Preparedness and response of assisted living facilities toward COVID-19 infection control in Houston, Texas, USA

Abstract

Background

Long-term care facilities (LTCFs) including assisted living facilities (ALFs) are hubs for high transmission and poor prognosis of COVID-19 among the residents who are more susceptible due to old age and comorbidities.

Aim

Houston Health Department conducted assessments of ALFs within the City of Houston to determine preparedness and existing preventive measures at the facilities.

Methods

Onsite assessments were conducted at ALFs using a modified CDC Infection Control Assessment and Response (ICAR) Tool. Data was obtained on IPC measures, training, testing, vaccination etc. Data was analyzed, frequencies generated, and bivariate associations determined.

Results

A total of 118 facilities were assessed and categorized into small scale 46 (39%), medium scale 47 (40%), and large scale 25 (21%). The facilities had 2431 residents and 2290 staff. Thirty-one (26%) facilities reported an outbreak in 2020, while 14 (12%) had an ongoing outbreak. Twenty-three (97%) large-scale and 12 (26%) small-scale facilities had COVID-19 testing program. Vaccination coverage among residents ranged from 99% in large-scale to 40% in small-scale facilities but was smaller among staff at 748 (45%) in large scale, 71 (36%) in small scale, and 193 (45%) in medium scale. While 24 (96%) large-scale and 34 (77%) of small-scale facilities conducted staff training staff on IPC practices, 22 (92%) of large-scale and 19 (56%) of small-scale facility staff demonstrated capacity (p = 0.01), respectively. Visitor screening was done at 100% of large-scale and 80% of small-scale and the medium-scale ALFs.

Discussion

Assisted living facilities within the city of Houston are at various levels of preparedness and interventions with respect to COVID-19 response.

Background

Long-term care facility means a nursing home, retirement care, mental care, or other facility or institution which provides extended health care to resident patients (Law Insider, 2013). Long-term care settings can be broadly divided into two groups; non-skilled care facilities whose staff provide non-skilled personal care like that provided by family members in the home (e.g., many assisted livings, group homes) and skilled care facilities where skilled personal medical are reasonably and safely provided by licensed caregivers, for example, physical therapy, wound care, intravenous injections, or catheter (Center for Disease Control & Prevention, 2022)

Long-term care facilities (LTCFs), principally skilled nursing facilities, and assisted living facilities constitute medical congregate settings. High transmission and poor prognosis of COVID-19 cases has been observed and documented among residents of LTCFs in various counties and states in the United States of America (Arons et al., 2020; Telford et al., 2020) with some states/counties recording about 51% of COVID-19 deaths among residents of LTCF at the height of the pandemic (FCBOH, 2020). Factors contributing to the high transmissibility and poor prognosis of the virus within these settings are old age of the residents, congregate nature of the setting, existence of underlying medical conditions, and frequent visit from outsiders and family members (Leone et al., 2015; Nanduri et al., 2021).

Other proven risk factors for infection transmission in LTCF setting include gaps in infection prevention and control (IPC) such as lack of knowledge of proper sanitizing and disinfecting products, insufficient hand hygiene policies, lack of written procedures for cleaning and disinfection, failure to designate staff or areas to care for residents with a known infection, failure to restrict visitors during an outbreak, and a lack of IPC leadership (Gamage et al., 2021; Donlon et al., 2013).

There are over 160 nursing homes in the Houston, Texas, metropolitan area (U.S. News &World Report, 2022). The Houston Health Department (HHD) has since the discovery of the novel virus in Houston (in 2020) supported the city’s LTCFs in early detection of cases, prompt outbreak investigation and response, provision of technical guidance, laboratory testing of staff and residents etc., all toward protecting the residents and workers in these homes.

To further prevent and mitigate the impact of COVID-19 in these settings, the Department assessed the levels of preparedness and response in these homes to inform additional site-specific strategic supports for improved COVID-19 response at these homes.

Objectives: The specific objectives of the assessment were to:

• (1) review facility status, processes and operations towards prevention and control of COVID-19;

• (2) provide immediate feedback to facility management on steps to prevent and/or control COVID-19;

• (3) recommend strategies to ensure equitable allocation of available resources toward a more effective response.

Methods

The Houston Health Department Nursing Home/Medical Congregate Team conducted onsite assessments of 118 Assisted Living Facilities (ALF) spanning 50 zip codes within the City of Houston (COH) between January 13 and 26, 2021.

The CDC Infection Control Assessment and Response (ICAR) Tool was modified and adapted for the onsite assessment. The tool was modified to capture the operations within assisted living facilities and meet the objectives of the field assignment. The Infection Control Assessment and Response (ICAR) tools was developed for use to systematically assess a healthcare facility’s infection prevention and control (IPC) practices and guide quality improvement activities (e.g., by addressing identified gaps). The tool can be used to conduct an assessment in-person or remotely via a Tele-ICAR depending upon several factors, such as available public health resources, the location and remoteness of the facility, and the presence of an active outbreak (Centers for Disease Control and Prevention, 2020).

The assessment team comprised six field teams, with each team made up of an epidemiologist-lead and two surveillance investigators. A 2-day training was conducted for all field staff on the use of the adapted tool. A pilot was conducted to ensure reliability and validity in the use of the tool.

Data Management: A real-time data collection system using Qualtrics was adopted, giving opportunity for immediate analysis, review and improvement of processes.

Site Selection: Convenient sampling method with exclusion criteria was adopted. A list of long-term care facilities registered under the Texas Health and Human Services was obtained. Selected and assessed facilities were determined by certain criteria:

Inclusion Criteria:

• 1. Must be an assisted living facility;

• 2. Physically located within the of City of Houston jurisdiction;

• 3. Must be active with residents on site.

Exclusion criteria

Facilities with multi-agency visits in the last 30 days prior to the Houston Health Department’s assessment.

Categorization of the facilities:

For the purpose of this survey, assessed long-term care facilities were grouped into three categories based on the bed capacity:

• 1. Small-scale facilities: ≤10 bed capacity;

• 2. Medium-scale facilities: 11–50 bed-capacity facility;

• 3. Large-scale facilities: >50 bed capacity.

Results

Facility demographics (Table 1): Residing and working within the 118 assessed facilities were a total of 2,431 residents and 2,290 staff members. Forty-six (39%) of the facilities had a bed capacity of ≤10. Forty-seven (40%) had 11–50 bed capacity, while 25 (21%) had >50 bed capacity. For the purpose of this report, facilities with ≤10 bed capacity are classified as small-scale facilities, 11–50 bed-capacity facility as medium-scale and facilities with >50 bed capacity as large-scale. Two-thirds (62%) of the residents’ population reside at the large-scale facilities, with about three quarters (73%) of the staff also employed at the large-scale facilities.

Table 1.

Facility distribution by bed capacity and population of residents and staff.

	Facility Types by bed capacity(n=118)	Frequency	%
1	≤10 beds	46	39%
	11–50 beds	47	40%
	>50 beds	25	21%
	Total	118	100%
2	Resident population(n=2,431)
	≤10 bed facilities	276	11%
	11–50 bed facilities	646	27%
	>50 bed facilities	1509	62%
	Total	2431	100%
3	Staff population(n=2,290)
	≤10 bed facilities	198	9%
	11–50 bed facilities	427	18%
	>50 bed facilities	1665	73%
	Total	2290	100%

COVID-19 Outbreak Exposure and support received (Table 2): A total of 31 facilities reported having an outbreak in the year 2020. At the time of site assessment, 14 facilities had cases of COVID-19, with 11 at an outbreak level. Three out of every four (77%) facility reported receiving COVID-19–related information from the HHD. Other supports received from the Houston Health Department (HHD) included technical guidance on infection prevention and control strategies, epidemic response, cohorting of residents, COVID-19 testing and interpretation of test results, etc. However, about 20% facilities still received information form non-technical sources like the social media.

Table 2.

Facility COVID-19 exposure and support received.

S/N	Facility status	Number of facilities (N = 118)	%
1	Facility COVID-19 experience
	Facility had COVID-19 outbreak in 2020	31	26%
	Facility had case(s) at time of assessment	14	12%
	Facility had an ongoing COVID-19 outbreak	11	9%
2	Source of information on COVID-19 ( n = 111)
	Houston Health Department	85	77%
	Centers for Medicaid and Medicare	40	36%
	News media	31	28%
	Social media	22	20%
3	Support received from HHD by type ( n = 95)
	Technical guidance	57	60%
	Epi assessment	43	45%
	Testing support	41	43%
	Outbreak response	23	24%
	Others	29	30%

Preventive and Screening Measures at the facilities (Table 3): The assessed facilities had implemented various CDC guidelines as needed for the monitoring and screening of visitors. A better performance was however observed among facilities with >50 bed capacity; with all 25 (100%) facilities taking visitors’ temperature, screening for symptoms and requiring visitors to wear masks. A high proportion of small-scale facilities n = 35 (80%) also check their visitors’ temperature; however, a lower proportion 30 (68%) screen for other COVID-19–related questions. While a large percentage of the large-scale (86%) and 51% of medium-scale facilities, only 12% of the facilities with ≤10 bed capacity restricted their guests to designated location or rooms of index residents.

Table 3.

Preventive and control measures put in place.

Measures	≤10 bed facility (n = 44)		11–50 bed facility (n = 47)		>50 bed facility (n = 25)
	Freq	%	Freq	%	Freq	%
Potential visitors had temperature check before entry	35	80	37	79	25	100
Potential visitors had symptomatic screening before entry	30	68	38	81	25	100
Facility requires visitors to wear face covering/face mask	41	93	44	94	25	100
Restrict visitor’s entry to the resident’s room or other designated locations	12	27	24	51	21	86
Signage at entrances advising visitors on expectations	33	75	29	62	18	75
Facility staff trained on the use/wearing facemask or respirator	34	77	39	83	24	96

COVID-19 Vaccination status (Table 4): At the time of assessment, 99% of residents living within the large-scale facilities had received at least one COVID-19 vaccines, compared with 77% at the medium-scale and 40% residents living within the small-scale assisted facilities. The proportion of fully vaccinated residents also followed the same trend with 90%, 69%, and 36% of residents at the large-scale, medium-scale, and small-scale facilities being fully vaccinated, respectively. Among the facility staff only 45% of staff at the large-scale and medium-scale facilities had received at least one COVID-19 vaccine while only 36% of staff at the small scale had one or more doses of COVID-19 vaccine. The proportion of fully vaccinated staff was much lower at 9% each in the large- and medium-scale facilities and 8% at the small-scale facilities. A whopping 60% residents and 64% staff at the small-scale facilities were not vaccinated while smaller fractions 23% residents and 55% staff at the medium-scale facilities were yet to receive any COVID-19 vaccine. The large-scale facilities had just 1% residents and 55% staff unvaccinated.

Table 4.

COVID-19 vaccination status of residents and staff.

Facility types		Residents		Staff
≤10 bed facility(Residents n = 276), (staff, n = 198)	2nd dose	10	4%	16	8%
	1st dose	100	36%	55	28%
	0 dose	166	60%	127	64%
11–50 bed facility(Residents n = 646), (staff, n = 427)	2nd dose	51	8%	38	9%
	1st dose	447	69%	155	36%
	0 dose	148	23%	234	55%
>50 bed facility(Residents n = 1509), (staff, n = 1665)	2nd dose	133	9%	150	9%
	1st dose	1361	90%	598	36%
	0 dose	15	1%	917	55%

Training on the Use of Face masks and the Appropriate Wearing (Figure 1): A large proportion of facilities reported providing training to their staff members on the use of face mask and respirators; 77%, 83%, and 96% in small, medium, and large-scale facilities, respectively. These trainings however did not translate to appropriate use of the face masks/respirators when staff members were requested to complete a donning/doffing session. Compared with the large-scale facilities (92%), lower proportions of staff at the small-scale (48%) and medium-scale facilities (51%) had staff that correctly wore and removed their facemasks/respirators when requested. Review of Infection Prevention/Control training content and implementation for front- and first-line staff is necessary.

Figure 1.

Training versus use of face mask by facility staff.

Availability of COVID-19 Testing Opportunity (Figure 2). Testing remains one of the bed rocks for COVID-19 pandemic response among staff and residents of LTCFs. The CDC had provided testing recommendations and algorithm for the various scenarios that arise within nursing facilities which is informative for assisted living facilities—be it in an outbreak setting or when a case is suspected. With the establishment of asymptomatic transmission of COVID-19, prompt and frequent testing serve as a strategy for halting the spread of the virus. The onsite assessment reveals that while 93% of large-scale facilities provided COVID-19 PCR testing for their staff and residents through testing partnership with registered laboratories, only 45% and 26% of the medium- and small-scale facilities had such partnership for COVID-19 testing, respectively. About 75% of the large scale, 13% of the medium scale, and 2% of the small scale also had onsite point of care (POC) COVID-19 testing with or without additional partnership with an external laboratory.

Figure 2.

Availability of COVID-19 testing opportunity at the LTCFs.

Discussion

Conducting an onsite in-person assessment was more beneficial than the remote assessment done by some other investigators because it is not prone to some technical limitations that may reduce the effectiveness of remote ICAR (Ostrowsky et al. 2022; Singer et al., 2022). Physical onsite assessment also allows interactions with the staff and residents and allows visualization of the facility IPC practices (NCIRD, 2021).

Assisted living facilities within the city of Houston are at various levels of preparedness and interventions with respect to COVID-19 response. While most of the large-scale facilities which housed about 62% of the residents’ population and accounted for 73% of the workforce performed better in terms of COVID screening and restriction of visitors to the facilities, many of the small-scale facilities performed poorly especially with restricting visitors’ movement within the facilities. Vaccination against COVID-19 among staff was poorer than vaccination among residents who record as high as 99% at the large-scale facilities. Full vaccination figure was however very poor in all the three tiers of facilities with all the facilities recording figure less than 10% for both staff and residents. The largest proportion of staff (64%) and residents (60%) who had not received COVID-19 vaccine at the time of assessment was found within the small-scale health facilities while few (23%) of residents at the medium scale were yet to receive COVID-19 vaccine. Half of the staff at the medium- and large-scale facilities had not received any vaccine dose yet as at assessment time.

About 77% and 96% of the staff received training on the proper use pf face mask and respirators but about 48% and 90% could demonstrate correct donning/doffing of face covers. The proportion of those who could translate training in correct application was least among staff at the small-scale facilities.

Opportunities for COVID-19 testing were made available across most of the facilities either through partnership with external laboratories or with the use of point of care onsite testing. While most of the large-scale facilities (70–93%) had either partnership with external laboratories or use onsite POC for COVID-19 testing, few (13–45%) of the medium-scale and still fewer (2–26%) of the small-scale facilities had any such opportunities for COVID-19 testing for their staff and residents.

Conclusion

The COVID-19 response activities across the country and city had focused on the large-scale long-term care facilities. The small-scale facilities had probably been underserved due to their small number of residents and staff. This study reveals gaps in the COVID-19 preparedness and response especially among the non-large-scale facilities propbably due to administrative and technical challenges, which might have led to non-detection of cases, unreported outbreaks and undecisive response strategies at facility level. Going forward, an inclusive planning and incorporation of small- and medium-scale assisted living facilities into COVID-19 response efforts is needed to ensure equitable distribution and allocation of needed resources targeted at protecting the residents and staff of all LTCFs within the City of Houston.

Recommendations

• 1. Strengthen LTCF staff training, reviewing the content of existing training materials to ensure identified infection prevention and control (IPC) gaps are addressed. Focus should be placed also on small and medium-scale facilities especially on the use of PPE;

• 2. More support to the small and medium-scale facilities in ensuring prompt and routine testing of residents and staff;

• 3. Focused messaging on benefits of COVID-19 vaccination, especially among staff of large-scale facilities;

• 4. Increased support to facilities in the accessing of resources at all levels of healthcare delivery.

ORCID iD

Abayomi Joseph Afe https://orcid.org/0000-0002-1631-8262