Residents in long-term care facilities face a higher risk of contracting and becoming seriously ill from COVID-19. Nursing homes and assisted living, residential care and intermediate care facilities account for about 31% of all COVID deaths, although their residents account for just under 3% of the U.S. population.
Early in the pandemic, individuals entering long-term care facilities from other locations, such as staff or family and other visitors, were identified as a significant source of infection as the virus spread from surrounding communities and other health care facilities.
As the pandemic persists, lawmakers continue to explore ways to mitigate the spread of COVID-19 in long-term care facilities and safeguard the health of residents by modifying various requirements for staff and visitors while balancing residents’ social and support needs.
Individuals who have direct contact with long-term care residents must adhere to several mandated state and federal requirements. In response to the pandemic, several states modified policies affecting direct care workers, including setting minimum staffing requirements and making vaccinations mandatory.
The public health emergency uncovered many of the staffing challenges often experienced at long-term care facilities. Nursing homes have reported a shortage of long-term care workers every month since summer 2020, according to AARP. Federal requirements establish minimum staffing ratios for the “highest practical well-being” of each long-term care resident. However, several states have exceeded those standards by increasing the required minimum number of hours of daily direct care for each resident or improving the ratio of nursing staff to residents.
In August, the Centers for Medicare & Medicaid Services issued an emergency regulation requiring vaccinations for all staff within the nation’s more than 15,000 Medicare- and Medicaid-participating nursing homes. While vaccine mandates for private employers vary, 23 states have specifically required all health care workers, including direct care workers, to be vaccinated as of November. Just over 72% of staff at federally funded long-term care facilities have been vaccinated.
In October, booster vaccinations were approved by the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices for adults living in long-term care settings. Whereas many long-term care facilities worked with national chain pharmacies to roll out the initial COVID-19 vaccination, almost all facilities are working with existing long-term care pharmacies for the rollout of booster shots for residents.
Workforce Recruitment and Retention
Workforce shortages were already prevalent among direct and long-term care workers prior to the pandemic. Recognizing this, Colorado implemented a wage pass-through program in 2019 for direct care workers. The program allocates additional funds to increase worker compensation through Medicaid reimbursement. Legislation also standardized training requirements for direct care workers, including a periodic review of training content to ensure relevancy and alignment with the state Medicaid program.
To meet staffing ratios and address turnover due to staff vaccine hesitancy during the pandemic, several states implemented new recruitment and retention strategies. To retain direct care workers beyond the public health emergency, Pennsylvania allowed temporary nursing aides providing critical direct care services to become fully certified once they met specific requirements.
To reduce COVID transmission among residents, some long-term care facilities prohibited visitors for most of the last two years, leading to increased isolation and loneliness among residents. To balance the social, mental health, and physical health needs of residents, states are reassessing their visitation requirements.
Connecticut, Minnesota and Washington passed legislation to allow essential support caregivers or designated representatives to visit and support activities of daily living among residents. Arkansas passed the No Patient Left Alone Act in 2021, establishing visitation rights of long-term care patients. Potential visitation rights under consideration include compassionate care visits to meet the physical or mental needs of a resident; end-of-life support; adjustment support after moving to a new facility; emotional support after the loss of a friend or family member; physical support with eating or drinking; and social support with crying, distress or depression.
Severe illness and death due to COVID-19 continues to impact long-term care residents disproportionately. Deaths increased at a faster rate in nursing homes than among other populations between July and August. States may need to continue to adjust their laws and regulations to meet the changing COVID-19 landscape and to continue to protect the health and well-being of long-term care residents.
Kelsie George is a policy analyst in NCSL’s Health Program.
This resource is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $853,466 with 100% funded by HRSA/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. Government.
Long-Term Services and Supports and COVID-19: Ensuring Access to Services Webinar, NCSL (March 2021)
Finding Long-Term Solutions for Long-Term Care, NCSL (March 2021)
Time Is Right to Examine Delivery of Long-Term Services and Supports, NCSL (November 2020)
Long-Term Services and Supports and COVID-19, NCSL (July 2020)