through, um, legal support, help communities know how to handle that before it happens? Not as a reactive statement, but a proactive approach and working with your facilities, um, and your staff on that.
Speaker 1:Those are great points. Darrell, what are your thoughts? Any parting words?
Speaker 3:Y Yeah, I mean, so, um, I would echo, uh, some of what April said that, that one of the positives to come out of this is, uh, in some markets anyways, uh, increasing collaboration with health systems. Um, we have one area where we've got a, you know, a cluster of, of communities and the, the health system that we work closest with there. We're having calls, you know, twice a week with them, uh, just very brief, 15, 20 minute calls where we go through a checklist of items. And, uh, they've been an invaluable source of information, believe it or not. Hospitals, you know, some sometimes are higher on the healthcare food chain, the nursing facilities. And, uh, so they have access to information and analytics, uh, that has, has helped us. And, uh, um, and we've also, as, as April said, we've worked with them as they've gotten their testing, uh, ramped up. We can get much quicker results, uh, on tests, um, when we're able to go through their system as opposed to our, our normal lab provider. And so that's, that's been a huge help, and we're able to take what we learn, uh, from those interactions and leverage them, uh, you know, to improve what our responses is like in our other communities and, and, you know, filter out best practices, et cetera. So that's, that increased collaboration with the hospitals has been, uh, a huge positive. And then the other thing that I would just say is, is, you know, proactively communicating with your staff in buildings where you don't have, uh, covid positives yet. You know, again, sort of expectations that, hey, this could happen to us and are we doing everything that we can? And, you know, making sure that, that, uh, your staff know that, that you care about'em, uh mm-hmm.<affirmative> And, uh, that you're doing everything you can to, to put them in the best position they can be in to, to deal with the situation. Uh, because we are starting to see cases where staff are, you know, they're, they're seeing the news every day and, and, uh, they're seeing cases maybe in the community of, you know, increased exposure or they know someone went out for a test in their building, they don't wanna come to work anymore. And keeping them calm and keeping them reassured, uh, you know, that's, uh, that's something that, that we deal with every day. Um, you know, just trying to keep the, the team together so that we can, uh, you know, have the resources in place, the folks in place to, uh, take care of the patients. Because, you know, when all is said and done, you know, our mission hasn't changed. You know, our job is to care for the, the, the frailest and, and, uh, most vulnerable, um, uh, folks in our society. And covid or no covid, that's what we've gotta keep doing.
Speaker 1:Right, right. Yeah. I couldn't imagine how scary it would be to have to go into the communities knowing that there's increased risk and, and still do your job. And that's, uh, it's gotta be a, a difficult position to be in. And they definitely deserve the support. Well, you know, we're, we're close to an hour. We were aiming for 30 minutes, and so we overshot our mark, uh, a bit. But, uh, I think it was interesting, uh, information and, uh, and it's, I know how hard it is to schedule these. And so, uh, I want to thank you guys, April and Darrell for, uh, making time and, and participating. And, uh, the, the goal is from, from the practice group's perspective is to hopefully have, have more of these down the road and maybe talk about, um, intermediate issues or long-term issues. Um, but to the extent that we can continue this conversation, we'd love to, uh, the folks that are listening, um, if you have ideas for topics that you'd like to cover, please reach out to the practice group leadership, um, and April and Darrell, thank you again for being gracious and generous with your time and your knowledge today. Sure thing, Daniel. Thank you for having us. Thank you.