Dear NASW-CA News Editor: 

With skepticism, I read your July 22, 2020 newsletter feature commentary, “Insights on a Virus: State dashboards show COVID-19 cases and related deaths much lower in residential board & care than nursing homes in California,” by Jason Bloome, who concluded “With fewer cases and related-deaths due to COVID-19, residential assisted living homes are safer than nursing homes for seniors who require 24-hour custodial care.”  I would like to address the following “insights”:

• Headline refers to residential “board & care”, while Bloome’s article refers to “residential assisted living homes (or residential facilities for elderly – RCFE)” (sic).  RCFE stands for Residential Care Facilities for the Elderly (“Care” is important), and often referred to as “assisted living” or “board and care”; “board & care” refers to smaller facilities with six or fewer beds, while “assisted living” refers to larger facilities with more beds.[1] This distinction based on facility bed count is important to California Department of Social Services (CDSS), which regulates RCFEs. 
• Bloome states “…residential assisted living homes have much lower rates of COVID-19 cases and related-deaths than nursing homes.”  Yet, Bloome merely compares numbers (not rates) of positive COVID-19 cases of residents and staff for each type of facility.  
• Meaningful comparisons of COVID-19 cases and deaths between nursing homes and RCFEs have been compromised by lack of universal testing for an asymptomatic disease like COVID-19.  In late May, California Department of Public Health (CDPH) called for universal testing in nursing homes; however, similar calls for testing have not come from CDSS.[2] On June 26, CDSS issued limited testing protocols for RCFEs.[3]   
• COVID-19 reporting of cases and deaths in RCFE industry has lacked transparency.  CDSS does not identify names of RCFEs with six or fewer beds (board & care) that have COVID-19 cases due to privacy concerns.[4]  Last week, CDSS attempted to delete names of RCFEs with COVID-19 deaths and even removed COVID-19 deaths in RCFEs from its website—until advocates protested and RCFE COVID-19 data returned on July 21.[5]  As noted by Sacramento Bee, this data scrubbing appears to be part of an alarming trend of the largely for-profit long-term care industry having a disproportionate amount of influence on California’s regulators.[6]  
• Bloome writes, “Many California nursing homes have low star ratings from Medicare Compare for poor staffing.” In contrast, RCFEs have no ratings from a regulatory body (no Centers for Medicare and Medicaid Services coverage because they are not health care facilities), no specific staff-to-resident ratio requirements, and minimal staff training.   
• State incentives for facilities to accept COVID-19 patients:  Bloome writes, “California has ordered nursing homes to accept COVID-19 patients discharged from hospitals…the reimbursement rate for a COVID-19 patient can be up to $800/day…” However, he fails to disclose CDSS’ May 1 offer to RCFEs with six or fewer beds (board & care) $1,000 a day from the time the first COVID-19 resident is placed, and a negotiated rate for RCFEs with more than six beds.[7]  In addition, Bloome appears to refer to CDPH order that was superseded in March[8]; nursing homes, like RCFEs, now volunteer to accept COVID-19 patients at higher payment rates to cover additional costs of staffing and preparation for COVID-19 units. [9] 

Bloome identified himself as owner of Connections – Care Home Referrals, described in its website as a “no-cost care home referral agency for the family (we charge a placement fee from the facility if you select one of the homes we have recommended).”  

Instead of publishing a shill piece promoting the RCFE industry, which has its own systemic problems (see Residential Care in California: Unsafe, Unregulated, and Unaccountable[10]), please feature newsworthy articles from non-profit advocates like California Advocates for Nursing Home Reform (CANHR)https://canhrcovidnews.com/, National Consumer Voice for Quality Long-Term Care https://theconsumervoice.org/, or Justice in Aginghttps://www.justiceinaging.org/resources-for-advocates/, where staff fact-check their work and promote social work values and ethics. Further, geriatricians, gerontological social workers, long-term care ombudsman and advocates might have better insights into the quality of facilities. 

The COVID-19 deaths of residents and staff at long-term care facilities (both nursing homes and RCFEs) have been a continuing tragedy, reflecting systemic problems such as ageism (overlooking unique COVID-19 symptoms presented by older people and provider bias in how older lives are valued when faced with scarce resources), racism/classism (nursing homes with the highest percentage of non-white residents are more than twice as likely to have COVID-19 cases and deaths as those with the lowest share[11]; devaluing underpaid caregivers who are mostly people of color, exploited by employers who fail to ensure safe working conditions – CDC found patient safety at the first U.S. nursing facility with COVID-19 outbreak was compromised by staff who worked without PPE and while sick in multiple facilities, helping to spread coronavirus in a controlled environment)[12], weak regulatory oversight, and underfunding of our public health system (limited COVID-19 testing, including failure to test its own inspectors sent to facilities)[13]. 

Having worked at both non-profit assisted living (which had a wait list and did not partner with referral agencies that charge placement fees) and Medicare 5-star rated nursing home and rehab center facilities, I continue to advocate for residents and staff during this COVID-19 pandemic.  As a former Meals on Wheels social worker, other home and community-based services also might be considered in the continuum of care for patients discharged from hospitals and needing rehabilitation. 

Sincerely, 

Carmen Lee,
NASW-CA member

Sources:
[1] http://canhr.org/factsheets/rcfe_fs/html/rcfe_fs.overview.htm 
[2] https://www.voiceofsandiego.org/topics/news/covid-19-testing-plans-leave-out-assisted-living-facilities/ 
[3] https://www.cdss.ca.gov/Portals/9/CCLD/PINs/2020/ASC/PIN-20-23-ASC.pdf 
[4] https://www.kpbs.org/news/2020/jul/22/san-diego-county-wont-disclose-which-assisted-livi/ 
[5] https://www.cdss.ca.gov/Portals/9/Additional-Resources/Research-and-Data/DSSDS/RCFE-7-21.pdf 
[6]  https://news.yahoo.com/california-backtracks-removing-covid-19-205509988.html 
[7] https://www.kpbs.org/news/2020/may/06/state-will-pay-assisted-living-coronavirus/ &https://www.cdss.ca.gov/Portals/9/CCLD/PINs/2020/ASC/PIN_20-17-ASC.pdf 
[8] https://www.npr.org/sections/health-shots/2020/04/20/832034662/discharging-covid-19-patients-to-nursing-homes-called-a-recipe-for-disaster 
[9] https://www.politico.com/news/2020/06/04/states-nursing-homes-coronavirus-302134 
[10] http://canhr.org/reports/2013/Residential_Care_in_California.pdf 
[11] https://www.forbes.com/sites/howardgleckman/2020/06/30/we-are-having-a-national-conversation-about-race-and-policing-why-arent-we-having-one-about-race-and-long-term-care/ &https://doi.org/10.1111/jgs.16661 
[12] https://www.cdc.gov/mmwr/volumes/69/wr/mm6912e1.htm 
[13] https://www.latimes.com/california/story/2020-07-24/california-failure-covid-19-test-nursing-home-inspectors

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