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By Thomas Goldsmith

Dr. Mandy Cohen, director of the state Department of Health and Human Services, announced Friday that North Carolina is heading in the direction of universal testing of North Carolina nursing home residents and staff.

That means that state health officials have issued guidance, or at least a recommendation, to follow the direction set out last week by the White House Coronavirus Task Force. The practice is up and running in the states of Washington, West Virginia, Maryland and South Carolina.

Advocates for older people, such as Billl Lamb, former executive director of Friends of Residents in Long Term Care, as well as some local health officials, were still perusing the state’s announcement afterward for details.

“‘Guidance’ is not a mandate,“  Lamb said in an email, expressing frustration after taking, along with Adam Sholar, head of the state’s nursing home trade association, a pro-testing message to the Governor’s Advisory Council on Aging last week,

Answering questions at a press conference, Cohen described the move as “escalation“ of testing for the state, especially among high-risk populations such as the frail elderly and people with disabilities in long-term care. According to data released Monday by DHHS, 397 North Carolinians in long-term care settings have died of COVID-19 related causes, amounting to about 60 percent of the 661 overall deaths in the state.

“So, we have already been in a place, for example, of testing all of the nursing home residents and staff when there is an outbreak,“ Cohen said. “Now we are moving to say we need periodic testing, regardless of outbreak or not.

“We just know that this virus is here, it’s getting into some of those high-risk settings, and we need to be even more proactive, now that we have the supplies, now that we feel like we have the capacity to do it.”

Neither Cohen nor DHHS information officers provided direct answers to such questions as:

  • Does the state public health laboratory have the capacity to process the tests from nursing homes?
  • Does the guidance have any force?
  • Will skilled nursing facilities that don’t comply receive a citation or other sanction?
  • What interval does the state mean by “regular“ testing of long-term care populations?

Defining regular

On the question of timing of tests, Cohen responded in the May 15 press conference:
“Our team is still working with our Testing Surge Workgroup to answer that question in particular. We know we want to get started on that work, but I think we’re still looking at the data and working with our scientists to know how to define “regular,“ which is why it is not yet defined in that provider guidance.

“What we are signaling, not just signaling, but saying, in this provider guidance, is that those populations are really important. We need to be testing them. The question is how often.“

Whether to test all nursing home residents, or even those at facilities where COVID-19 has broken out, has been a matter of debate and discussion both nationally and in North Carolina for months.

Public and internal documents show that DHHS appears to have followed an inconsistent course on whether COVID-19 tests, especially for nursing home residents, should be handled at the local, state or federal level. Changes in policy came, of course, as the severity of scope of the pandemic took shape.

“Currently, DHHS is working with local health departments and clinicians to evaluate any potential cases and coordinate care and testing as needed,” the department said in a Feb. 12 press release. “Working closely with the CDC, the department is coordinating health information sharing as this situation continues to evolve. North Carolina has not had any confirmed cases of the virus.”

On April 3, DHHS sent out this guidance in connection with testing:

“Persons who live or work in a LTCF (long-term care facility) are considered by the NC Department of Health and Human Services as a priority group for testing. Testing from people who live in or have frequent contact with these settings and have symptoms consistent with COVID-19 can be tested through the North Carolina State Laboratory of Public Health (NCSLPH).“

Federal regulators gave an overall rating of 1, the lowest possible, to the Durham Nursing and Rehabilitation Center in early 2020. One of more than 30 NC nursing homes to experience COVID-19 outbreaks, it scored a 2, or below average, for staffing. The facility now has 111 cases of COVID-19 and 14 deaths. Photo credit: Rose Hoban

Gov. Roy Cooper sent out an April 9 order that set out public health and safety requirements for nursing homes, but did not mention testing. According to the plan, nursing homes should be “canceling communal activities, including group meals, taking the temperature of employees and essential personnel when they enter the facility, requiring specific personal protective equipment in the facility,“ and “requiring close monitoring of residents for COVID-19 health indicators like body temperature.”

The health department will advise

The issue of whether to test residents who have not shown any symptoms of the virus remained as part of the dialogue. Many epidemiologists maintain that the practice is necessary to prevent mingling of residents who have tested with those who don’t show symptoms, but are infected with COVID-19 nonetheless.

On April 14, according to a recording of a meeting of county health officials, Lauren Tanz, a state epidemiologist, appeared to put the brakes on testing by the state lab, which was, at the time, still short on supplies:

“Please encourage facilities with an outbreak to work with other labs to test asymptomatic persons if possible. If a facility does decide to initiate testing of a large group of asymptomatic persons in a congregate living setting, please notify your TATP nurse,” referring to the Technical Assistance and Training Program of the Communicable Disease Branch.

Then, on April 21, a DHHS spokeswoman told North Carolina Health News that the decision on whether to test all residents would not rely on the state’s guidance, but on individual health departments.

“Depending on testing capacity, clinical scenario, circumstances of the facility, the health department will advise whether testing of all residents or a group of residents is required,” spokeswoman Kelly Haight Connor said in an email.

By April 27, another spokeswoman, Chris Mackey, said that DHHS supported expanded testing for nursing home residents, but raised again the idea that the state health laboratory would be hard-pressed to meet the demand.

It’s part of NC’s strategy

“There is currently excess capacity in some of our commercial labs with short turnaround times (commercial labs have resolved delays and now have capacity to run more tests),” Mackey said in an April 26 email. ”And so therefore we are encouraging health departments and nursing facilities to use those capabilities as appropriate. In facilities with a large number of residents or staff that require testing, it may be necessary to use more than one lab to meet the demand for testing.”

Friday’s announcement was coupled with the message that increased testing overall would help smooth North Carolina’s path toward rescinding measures intended to protect state residents from infection.

“Testing, along with contact tracing and supplies of personal protective equipment, is part of the state’s strategy to slowly ease restrictions, while protecting North Carolinians from COVID-19,” DHHS said.

Thomas Goldsmith

Thomas Goldsmith worked in daily newspapers for 33 years before joining North Carolina Health News. Goldsmith is a native Tar Heel who attended the UNC-Chapel Hill, and worked at newspapers in Tennessee...