Nearly 2,200 nursing home residents have tested positive for COVID-19, according to data released by the state for the first time today.
In a press conference Friday, Dr. Joneigh Khaldun, the state’s chief medical officer, said there are 2,198 confirmed cases in nursing homes, the vast majority (75%) of which are in southeast Michigan. Out of the state’s 458 facilities, only two-thirds have submitted data.
Khaldun says the state will spend “$3.8 million to support response efforts” in these facilities, which will include “teams of public health experts and clinicians to provide assistance” and work “to expand testing.”
This comes a few days after Michigan’s Department of Health and Human Services confirmed it would start releasing facility-specific COVID-19 information. Earlier this month, the Detroit Health Department began testing residents and staff at the city’s 26 nursing homes, where they’ve so far measured a https://www.youtube.com/watch?v=N6DhvQUHMHs?t=1431">25% percent infection rate. Gov. Gretchen Whitmer days later signed an executive order requiring nursing homes to report COVID-19 cases, and outlined procedures for isolating those patients.
Directed at all long-term care facilities, the new rules apply to skilled nursing homes and licensed assisted living facilities, which include adult foster care facilities and homes for the aged.
They also apply to unlicensed assisted living facilities, which according to experts could number in the hundreds. But Michigan doesn’t currently track unlicensed facilities, so the state’s new rules may be impossible to enforce.
“I’ve been really, really worried about the unlicensed homes,” said Alison Hirschel, managing attorney of the Michigan Elder Justice Initiative.
“Since the state doesn’t have a direct line of communication with them, it’s just harder to know … all the things we need to know to protect people in those facilities, who are just as vulnerable as people in the licensed facilities.”
Licensed vs. unlicensed assisted living facilities
According to Michigan’s Department of Licensing and Regulatory Affairs (LARA), the state counts458 skilled nursing homes, 292 homes for the aged, and 4,211 adult foster care facilities among its long-term care facilities.
As for those without a license, we don’t know how many there are; there’s no public record listing all the facilities. Only a patchwork of unofficial, privately managed records exists. Sarah Slocum, co-director of the Program to Improve Eldercare at Altarum, in Ann Arbor, said some unlicensed facilities house residents who receive Medicaid-funded services, and that the local agencies that deliver those services may keep a list.
“But again, we don’t know what proportion of the unlicensed assisted living are involved with the Medicaid program,” she added. “So that’s not a complete picture either.”
At MEJI, when Hirschel and her colleagues hear about a facility for the first time, they’ll check LARA’s website to see if it has a license. But that’s “the only way” they have of knowing, she said.
And while they’re invisible to regulators, these facilities may look totally normal to residents and their families. According to LARA, an assisted living facility needs a license if it provides room and board, personal care services, and 24/7 supervision. But if a facility hires a company to take care of one of those items, then its licensing obligations disappear.
“The way our state law is written, it can be perfectly legitimate to not be licensed in the state,” said Hirschel.
Hirschel emphasizes that an unlicensed status doesn’t mean the facility is providing a lower standard of care. In fact, both administrators and residents may have many reasons for preferring the flexibility that comes with being unlicensed.
But during a public health crisis, residents of unlicensed homes will find themselves at greater risk, because they do not have a direct line to the state.
“It’s not just a question of wanting to come down hard on a facility. Even if you just want to help protect the residents of those facilities, it’s hard to know even who they are,” said Hirschel.
Changes in the works?
It’s unclear what progress has been made at the state level to increase oversight of a system that, as Hirschel noted, likely contains hundreds of facilities. (MDHHS did not respond to questions about oversight of unlicensed facilities before this article was published.)
The assisted living industry came of age in Michigan in the 1990s, as the state got older on average. In 1997, LARA (then the Department of Consumer and Industry Services), created the Assisted Living Task Force. Among other things, the task force identified the need to establish a database of assisted living facilities.
Writing in a 2002 paper, Michigan State University professor Maureen Mickus observed that by the early 2000s, the task force had done little to meet its goals. (Mickus now studies occupational therapy at Western Michigan University). And according to Hirschel, going forward, the state never mustered the political will to fit unlicensed homes into a trackable system.
In 2015, LARA reportedthat “More and more providers are under the belief that licensure is an option and not a requirement as long as they do not directly offer all the services requiring licensure,” and added that it was working with the Office of the Attorney General to further address the issue of the unlicensed facilities.
Four years later, Attorney General Dana Nessel announcedthe creation of the Elder Abuse Task Force, but it’s unclear what role that group might play in rounding up unlicensed facilities.
Courtney Covington, a spokesperson for the office, said the task force is “aware of concerns about the lack of oversight when it comes to facilities that are not required to be licensed and is considering this information as they work toward establishing the next set of initiatives.”
Slocum, with the Program to Improve Eldercare at Altarum, noted that in recent years LARA has at least shown interest in looking into these homes. But the most reliable data is still unreliable, coming from the patchwork of local and private sources.
Slocum spent 13 years as Michigan’s long-term care ombudsman, a federally funded position that advocates for improved care at licensed long-term care facilities. She agreed with Hirschel that the main problem with unlicensed facilities isn’t quality of care, but rather their distance from state support.
“There are certainly unlicensed assisted living providers that do a good job, and where people are living very happily. That’s great,” she said.
“It’s just that when something goes wrong, or there’s a big public health issue like the coronavirus, there’s not a database to say, ‘Oh we need to make sure that these settings are getting instructions about what to do.’”
Editor's note: This post has been updated to reflect the correct number of confirmed cases.
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