LOWRY CITY, Mo. — At Truman Lake Manor in rural Missouri, every day begins the same way for every employee who walks through the nursing home doors — with a swab in the nose, a swirl of the test solution, and a brief wait to see if a a thin red line appears indicating a positive case of COVID-19.
Only the healthy are allowed in to care for virus-free residents.
Despite these precautions, an outbreak of the coronavirus hit the facility late last year. An inspector later cited him for violating the federal government’s COVID-19 vaccination mandate for healthcare facilities.
Truman Lake Manor is one of approximately 750 nursing homes and 110 hospitals nationwide filed for violating federal staff vaccination rules during the past year, according to an Associated Press analysis of data from the Centers for Medicare & Medicaid Services. . Most have been given a bureaucratic push to do better, although some care homes have also received fines, especially when they have had many other problems.
One year after it began its nationwide enforcement on Feb. 20, 2022, vaccination mandates affecting about 10 million health care workers are the last major mandate left from President Joe Biden’s sweeping bid to boost vaccination rates national. Similar requirements for large employers, military members and federal contractors have all been abolished, repealed or partially blocked.
The health care vaccination mandate is expected to run through November 2024. But some say it’s time to stop now, citing fewer severe COVID-19 cases, a shortage of health care workers, and the impending May 11 deadline of a national public health emergency that has been in place since January 2020.
“Their regulations are making it harder to give care, not easier,” said Tim Corbin, the administrator of Truman Lake Manor who also serves as a nurse, adding that “terms need to end.”
CMS said in a statement to the AP that “the requirement for staff to be fully vaccinated has been a critical step in the response to the pandemic” and “has saved Americans from countless infections, hospitalizations and deaths.”
The policy requires workers, contractors and volunteers at facilities receiving Medicare or Medicaid payments to have the full primary dose of an original COVID-19 vaccine, with exemptions for medical or religious reasons. While nursing homes can be fined for violations, CMS has generally given violating facilities more time to update their policies and comply.
The Republican-led US House recently passed legislation that would end the mandate, but the bill is unlikely to pass the Democrat-led Senate.
Meanwhile, the requirement continues with mixed results and, in some cases, widespread exceptions.
When a state inspector visited Truman Lake Manor in December, an outbreak of the coronavirus had infected 26 of the 60 residents and about a quarter of the staff in the previous weeks. Corbin said the outbreak originated from an unvaccinated employee with a religious exemption who tested negative for COVID-19 before shift work and wore a mask. The employee was not feeling well and tested positive after arriving home.
The inspector found that more than 40% of staff had been granted religious exemptions from being vaccinated. But the federal Centers for Medicare and Medicaid Services are not examining the rationale for those exemptions. The reason the facility was cited for vaccination shortfalls was because three employees had not received their second dose of vaccine and had no exemptions on record. After the subpoena, each got a second strike, and regulators approved the fixes in January.
It’s hard to find workers willing to get vaccinated, Corbin said, because many local residents remain opposed to the vaccine or doubt its effectiveness. Only 42 percent of adults in St. Clair County are vaccinated against COVID-19, a rate just half the national average.
The 120-bed facility is operating at half capacity and turning away potential residents, “because I can’t hire enough people to care for them,” said Corbin, who posted ads touting a $5,000 signing bonus for nurses .
Rhonda Martin, a nurse educator at the facility, said she understands people’s hesitancy to get vaccinated. Although she received the initial shots and a booster, Martin still caught COVID-19 last fall and missed a couple of weeks of work.
“I was initially in favor of the vaccine, because I felt that as healthcare professionals, we had to protect ourselves and the patients we care for,” she said. “The longer this goes on, the vaccines don’t seem to help.”
At a facility in Greenwood, South Carolina, the vaccine mandate has caused an exodus among nursing staff that has taken some time to reconstitute.
“People were like, ‘You know what? I’m just going to stop working,’” said David Buckshorn, CEO of Wesley Commons in Greenwood. “Having a requirement that someone feels strongly they don’t want to follow, that really limits our ability to get people on board.”
Workforce shortages are forcing more than half of nursing homes nationwide to limit resident admissions, according to the American Health Care Association, which represents long-term care facilities. While most other health care sectors rebounded, nursing home employment fell 13% in 2022 from pre-pandemic levels and reached lows not seen since the 1990s.
LeadingAge, an association of non-profit nursing homes and other aging service providers, initially supported the mandate and still encourages vaccinations. But now he says a federal requirement is no longer needed.
“Our country is in a very different place now than it was in the summer of 2021 when the mandate was initially proposed,” said Katie Smith Sloan, president and CEO of LeadingAge.
Although deaths have dropped significantly since their January 2021 peak, older adults and people with underlying health issues remain more susceptible to severe cases of COVID-19. For this reason, some medical professionals believe the vaccine mandate should continue in nursing homes and hospitals.
“This is an important requirement,” said Dr. Georges Benjamin, executive director of the American Public Health Association. “Not only does it protect the healthcare worker themselves, but it also protects the patients.”
Even some patient advocates continue to support the vaccine mandate.
“The more we crack down on requirements overall, the more dangerous it becomes for nursing home residents,” said Marjorie Moore, executive director of the St. Louis-based nonprofit VOYCE, which advocates for long-term care residents .
Nationwide, about 5 percent of the more than 15,000 nursing homes caring for Medicare or Medicaid patients were cited for violating their COVID-19 vaccination mandate, and about 2 percent of 4,900 hospitals, according to the analysis of the AP. But those citations weren’t evenly distributed across states and occurred less often during the second half of 2022.
Twenty-four states have cited no hospitals for COVID-19 vaccination violations.
Nearly 1 in 5 nursing homes received staff vaccination citations in Louisiana and nearly 1 in 7 in Michigan, the highest rates nationwide. In contrast, 14 states and the District of Columbia had two or fewer named facilities. Texas, which has the most nursing homes participating in Medicare or Medicaid nationwide, sued just one nursing home for violating the vaccination rule.
Kansas, Florida and Texas each declined to check for vaccination violations, instead leaving that process to CMS, which hired contractors. As a result, CMS said Texas received more than $2.5 million in federal funding, Florida more than $1.2 million and Kansas nearly $350,000.
Kansas Gov. Laura Kelly, a Democrat facing reelection in a Republican-leaning state, said last year that the vaccine mandate conflicted with state law and could worsen the workforce shortage.
Like Kansas, Kentucky also has a Democratic governor with a Republican-led legislature. But Gov. Andy Beshear’s administration said state inspectors didn’t notice vaccination shortfalls because hospitals and nursing homes all met federal guidelines when accounting for exemptions.
“We have been at the forefront of encouraging vaccines,” said Betsy Johnson, president of the Kentucky Association of Health Care Facilities and the Kentucky Center for Assisted Living. “We know vaccines save lives.”
Nationwide, the number of nursing homes cited for immunization violations dropped sharply after CMS last June stopped requiring state inspectors to check compliance when responding to complaints about unrelated allegations, such as neglect of patients. CMS cited substantial compliance with the vaccination requirement during the change.
Prior to that, Gil-Mor Manor in rural Morgan, Minnesota was one of only three structures cited for the worst category of shortage, indicating widespread “immediate danger” to residents.
A May inspection report said the facility lacked policies to mitigate the spread of COVID-19, such as requiring N95 masks, for 15 unvaccinated employees with religious exemptions. He said three other staff caring for patients were neither vaccinated nor exempted.
The “bankruptcies resulted in 7 of the 27 residents contracting COVID-19,” the report said.
The nursing home has responded by approving exemptions for unvaccinated employees, updating its policies and hiring a consultant to provide additional training to its infection control nurse manager, said facility administrator Terrie Rothmeier. Inspectors revoked the “immediate risk” designation within three weeks. The facility has not been fined.
“We fixed the problem,” Rothmeier said.
Harjai reported from Los Angeles and is a corps member for the Associated Press/Report for America Statehouse News Initiative. Report for America is a non-profit national service program that places reporters on local newsrooms to report on hidden issues.