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Aging

Texas Winter Storm Exposes Gaps in Senior Living Oversight

HOUSTON — When the big, red and extremely loud fire alarm went off in Maria Skladzien’s apartment, the 74-year-old ventured into the hallway with fellow residents of her Houston-area senior living community. The brutal winter storm that swept through Texas had knocked out power, which, in turn, disrupted water to the four-story building. The blaring alarms raised fears of fire.

The building’s elevators were unusable without power. Dependent on her wheelchair, Skladzien went back inside her second-floor apartment. She watched as residents gathered in the subfreezing temperatures outside, wondering if she would have to “throw herself out the window” to survive.

“It’s a very uneasy feeling,” she said, sitting in the living room of her small apartment a week later, packages of water brought by friends and volunteers tucked against walls and sitting on tables. No fire had occurred, but her fears continued because the elevators were still not functioning. “So many crazy things race through your mind in a situation like this.”

Winter storm Uri brought power failure and burst water pipes to millions of homes and businesses throughout Texas. But the impact, as is often the case in emergencies, was most profound on the state’s most vulnerable — including residents of senior living facilities.

Of the state’s 1,200 nursing facilities, about 50% lost power or had burst pipes or water issues, and 23 had to be evacuated, said Patty Ducayet, long-term care ombudsman for Texas. Of 2,000 assisted living facilities, about 25% had storm-related issues and 47 were evacuated. Some facilities reported building temperatures in the 50s.

The federal government requires nursing homes to maintain safe ambient temperatures but does not stipulate how and does not require generators or other alternative energy sources to run heating and air conditioning systems. States can implement more stringent guidelines, but, to date, Texas has not. Several bills were introduced in the Texas legislature after Uri to do just that, said Ducayet.

Uri was the latest disaster to highlight an ongoing problem. Evacuations and nursing home deaths in Hurricane Katrina in 2005 led to calls for similar protections. In 2009, Hurricane Sandy forced the evacuation of more than 4,000 nursing home residents in New York when backup power systems failed and emergency plans buckled. And calls for stricter rules were renewed when Hurricane Irma tore into Florida in 2017 and left a dozen residents dead in a nursing home that lost air conditioning. Multiple blackouts and wildfires in California also have exposed lax adherence to federal requirements for backup power at skilled nursing facilities, as well as weak state enforcement of those rules, according to a 2019 report from the U.S. Department of Health and Human Services.

“Every time we come back around with a new disaster, you see that these facilities still aren’t as prepared as, maybe, they can or should be,” said Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care, an advocacy organization based in Washington, D.C. “And many of them still aren’t following the requirements that are in place. So it’s like: What’s it going to take to actually get the plans in place and to get enforcement of those plans?”

In November 2016, the Centers for Medicare & Medicaid Services implemented a slate of new regulations, including rules on disaster planning and emergency backup power in the nation’s nursing homes.

A month later, Mark Parkinson, president and CEO of the long-term care industry’s trade group, the American Health Care Association and National Center for Assisted Living, sent a letter to then-President-elect Donald Trump requesting new rules because the regulations were burdensome and financially onerous, according to reporting by ProPublica.

In 2019, CMS published final rules with revised emergency preparedness guidance, agency spokesperson William Polglase said, after feedback from the public that those requirements were “overly burdensome and duplicative.” But, he added, the rules require such facilities to have emergency and standby power systems and emergency plans. “We did not remove or modify any requirements that would endanger patient health or safety,” he said.

Advocates for older adults, however, decried the changes as watering down the protections.

“The facilities push back because of the expense, but what I think recent years have shown us is that we’re not talking about once-in-a-century type of disasters,” said Eric Carlson, directing attorney with Justice in Aging, a national legal advocacy nonprofit.

But it’s not just nursing homes at risk.

Cristina Crawford, an AHCA spokesperson, said prioritizing long-term care facilities at all levels is important in emergencies. “Nursing homes and assisted living facilities should be prioritized for power restoration and supplies for resource delivery in emergency situations,” she said. “Long-term care facilities should also be included in community-based exercises to help ensure successful coordination in actual emergencies.”

Although nursing homes face federal oversight, the licensing and regulatory authority for assisted and senior independent living facilities lies with the states, meaning a patchwork of definitions and guidelines for the facilities. Given that assisted and independent living communities have been the fastest-growing sector in senior living for many years, the disparate definitions and rules often leave residents and their families without a clear understanding of a facility’s offerings and safety guardrails.

“There’s no transparency from a consumer perspective about what are these different options, what am I getting in each of them,” said David Grabowski, professor of health care policy at Harvard Medical School.

Years ago, Grabowski and others said, independent and assisted living facilities were filled with a generally healthier population who didn’t need much medical assistance and who could afford to pay out-of-pocket for enhanced lifestyle amenities such as restaurants or outings.

But as the population ages, residents are often less healthy and may not have the financial resources to afford the higher level of care they need. And unlike nursing homes, assisted and independent living facilities do not necessarily operate under regulations that require building codes to address the needs of elderly or disabled residents, or requirements for backup power or emergency systems. It depends on where they are.

In Texas, assisted living facilities are required to have emergency plans but not generators. The legislation introduced in the wake of winter storm Uri seeks to change that. Independent living facilities like the one Skladzien lives in might not be covered, though; they already have even fewer state guidelines to follow.

“We still don’t have good emergency management planning and preparation ingrained within the regulations to make sure our loved ones are safe within these facilities, because it just comes down to the money,” said Brian Lee, executive director of Families for Better Care, a nonprofit in Austin, Texas, focused on the nation’s long-term care facilities.

The debate is analogous to previous efforts to require sprinkler systems in nursing homes, he said. “How many more people have to be injured, maybe even have to have suffered death, because of power failure negligence?”

Lee and others said there is a distinction to be made between staff members — some of whom stayed in their facilities throughout the winter storm to keep residents safe — and industry forces resisting regulatory efforts to beef up backup safety systems.

“We can’t, and shouldn’t, let the industry decide how this is going to work,” said Ducayet. “There needs to be involvement and organization at government levels, so that there is clarity and information about how these different settings work.”

With elevators still not working at Skladzien’s independent living building a week after the storm, she was trying to figure out how she would get to her weekly post-cancer medical treatment.

Skladzien, who owned her own cleaning business for 25 years and drove a school bus for 15 years, moved into senior housing in 2019 when she could no longer handle the upkeep on her home. When she was looking for a place to live, though, it never occurred to her that apartments marketed toward older adults would not have a generator or plans to help residents in an emergency. And she never thought to ask.

“I had no experience,” she said.

It may not have mattered: Medical bills had depleted her savings, leaving her only the choice of what was available in low-income housing. In her building, she was told, wheelchair-accessible apartments on the first floor were beyond her financial reach.

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Family Caregivers, Routinely Left Off Vaccine Lists, Worry What Would Happen ‘If I Get Sick’

Robin Davidson entered the lobby of Houston Methodist Hospital, where her 89-year-old father, Joe, was being treated for a flare-up of congestive heart failure.

Before her stretched a line of people waiting to get covid-19 vaccines. “It was agonizing to know that I couldn’t get in that line,” said Davidson, 50, who is devoted to her father and usually cares for him full time. “If I get sick, what would happen to him?”

Tens of thousands of middle-aged sons and daughters caring for older relatives with serious ailments but too young to qualify for a vaccine themselves are similarly terrified of becoming ill and wondering when they can get protected against the coronavirus.

Like aides and other workers in nursing homes, these family caregivers routinely administer medications, monitor blood pressure, cook, clean and help relatives wash, get dressed and use the toilet, among many other responsibilities. But they do so in apartments and houses, not in long-term care institutions — and they’re not paid.

“In all but name, they’re essential health care workers, taking care of patients who are very sick, many of whom are completely reliant upon them, some of whom are dying,” said Katherine Ornstein, a caregiving expert and associate professor of geriatrics and palliative medicine at Mount Sinai’s medical school in New York City. “Yet, we don’t recognize or support them as such, and that’s a tragedy.”

The distinction is critically important because health care workers have been prioritized to get covid vaccines, along with vulnerable older adults in nursing homes and assisted living facilities. But family members caring for equally vulnerable seniors living in the community are grouped with the general population in most states and may not get vaccines for months.

The exception: Older caregivers can qualify for vaccines by virtue of their age as states approve vaccines for adults ages 65, 70 or 75 and above. A few states have moved family caregivers into phase 1a of their vaccine rollouts, the top priority tier. Notably, South Carolina has done so for families caring for medically fragile children, and Illinois has given that designation to families caring for relatives of all ages with significant disabilities.

Arizona is also trying to accommodate caregivers who accompany older residents to vaccination sites, Dr. Cara Christ, director of the state’s Department of Health Services, said Monday during a Zoom briefing for President Joe Biden. Comprehensive data about which states are granting priority status to family caregivers is not available.

Meanwhile, the Department of Veterans Affairs recently announced plans to offer vaccines to people participating in its Program of Comprehensive Assistance for Family Caregivers. That initiative gives financial stipends to family members caring for veterans with serious injuries; 21,612 veterans are enrolled, including 2,310 age 65 or older, according to the VA. Family members can be vaccinated when the veterans they look after become eligible, a spokesperson said.

“The current pandemic has amplified the importance of our caregivers whom we recognize as valuable members of Veterans’ health care teams,” Dr. Richard Stone, VA acting undersecretary for health, said in the announcement.

An estimated 53 million Americans are caregivers, according to a 2020 report. Nearly one-third spend 21 hours or more each week helping older adults and people with disabilities with personal care, household tasks and nursing-style care (giving injections, tending wounds, administering oxygen and more). An estimated 40% are providing high-intensity care, a measure of complicated, time-consuming caregiving demands.

This is the group that should be getting vaccines, not caregivers who live at a distance or who don’t provide direct, hands-on care, said Carol Levine, a senior fellow and former director of the Families and Health Care Project at the United Hospital Fund in New York City.

Rosanne Corcoran, 53, is among them. Her 92-year-old mother, Rose, who has advanced dementia, lives with Corcoran and her family in Collegeville, Pennsylvania, on the second floor of their house. She hasn’t come down the stairs in three years.

“I wouldn’t be able to take her somewhere to get the vaccine. She doesn’t have any stamina,” said Corcoran, who arranges for doctors to make house calls when her mother needs attention. When she called their medical practice recently, an administrator said they didn’t have access to the vaccines.

Corcoran said she “does everything for her mother,” including bathing her, dressing her, feeding her, giving her medications, monitoring her medical needs and responding to her emotional needs. Before the pandemic, a companion came for five hours a day, offering some relief. But last March, Corcoran let the companion go and took on all her mother’s care herself.

Corcoran wishes she could get a vaccination sooner, rather than later. “If I got sick, God forbid, my mother would wind up in a nursing home,” she said. “The thought of my mother having to leave here, where she knows she’s safe and loved, and go to a place like that makes me sick to my stomach.”

Although covid cases are dropping in nursing homes and assisted living facilities as residents and staff members receive vaccines, 36% of deaths during the pandemic have occurred in these settings.

Maggie Ornstein, 42, a caregiving expert who teaches at Sarah Lawrence College, has provided intensive care to her mother, Janet, since Janet experienced a devastating brain aneurism at age 49. For the past 20 years, her mother has lived with Ornstein and her family in Queens, New York.

In a recent opinion piece, Ornstein urged New York officials to recognize family caregivers’ contributions and reclassify them as essential workers. “We’re used to being abandoned by a system that should be helping us and our loved ones,” she told me in a phone conversation. “But the utter neglect of us during this pandemic — it’s shocking.”

Rosanne Corcoran (right) and her mother, Rose, at Rose’s 80th birthday party in 2008. Rose now has advanced dementia and lives with Corcoran and her family. Corcoran hopes to get the vaccine but has been unable to yet. “If I got sick, God forbid, my mother would wind up in a nursing home,” she says. (Daniel Francis)

Ornstein estimated that if even a quarter of New York’s 2.5 million family caregivers became ill with covid and unable to carry on, the state’s nursing homes would be overwhelmed by applications from desperate families. “We don’t have the infrastructure for this, and yet we’re pretending this problem just doesn’t exist,” she said.

In Tomball, Texas, Robin Davidson’s father was independent before the pandemic, but he began declining as he stopped going out and became more sedentary. For almost a year, Davidson has driven every day to his 11-acre ranch, 5 miles from where she lives, and spent hours tending to him and the property’s upkeep.

“Every day, when I would come in, I would wonder, was I careful enough [to avoid the virus]? Could I have picked something up at the store or getting gas? Am I going to be the reason that he dies? My constant proximity to him and my care for him is terrifying,” she said.

Since her father’s hospitalization, Davidson’s goal is to stabilize him so he can enroll in a clinical trial for congestive heart failure. Medications for that condition no longer work for him, and fluid retention has become a major issue. He’s now home on the ranch after spending more than a week in the hospital and he’s gotten two doses of vaccine — “an indescribable relief,” Davidson said.

Out of the blue, she got a text from the Harris County health department earlier this month, after putting herself on a vaccine waitlist. Vaccines were available, it read, and she quickly signed up and got a shot. Davidson ended up being eligible because she has two chronic medical conditions that raise her risk of covid; Harris County doesn’t officially recognize family caregivers in its vaccine allocation plan, a spokesperson said.

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Vaccine Hesitancy vs. Vaccine Refusal: Nursing Home Staffers Say There’s a Difference

CONCORD, N.C. — It had been months since Tremellia Hobbs had an excuse to bring out the pompoms. Before the pandemic, they were a crowd favorite at movie nights and bingo tournaments that Hobbs organized as activities director at the Brian Center Health & Retirement/Cabarrus nursing home.

On Jan. 14, she finally had a reason. After nearly a year of living with pandemic restrictions and a summer outbreak that killed 10 residents and infected 30 staff members, the nursing home was hosting its first covid-19 vaccine clinic.

So Hobbs lifted the red and silver tassels into the air and cheered as her co-workers lined up to get shots from two visiting CVS pharmacists. “Stewart, Stewart, he’s our man! If he can’t do it, no one can! Goooo, Stewart!”

But even as Hobbs rooted for her colleagues, decorated the dining hall with green and blue balloons, and assembled goodie bags with Life Savers gummies for those who received their shots, she knew she wouldn’t be getting the vaccine herself.

“Being able to diagnose, come up with a vaccine and administer it all within the same year just seems a little puzzling,” she said. “I would like to see, give it a little more time.”

Hobbs’ hesitancy has been echoed by nursing home staff members across the state and country. But her reasoning — as well as that of her colleagues who also opted against the vaccine that day — goes far beyond a simple yes or no. The decision is complicated and multifaceted, they said, which means persuading them to say yes will be, too.

In North Carolina, the health secretary has said more than half of nursing home workers are declining the vaccine. A national survey found that 15% of health care workers who had been offered the vaccine said no, with nursing home personnel more likely to refuse than hospital staffers.

The trend has concerned public health officials, who say vaccines are among the best ways to protect vulnerable elderly residents who may be infected by asymptomatic staff members. Although long-term care facilities house less than 1% of the nation’s population, they’ve accounted for 37% of covid deaths, according to the COVID Tracking Project.

Tremellia Hobbs, activities director at the Brian Center/Cabarrus nursing home, cheers on her co-workers as they receive the covid-19 vaccine at the Brian Center/Cabarrus nursing home. (Aneri Pattani)

Early reports suggest nursing home residents are getting vaccinated at a higher rate than workers. A CDC analysis of more than 11,000 long-term care facilities found that in the first month of vaccinations, about 78% of residents got at least one dose, but only 38% of staffers did.

But some nursing home staffers say their reluctance is being misconstrued. Most are not saying they’ll never take the vaccine, but simply that they have concerns about such a new product. They understand it went through months of clinical trials, but what about possible long-term side effects, for instance? Or how did politics play into the development process? For communities of color, their historical mistreatment by the medical system can also factor into the decision.

“We should stop saying that people are just saying no,” said Dr. Kimberly Manning, a professor at Emory University School of Medicine who is participating in the Moderna vaccine trial. A Black physician herself, she has been speaking with many Black Americans about the vaccine and instead refers to people as “slow yeses.”

“We just are too impatient to get to the point where we let them get to their yes,” she said. “We’re like the used-car salesman. We’re just trying to close the deal.”

But human beings respond better to empathy and patience than to pressure, Manning said. She tries to ask people about their individual concerns and work from there. Sometimes it’s skepticism about the government’s intentions. Other times it’s worry about how the vaccine may interact with fertility treatments.

“It’s important to not lump anybody into a group and say ‘How dare you just not get vaccinated?’ because you’re a health care worker,” she said. “You’re still a person.”

Vials of the Moderna covid-19 vaccine thaw before they can be administered to residents and staffers at the Brian Center/Cabarrus nursing home. (Aneri Pattani)

Hobbs, at the nursing home, is not against immunizations in general, she said, and her decision has nothing to do with distrusting the medical system as a Black woman.

“I totally trust the science. I love Dr. Fauci,” Hobbs said. “My thing is the timing.”

She wants to wait and see how others who get the shots fare. In the meantime, Hobbs said, she’ll continue masking, physical distancing, and sanitizing — all of which have kept her covid-free for 10 months and which she hopes will continue to protect the residents, each of whom she knows by name and favorite activity.

Caitlyn Huneycutt, a certified nursing assistant at the center, also opted out of getting a shot — but for an entirely different set of reasons. She expects covid vaccinations will be mandated for health workers in the future, much like other immunizations. And she’ll get them then. But for now, she’s still weighing the risks.

She recently started a new medication and is not sure how it’ll interact with the vaccine. She doesn’t want to bring covid home to her 1-year-old daughter, but she’s also heard of people who received the vaccine and fainted or developed kidney infections. (The Centers for Disease Control and Prevention does not list either of these as common side effects for the two covid vaccines in use.)

“I want to make sure I’m going to be healthy if I take it,” Huneycutt said.

A CVS pharmacist prepares doses of the Moderna covid-19 vaccine during a clinic at the Brian Center Health & Retirement/Cabarrus nursing home on Jan. 14, 2021. (Aneri Pattani)
Josiah Howard (right) was one of two CVS pharmacists who administered the Moderna covid-19 vaccine to staff members and residents at the Brian Center/Cabarrus nursing home on Jan. 14, 2021. (Aneri Pattani)

Across the country, nursing homes are taking different approaches to persuade their staff to get vaccinated. SavaSeniorCare, which owns the Brian Center/Cabarrus, has offered cash to its 169 long-term care homes in 20 states to pay for gift cards, parties, or other incentives. For over a month now, the company has also been hosting weekly phone calls to educate staffers about the vaccine and making Sava doctors and pharmacists available to answer questions.

At least one nursing home chain in the U.S. announced it will require all employees to receive a vaccine, but most others, including Sava, have not yet done so.

Stewart Reed, the administrator for the Brian Center/Cabarrus, is hoping to lead by example instead.

Reed experienced the harsh reality of covid firsthand and was out of work for two weeks in the fall. In January, he was among the first in line to get the vaccine. For the rest of the day, he popped in and out of the dining hall where shots were being administered to thank staff members for doing their part.

In total, about 48% of staff members and 64% of residents at the center received their first dose of vaccine that day. The numbers are well below Sava’s goal of 90%, Reed said, but the pharmacists will return for two more clinics in the coming months.

“The people that didn’t get it [today] will see that the guys that got the shot are OK,” Reed said. “When the next clinic comes up, they will not hesitate to get their first shot. It ought to go much better.”