The Department of Public Health and Mayor London Breed this morning announced that, in the not-too-distant future, the staff and residents of San Francisco’s 21 skilled nursing facilities will begin being proactively tested for COVID-19. 

This is, obviously, a very good development. Nursing facilities for the elderly have been ravaged by the pandemic worldwide. In California, perhaps one-third of all COVID-related deaths are tied to nursing facilities. In San Francisco, which has, thus far, remained relatively unscathed, nursing home outbreaks have been disproportionately deadly — four patients died and 65 staff and patients were sickened at the Central Gardens Post Acute facility alone. 

Staff at this Fillmore-area nursing facility told Mission Local that they had demanded universal COVID-19 testing in early April, but were denied. Instead, a lethal outbreak had to occur before the California Department of Public Health came in and administered the tests some two-and-a-half weeks after staff say they asked for this. Those tests revealed a huge percentage of workers and residents on-site were infected. 

The vast majority of these infected staff and patients at Central Gardens were asymptomatic. For what it’s worth, the vast majority of the 102 homeless residents and staff that tested positive for COVID-19 at MSC-South were also asymptomatic.  

And yet, in San Francisco, asymptomatic patients and staff at nursing facilities, with few exceptions, have not been proactively tested (and these marginally paid workers may make ends meet by working in several nursing facilities, which is problematic during a pandemic). Homeless shelter staff and residents have not yet been proactively tested either. In fact San Francisco, officials purportedly nixed plans to undertake large-scale proactive testing in shelters, prioritizing skilled nursing facilities instead.  

Your humble narrator on Thursday phoned every skilled nursing facility in all San Francisco. Only two outfits positively confirmed they’d proactively tested asymptomatic staff and patients, one on their own and one via the Health Department — though administrators at other sites did intimate they were tipped that a health order was pending. Even Laguna Honda Hospital won’t begin universal testing until May 4, per today’s order. 

At several sites, nurses or administrators conflated “screening” and “testing.” These are not the same thing: Screening involves taking people’s temperatures and keeping an eye out for telltale signs of COVID-19 infection. That’s great, but it does absolutely nothing to reveal the asymptomatic carriers who, it seems, are driving this pandemic in hotspots such as nursing facilities, prisons, mass transit, and other gathering places. 

William Steel, the SEIU 2015 union rep for 17 Bay Area nursing facilities, says none of the workers at his sites are being proactively tested: “In situations where there aren’t deaths, it’s operations as normal.” 

Marcus Young, a spokesman for the Campus for Jewish Living, one of the city’s largest skilled nursing facilities, minimized the value of testing staff and residents. 

“If we tested all 1,000 people on campus today, we’d have to test all 1,000 people tomorrow and the day after that,” he said. Testing would only provide “a snapshot in time.” 

This is an odd bit of logic. Ignorance is hardly bliss during a pandemic and, in fact, medical experts — including UCSF’s Dr. Diane Havlir — are now advocating for testing and periodic re-testing at nursing facilities

Some doctors would, in fact, prefer a snapshot in time to nothing. One Kaiser physician ordered COVID-19 tests for his 20-odd patients residing at the Campus for Jewish Living, and they were undertaken last week. They all came back negative (Kaiser acknowledged it took the initiative here in a statement sent to Mission Local: “In coordination with our infectious disease physicians and the county, we conducted COVID-19 testing of our long term patients at Campus for Jewish Living to help ensure our patients’ safety and well-being.”).

Only two Campus for Jewish Living staffers have tested positive here so far; they were screened and sent home to recuperate.  

Waiting around for people to start showing signs of sickness and an outbreak to occur is bad policy — we’ve tried that and it doesn’t work. So, proactively testing the asymptomatic staff and patients in nursing homes and getting ahead of the virus is crucial to saving lives. The city’s testing capacity finally seems able to accommodate this. On a municipal level, this is a move in the right direction. 

And yet, on the statewide level, we may be making a grievous move in the wrong direction. 

Central Garden Convalescent Hospital, site of the city’s deadliest COVID-19 outbreak.

On April 9, a consortium of the state’s heaviest hitters in the hospital and assisted living world sent a letter to Gov. Gavin Newsom. 

When these groups talk, elected officials listen — and what they were talking about was fairly extraordinary. 

The letter, penned by the California Association of Healthcare Facilities, the California Medical Association, the California Assisted Living Association, and others, requested broad legal indemnification from liability during the ongoing COVID-19 crisis (and while San Francisco is mandating staff be tested, other counties haven’t yet done so). Here’s their ask, in a nutshell: 

In recognition of these extraordinary and unprecedented circumstances, such facilities, plans, physicians, professionals, and employees shall be immune from any administrative sanction or criminal or civil liability or claim for any injury, death, or loss alleged to have resulted from any act, omission, or decision made related to providing or arranging services …  All state statutes and regulations are hereby waived to the extent necessary to achieve this immunity.

Yes, that said “criminal.” Yes, this is a very broad ask. And, yes, not everyone is thrilled. A consortium of watchdog groups, including the ACLU and the Western Center on Law & Poverty, on April 28 sent its own letter to Newsom

The proposed executive order would be extremely broad and would cover both reckless elder and dependent abuse situations as well as non COVID-related negligence in any health care setting. … With no public oversight you would be ensuring that we never truly know how many deaths this virus has caused among our elderly population.

Meanwhile, all of this — the city’s move to finally test asymptomatic staff and the industry’s pitch to Gov. Newsom for broad legal immunity — is coming while acute hospitals are moving to place recovering COVID-19 patients in wings of skilled nursing facilities. Considering nursing facilities’ poor record with infection control even prior to the pandemic and the elderly and unhealthy people living here, this is a curious move — somewhat akin to placing the match factory next to the dynamite factory. 

And yet it’s happening. 

Mike Dark is the staff attorney at California Advocates for Nursing Home Reform, one of the groups that penned the letter to Newsom opposing broad immunity for hospitals and nursing facilities. And he thinks he sees the puzzle pieces fitting together here. The picture revealed has something to do with freeing up beds so that hospitals can return to elective surgery — and, step three: Profit.  

“Big hospitals are not making money because they cannot do elective surgery, which is their bread and butter,” Dark says. “There has been, from the acute hospital industry, a push to have COVID patients go into nursing homes. Not so much because there are no beds available to facilitate them, but to re-open elective surgery.” 

Because Medicare reimbursement rates are tied to the level of care provided, a COVID-19 patient on Medicare could net a nursing home four times the money of an average patient on Medi-Cal, Dark says. 

There is, however, a catch: Bringing COVID-19 patients into a nursing home seems like a great way to get people sick and open facilities up to spectacular legal consequences.

Unless there weren’t any legal consequences. Unless facilities had broad immunity. This, he says, is what the April 9 request of Gov. Newsom is all about: Facilitating hospitals to start making money by doing elective surgeries, enabled by transferring COVID-19 patients to nursing facilities — and providing indemnity for all parties in the event of ensuing injury, death, or loss. 

In fact, COVID-19 patients have already been transferred to the 9-acre Campus for Jewish Living. Your humble narrator has spoken to several relatives of residents here, and you’ll be shocked to learn that they’re not pleased. 

The facility on Silver Avenue, for what it’s worth, is a highly regarded institution. It’s also a vast place with separate, unattached buildings being used for COVID patients — serviced by separate clinical and housekeeping staff. The facility also claims it is not taking COVID-19 patients for financial gain, and, in fact, expects to lose money on the deal. 

Even if we take management at its word, however, if gifted broad immunity by the state, other facilities — dodgy facilities with checkered records and without vast grounds, separate buildings, individual bathrooms, and separate staff — could begin taking COVID-19 patients. These facilities wouldn’t even need to maintain the pretense of altruism. 

So, today’s move for mandatory testing in San Francisco is a good one. But it may just end up revealing what a venal and reckless move the state is poised to make.  

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