An astounding 49% of seniors do not trust senior care safety. Rebuilding that trust will require a robust Infection Prevention and Control (IPC) function and leaders to manage the program.
Watch our free webinar with Donna Nucci, a renowned infection preventionist with Yale New Haven Hospital and consultant to hospitals, senior care, and regulators. Donna and CareSafely founder Raj Shah will share their insights on:
- Emerging IPC program challenges
- Regulatory mandates for IPC programs & lessons from other sectors
- Staffing and empowering the “IC Lead” role
- Modernizing IPC program management
Click to read the full audio transcription
How the Role and Function of Infection Prevention & Control Will Change
Kate Wallace: Hi everyone, and welcome to the webinar – How the Infection Prevention and Control Function and Role Will Change. Donna, can you move the next slide, please? Thank you. Today’s discussion will include the state of COVID-19 and emerging IPC program challenges, regulatory mandates and lessons from other sectors, staffing and empowering the “IC Lead” role, modernizing IPC program management, and a Q&A section at the end.
Today’s panelists are Donna Nucci. She’s an RN, has a master’s degree as well, and is a Certified Infection Preventionist with over 30 years of nursing experience. She’s consulted with around 40 healthcare organizations. She works at Yale New Haven Hospital, on the Board of Directors at Connecticut Patient Safety Organization, and author speaker and recipient of the Healthcare Quality Awards. Also, on our panel is Raj Shah, the founder of CareSafely. He has 25 years of expertise in safety, quality, and compliance, and was past president of Alchemy Systems. He has industry experience in food, manufacturing, technology, retail, and banking. As well, he’s an MBA from Kellogg Northwestern. Thanks so much for joining us. Raj, take it away.
CareSafely Quality, Safety, Compliance Platform
Raj Shah: Thanks, Kate. Morning, folks, or good afternoon folks, wherever you might be. Just a quick introduction to CareSafely, because some of you may not know much about us, but we are a software platform specifically designed for the senior care sector to help them with their quality, safety, and compliance management. We consider infection control to be a core part of, of course, safety itself as well as many quality initiatives. And our platform is used by our clients to basically manage their entire safety program and IPC program, including assessing risks, managing the COVID response, and managing administrative time it takes to manage the whole program, identifying high-risk employees, as well as facilities, and especially if it’s multi-facility organizations. So, a variety of things. We’ll talk a little bit later about it. Just wanted to give you a high-level view of CareSafely. I know you all here to hear Donna. So, we’re going to very quickly now take it over to Donna.
State of COVID-19 and Emerging IPC Challenges
Donna Nucci: Hi, I’m Donna and I am an infection preventionist, as I was introduced and welcome.
History of Pandemics
Donna Nucci: I’m going to start off with this to give you a little background on our history of pandemics. I know some of you probably have some experience with infection prevention and for some of you, this is going to be a lot of new information. Those of us who have been doing infection prevention for a long time have a lot of fun reading actually. There are a few really interesting books about the history of pandemics. And so if you’re kind of a pandemic nerd like myself, this is something that you’re really interested in. I just felt like this was kind of an interesting infographic it sort of puts in line for you. You can see where we are. And I think this is why when you hear some of our public health professionals in the United States speak a little bit about COVID-19 and how they’re still nervous. When we compare COVID-19 to other respiratory pandemics, we’re at a very small rate of death. I know we all like to believe that maybe we have masks which are probably just one form of protection, but we do travel much more than they did during some of the other flu. So, oftentimes in my circles, we compare it to the Spanish Flu which was in 1918 and 1919, where it killed between 40 and 50 million people. So, I think as we looked at a predictive and a projection model now worldwide we would not be surprised if this number changes considerably. I know we feel like we’re making really great strides, but with the variance, I think we get a little nervous. So and I do put a link for most of my slides.
COVID-19’s Devastating Impact
Donna Nucci: Here you can see that most of you have already seen this if you read any newspapers, if you’re online at all, you’re going to see lots of graphics like this that are going to talk about COVID deaths. I do think the industry of senior living, skilled nursing facilities has become a bit of a scapegoat, right? So, a lot of it because there have been such high amounts of deaths and people contracting COVID within the long-term care and assisted living sector even adult daycares. I think that we’ve seen a lot of this come to light where many news articles and so forth talking about this. As of March 7th as you can see, 174,000 plus deaths in senior living and residents and patients that were affected is 1.3 million. I’d be interested to see what the data would be on the people who work in our long-term care facilities and not just our nurses and physicians, but those that support long-term care. Over 33,000 facilities have been impacted. So, you are going to see a wide variety of these numbers. We could debate how the data is kept. I certainly think internally, I live in Connecticut, work here in New Haven, we keep copious amounts of data and our state does, as well. So, we know where residents are coming from, what towns they’re coming from and most other states are really doing a lot with data as well and drill-downs. So, I would save anything, this is probably on the light side of counting, rather than the heavy side.
We May Be Done with COVID, but It’s Not Done with Us
Donna Nucci: So again, we might be done with COVID. I’m certainly done. I’m very exhausted with having to wear my mask and socially distance from my family and friends but I liked this graphic just because I do feel as if COVID came in right like a wrecking ball. So, last year at this time, before COVID started, I was actually in Italy for a few weeks and came back over on a plane, didn’t really realize the pandemic has started to take hold of, you know, people were so nervous and I was with my twenty-something daughter who coughed the entire flight over here, so I think for me then life changed from then. From last February on and hasn’t gone back to normal. And certainly in my job, in the beginning, I would say through almost most of last year I was working 12 and 14-hour days. We are now looking at some good news, right? We’re getting a bunch of our population vaccinated. I actually worked at our vaccination clinic this morning where we were vaccinating people with developmental delays. And so it was a really happy time. A lot of parents of this clientele were extremely happy to get their loved one vaccinated. We’re seeing a decline in new cases in nursing homes. I think it was a great move to vaccinate our nursing homes and assisted living and over 80-year-olds because it had the greatest impact. And now we’re seeing a 65 percent decline in deaths at facilities. The bad news is of course that these variants are more transmittable and I think we’re seeing higher mortality, vaccine hesitancy. So, as we’ve opened up in my state on April 1st, it opened up for everyone and I will say that they’re still appointments available. When I see appointments available, it makes me a little bit more nervous because I feel like that vaccine hesitancy in staff. I don’t know if you saw that Italy and some other countries have made vaccination mandatory. I think it will be interesting to see some universities are starting to do that. I haven’t seen any health systems. I would fully anticipate larger health systems in the country will make that mandatory similar to the flu vaccine in some states, as well. And again the duration is one year. This is true. And I would say it’ll be very interesting to see what they come out with for next year and moving forward and how we vaccinate children. I also think the long-term effects of COVID are still yet to become. We’re going to be starting to open up our long-hauler clinics and we have a lot of young patients with significant cardiac issues related to having COVID. Many, many people recover from COVID and have no issues, but we’re starting to see the impact of that long-term COVID. And here you can see doctor Walensky, I know got a lot of pushback on this about being scared and I think that we all do need to realize the CDC has data that we don’t have. So, what you’re seeing in the news is probably just the tip of the iceberg. So what I’m on calls with the CDC or my State Health Department or with any other regulatory body some of what they have to say that the general public might not be aware of is very frightening and I think WHO, the World Health Organization is working to that end, as well.
We are not in Kansas Anymore
Donna Nucci: So, we’re not in Kansas anymore. Right? I think that Dorothy, you know, I think this analogy is pretty true. If Dorothy, we’ll talk a little later on the presentation of our risk assessments, if maybe Dorothy’s on, had really been prepared for that tornado, she wouldn’t have ended up in Oz and all that goes along with that. So, I think for many of us what we feel like is, you know, were we prepared for a pandemic? I certainly feel if those of us in acute care and I work in ambulatory long-term care, in every sector, I feel like some sectors were certainly much more prepared than others for where we’ve been transplanted. And certainly our heroine Dorothy was able to navigate well her way through Kansas. And so I think that some of us might want to look at that analogy a bit.
Pandemic has Changed the Way We Think
Donna Nucci: The pandemic has really changed, I would say, the way that we think and the way that we think about our lives. I think that it’s important for everybody to think of all the different sectors. So if you’re looking at your sector and I always look, I like to travel, so for me, I always try to compare, you know, the hospital experience. I think those of you that are in long-term care is going to think a little bit differently than assisted living, a little bit differently than other kinds of sectors is, but now our consumers are very sophisticated. So, we have social media. We have different rating systems. We have the news, you know, what is the most likely thing are people going to really look at the cruise lines now and say what is Cruise Line A and B going to do to make my travel and my trips? I personally will not be taking a cruise, but I think that those that do a cruise that I have talked to that are going on in the fall are starting to analyze what the requirements are going to be. And my understanding is that it’s going to be mandatory vaccinations. To get on that boat, you are going to have to be vaccinated. I fully anticipate that maybe we’ll see some of that for international travel. I have a wedding in Italy next year and for my international travel, I’m anticipating having to have some sort of vaccinations. I think that there’s a lot of controversy right now around this vaccination requirement or certificate, but I think for many years we’ve had to be vaccinated against different diseases. My kids all traveled abroad and studied abroad and they couldn’t go without certain vaccinations. People coming to this country have to have specific vaccinations and certainly, to work at my hospital you have to have your hepatitis B vaccine. So, I think that we are socializing it right now with the pandemic but we’re fully going to see this come about. When I go to hotels that’s one of the first questions I ask because I still have traveled for work and I do a little bit of speaking use to kind of talk a little bit about when I visit clients, when I have to stay at a hotel, what they’re cleaning practices are and so forth. So, I think that we’re going to see our consumers really being very thoughtful about the way that they consume different services. So, again trust in senior care, right? And safety. And this is just looking at a percentage of respondents.
Raj Shah: Sorry, Donna, interrupt you on it. Would you mind showing your screen?
Donna Nucci: Sure. Hold on. I think that what happened was, Raj, I got kicked off. Hold on one second. I’m going to have to do the share screen again.
Raj Shah: There you go.
Americans Don’t Trust Senior Care on Safety
Donna Nucci: Okay. All right. Great. Let me go backward though. Okay. So here is again trust in senior care. I think trust in a lot of things. I think again as we said, we’re not in Kansas anymore, for a lot of things. We’re going to see our consumers be looking at things very differently than they are now. So, here you can see of course the different generations. I’m sure a lot of you have already analyzed a lot of this data, where are people coming into this industry of long-term care, who’s doing the research. So again, very active on social media. I know but I want to try to find a recommendation or something or Yelp or other things certainly there are people out there, people as you all know are more likely to write a negative response than a positive response. I think we’re going to see a whole generation coming in having a questioning attitude. We certainly see that in the hospital setting. So, very different, and have a lot of questions for us. Very still hesitant. I think our emergency room numbers are still down. I know I have been seeing some studies in long-term care and assisted living. I think I have another slide that speaks to that. But really looking at what is that consumer trying to do to make that decision about using health care at all. And I would say about maybe even changing their decision about where they live, you know are people going to be likely to go into an assisted living setting or put their parent into an adult daycare or long-term care or rehab without having a lot more information now about the trust and trust in people with the quality and safety of their loved ones. As you all know, the centers for Medicare and Medicaid services do provide this five-star quality rating and they are going to go back to measuring that. So, if you take Medicare dollars and I think that Medicare in the conversations I’ve had at Medicare I think we’re going to see Medicare pay for many more things. I think we will see an expansion in Medicare and what Medicare pays for and with what that comes with is on January 27th Medicare told hospitals, long-term care, acute care, rehab, ambulatory, surgery centers, everyone, that with their health inspections, they would now resume their focus on quality and infection prevention. So, I think those of us that have Medicare surveys or looking very closely at what that looks like. In addition, making sure that everybody wants to be getting this five-star quality rating.
Here you can see more than one-third of all US nursing homes have an overall rating of only one or two stars accounted for 30% of all nursing homes. I think again, we debate all the time. There are so many different metrics for hospitals. We have LeapFrog. We have a Joint Commission. We have TripleHC. We had a Magnet survey last week. Ambulatory care places have different ratings. I know that long-term care does. And so the question is we can all debate again what the star ratings mean, what the quality metrics are, but I think when you are looking at the consumers, the consumers are trying to look at something that’s easily digestible. So, they’re really looking to try to find out colorful fun graphs that can be shared on social media. They can talk to their friends and family. They can go on the Medicare website, to a Medicare compare and then put in different for us, they can put in different hospitals and look at different quality metrics. I think that the hot place to be right now is public health. So you have kids going to college, kids looking at colleges, kids in high school. Public health is going to become the new hot job. So I think it’s an interesting topic and certainly, if you have kids that are interested or if you yourself are looking at another degree, public health is going to become something that we’ll all be looking at a lot more closely. So, here you can just see some of the data that’s out there.
Brand and Safety
Donna Nucci: And I think for me, my mom happens to be 78. I have been looking at different assisted living aging in place and a lot of new places near me in Connecticut. She currently lives in Rhode Island, and we’re touring places in Rhode Island, as well. I think being a nurse I had other questions. So I had a lot of questions prior to COVID, more surrounding safety and falls, and so forth. And I had to put this slide up to say – for me, as an infection preventionist when I’m on the part of, let’s just say, design and construction and textiles. I often will have architects, builders, CEOs, Chief Operating Officers asking me about the environment of care and the design and the flow, and the safety. I think the consumer, on the other hand, now is looking at this and saying “For the care and love and safety of my loved one, I want them to be able to socialize.” Unfortunately, this pandemic has changed things so much. As I said, people look at that cruise ship and ask, have a question. We’re going to be doing the same thing when they’re coming in and they’re asking about the quality and safety that’s been provided where their loved one will now be aging in place. I think it’s really important to be able to address comprehensively those questions that the consumer is going to have, as well as, I think we’re going to see a very big shift in insurance dollars or in Medicare dollars or even private pay. There is going to be a certain expectation about what a quality infection prevention program looks like.
How Will You Set Yourself Apart?
Donna Nucci: So, how do you set yourself apart? And the next part of the topics, I think Raj you have on our next slide, I’ll be talking about that. But I think how you set yourself apart for infection prevention for me anyways is when I go in and survey a facility is – I like to be able to talk to the person on the ground that infection prevention liaison who can really have a crucial conversation about their thoughtful process. So, what have they done for a risk assessment? How did they evaluate what the risks were to the client that is coming in either for surgery, to the person that is coming to live in the assisted living, to the skilled nursing facility, who maybe is having a higher acuity of care? So, I really like to have a point person that’s there that can speak to the credit ongoing education. Lots of the studies that we see in a hospital setting is you can educate somebody one month that’s physicians, that’s nurses, nurse’s aids, dietary aids, and the next month and every month after and every week after they can lose 10% of what you’ve educated them on before. So, whether that be concerning personal protective equipment, cleaning of equipment, and any other metrics that you have, it’s very difficult to maintain that level of competency that you really need. So, when I go in and take a look, I really like to see a really good program plan and risk assessment that’s well thought out and has been looked at every year and updated every year.
Think “Shift Left”
Raj Shah: Thanks, Donna. By the way, Donna, on that forgetting, I actually did some work. There’s a very famous, I think, he is a professor. His name is Ebbinghaus and he did something called “a forgetting curve”. And the idea was how much do you forget over time? If you just think back to two weeks ago today and think back two weeks ago. What did you have for lunch? You probably don’t remember and even training that’s the case, 80% of what you trained on is lost within two weeks, all the details. So, it’s the core part that matters, the details get lost all the time. So, we have to continuously reinforce the training related to that. It’s called the Ebbinghaus curve, for the folks who want to hear about it. It’s called the forgetting curve. What I wanted to chat about here is just sort of it if you think about the spectrum from hotels that Donna talked about, what the hotels do all the way, the spectrum down to the hospitals to the right. Just think about pre-COVID, imagine these dials, the blue dials if they pre-COVID from an IPC program, you had to be at a level two for a hotel, at a level four for senior living, at a level six for SNFs, at a level eight for hospitals. Essentially, what we’ve had to do is shift left. What I mean by that is in post-COVID go forward way even hotels have to think about their infection control programs, their cleaning mechanisms and all the solvents and everything they do to sanitize the room much more, probably two times more than what they did before that. Safety goes now for assisted living memory care seniors living in general, we’ve had to wrap up and bump up and accelerate our whole IPC program to a level of six. If you’re skilled nursing, if you were originally, let’s say a six on a scale from one to 10, now you are at eight. And then for a hospital, if you are a point at eight. And I don’t know how old folks are on the call here. But if you remember the movie “This Is Spinal Tap” remember the guy, he had an amp, it was turned all the way up to 11. Essentially, that’s what hospitals have had to do is they had to turn up their IPC dial, if you will, all the way up to 11. So, mentally, this is a really important concept just to kind of make sure you are thinking about as an IPC program, everything has shifted left, in a way that it has to be much more aggressive and much more structured, much more thoughtful than it ever had to be for everybody of all across the spectrum, from hotels to the hospitals. Donna?
Donna Nucci: Thank you and I agree with you. I think this is a great slide in stating that. I think that for hospitals, you know, we don’t see the same amount of healthcare-acquired COVID. So, we just have general regular practices and we’ve been dealing with tuberculosis, measles, airborne illnesses for years, for 15 years. So, we already have practices and protocols in place. So, I would say moving forward, really what we were looking at senior living and SNFs is the expectation that your program should be completely up to speed now and moving forward because next winter we will see more COVID that there shouldn’t be a transmission of COVID within your facility and there certainly shouldn’t be deaths related to COVID. I think I was surprised that we still did see gaps this last January and February in long-term cares throughout the country because I felt like people had a good eight months but to your point, getting that dial turned up two or three degrees, it’s a big lift for most places and we’ll talk about some of those challenges going forward.
Regulatory Mandates and Lessons from Other Sectors
Lessons from Food Industry Regulatory Scrutiny
Raj Shah: So, I thought it’d be good to just kind of share with you all some lessons I’ve learned from working in other sectors related to the whole regulatory scrutiny that’s about to join us over the next few years I think. If you recall last time, I was talking to a senior advisor of ours who is in the industry and he said “Look, you know, the senior living industry has gone to Congress and said to Congress. ‘Hey, we have a lot of needs in terms of who we are taking care of. Folks that are in our facilities, in assisted living memory care are having the same challenges that may be as an SNF might have. And so we need additional COVID funding related to the COVID Acts that happened over the last two years.’ So Congress actually has given billions of dollars, right, to these senior living and assisted living communities, all the different communities here. At the same time, when Congress gives they also want something in return, and what we’ve essentially done”, he said “was to open the eyes of Congress. And so what we can expect is a lot more regulatory scrutiny going forward.” Donna, you just said a minute ago that, you know, we better turn that dial because what may have been okay at the beginning of the pandemic in February, March, April would not be okay later in the year and it will definitely not be okay next year in terms of the response that the industry’s had. And this is a good segue to the food industry. If you all recall, you know, about 10, 12, 15 years ago, there were a lot of issues with food recalls and sickness from E. coli, salmonella. Essentially, it’s a pathogen, just like COVID is and it was infecting and affecting our entire nation’s food supply. Every consumer was affected by it. We had these salmonella outbreaks, and beef, cantaloupes, lettuce, chicken, etc. So, Congress passed the Food Safety Modernization Act in 2011 and what that act did essentially gave the FDA and USDA a whole lot more enforcement powers, new regulations, and new fines to the point where they actually shut down an entire processing plant in food if they found some inspection issues. So, in response to that the whole industry, the food industry had to totally upgrade their training at their front line workers, become audit-ready, because the auditors from the FDA and USDA could just show up at any time they chose to, it was all surprise audits. And they invested in the technologies to, you know, to make sure all the food systems were in good shape, everything from X-ray scanners to make sure foreign materials weren’t in, much higher levels of testing of the food itself before it was shipped out, things like that. And they built a continuous and sustained improvement process for food safety to the point where food safety is now just one of the safest things you can think about. When you think about it we have over 330 million people in the US. Each of us eats at least three, in my case, maybe four or five meals a day, especially with COVID. So, we are about 1.2 billion to 1.5 billion meals that everyone is eating on a daily basis. And just think about how many issues we’re having with E. coli or salmonella in the big scheme of things of 1.2 million meals per day. It’s almost minuscule. Right? So, that’s an example of what’s happened in the food industry. How it had to react to all the outbreaks that were happening with E. coli and salmonella, how the government got involved in and now how the industry itself has had to make all the changes, but not just for the government’s sake of course, but for consumers demanding it as well from the safety perspective. Donna?
Existing Data Collection Infrastructure
Donna Nucci: And so many of you who are in the long-term care sector will be familiar with this. From NHSN which is the National Health Safety Network. So, all the hospitals we give a considerable amount of data to NHSN so they can monitor so every month I report infections in my hospital. I report our catheter-associated infections, all different other kinds of metrics. And I would say, here is the module, I just took a screenshot of our long-term care module for COVID-19. There are actually five surveillance pathways for NHSN. True to Raj’s point, we’re really looking at, there’s already a computer program that’s already a platform, that’s going to have an expectation for data to be inputted. The question is how do we abstract that data and ensure that we’re giving the correct data to the Federal Government. Many of you might have an EMR, you might have an easy way to do this, but I would only expect this to be, from the government standpoint as well as from the consumer standpoint, for this to expand. And quite frankly, the right thing for the patient or the right thing for the resident. I think looking at that impact, so looking at your admissions, your newly positive tests, and I think this will expand. It is not going to be just COVID. What else might that senior with a very fragile immune system have when they come in, what kind of test type, what’s the vaccination status, re-infection, deaths, influenza, respiratory illness, that’s other respiratory illnesses, which we used to see. People came from a long-term care facility, we were already always on alert they might have some sort of multiple drug-resistant organism or infection. It was very common. I don’t think that’s going to be acceptable any longer. Any kind of co-infections, viral testing, testing resources, they are going to want to know about your staff and personnel. This is a very hot topic and we’re also seeing, many of my centers are seeing staff and personnel actually bring litigation against their employer for exposing them. So, I think we’re going to see this now if the employee gets a needle stick if the employee is exposed to COVID if the employee is exposed to any other disease what might that employee now feel like their personal rights are. Looking at those PPE supplies and supply chains, all of that changed very much. I know many of you had a hard time getting some of the supplies that you needed including cleaning supplies last year. Then later capacity. And of course therapeutics. Okay, so looking at all of that and how the residents are checked.
Senior Care Dramatic Operations Changes
Donna Nucci: I think this is a great slide to kind of talk. You know, a little bit about what the operations are and how you had to change everything that you’ve done. I think, you know, kudos to every healthcare organization and any organization. As I said, you can go all the way from cruise ships and travel to those of us that serve a population that might be immunocompromised. So again, all the visitor restrictions and the impact that had on your residents and your family and even residents being able to visit with each other. The screening. How do you operationalize that? Giving tours to people who might want to come into the facility. Move-ins. A lot of you had suspended move-is. Daily screening of staff for COVID symptoms. I know there’s a lot of current controversy about this around the country about whether you can actually screen your staff on daily screening of residents. Communal dining rooms being closed. More frequent communication with residents and family members. Video chats and all the communication. How do you, all of a sudden, create the infrastructure that can change all these operations? And more frequently disinfecting some surfaces. And this is just to name a few. All of you out there really know of all those other operations changes and I bet that if I had you make a list, it would be three or four times longer than this of all the things that you had to change immediately throughout this endemic and I would really question to say that I don’t think anything is going to change back and if anything things going to be made permanent, and more infrastructure is going to have to be created.
Key CMS Nursing Home COVID-19 Guidance and Actions
Donna Nucci: Here’s just a great infographic that kind of speaks a little bit to all the changes that happened and how quickly. So at this point, back in February, I was having, you know, almost weekly webinars with my clients to come in to call in, just like this, and go over what all the new changes were, there were so many. And starting in July, of course. Here’s the announcement of quality improvement organizations to assist facilities and hotspots. I really don’t want to be the bearer of bad news, but I fully anticipate next winter. we could potentially see additional cases. I think we’re going to get to a point where, you know, right now, if we average a thousand deaths a day, thousands of thousands of cases a day. We all become kind of immune and numb to the numbers. I think we start looking at July 2021 and December – February 2021 and we can start going into 2022, we’re not going to be numb anymore. The expectation is going to be any outlier is an exception and unacceptable. So, although there could be in every state, let’s just say, double-digit deaths in long-term care assisted living in the population over the age of 80, I think by 2021, that’s not going to be acceptable to even have one death. That’s going to be considered a never event, like a plane crash. Right now, there’s more death per day, sometimes there are more deaths per day than 9/11. I think right now, we are numb, but I think that’s going to change considerably in 2021.
Senior Care Worker Injury/Illness Rates 2x-6x
Donna Nucci: Let’s talk a little bit about the rate of injury and illness and so here you can see how much that has changed, it has become 2 to 6 times higher. And these are non-fatal injuries. Some of them are going to be back injuries, for acute care hospitals employees can put in an exposure report which is considered a potential injury, and certainly, that has to be investigated. So, certainly, if you have employees who think that they’ve been exposed to COVID and contracted COVID while at work, that becomes a workers’ comp claim and I know a lot of you have probably had to deal with that throughout the pandemic. So, even if you are an acute care skilled nursing facility, caring for patients that are bed-bound and maybe have respiratory symptoms and have many licensed staff, all the way to, when I was interviewing just the age and place pictures for my mom, basically can send somebody in just checking on your mom 15 minutes a day. Well, I wanted, kind of all the little information about that, too. As far as the screening of that employee that might be only spending five or ten minutes, the person who’s running the swimming class or the aerobics class or the yoga class or giving golf lessons. I think it’s going to make people have a questioning attitude about everybody, their exposure and going to make your staff members also be very astute into the possible exposure they are going to have at work.
OSHA: Worker Safety
Donna Nucci: So again, I am not going to read through this slide about McKnight’s Senior Living, a little bit about worker safety, calling about greater enforcement for OSHA. I think I have not really dealt with OSHA for many years. And I think now throughout the pandemic many of the people I consult for, had staff members call with the OSHA complaint and then had OSHA come in and say “What exactly are you doing to protect your employees from these respiratory illnesses and any other illnesses that they might be exposed to?”
Raj Shah: Donna, the numbers you were showing, the 6.1 injury rate. That was actually 2018 data, so this is pre-COVID data that shows how dangerous frankly from an injury point of view, it is to be working in a senior care industry in general. So twice as more dangerous for example, than the coal mining construction. My expectation is that 6.1 will go higher because of what you just mentioned which is if they didn’t report respiratory illness as part of this and things like that. This number might actually trend upwards in the coming years. This is 2018 data.
Donna Nucci: Okay. So this doesn’t even include all the persons who work and might potentially want to call OSHA because they feel like they’ve been exposed because of maybe a lack in a Respiratory Protection Program.
Respiratory Protection Program Requires
Donna Nucci: So, if you have not done a Respiratory Protection Program, I actually feel like this is great for hospitals. But certainly, the long-term care sector should have been during this and if they have been doing this for the last 10 years, I think we would have seen many less cases of COVID because of a comprehensive Respiratory Protection Program OSHA has on their website. This is sponsored by the CDC and NIOSH. And again, I have a link to this, is spending a good amount of time, I would say we’re looking at that ICP roll, they should be spending at least three or four hours a year reviewing their Respiratory Protection Program kit, make sure they’re maintaining the Respiratory Protection Program and then implementing the Respiratory Protection Program. And that’s really for all levels of acuity. I feel like nowadays, I have a Respiratory Protection Program at my own house. So, we had people for Easter and we’re all vaccinated and I feel like I was kind of like “Okay, who is going to wear a mask? How close is everybody going to be to one another?” And so I feel like I have my own internal Respiratory Protection Program at this point.
Water Management Plan
Donna Nucci: In addition, part of the role for the infection prevention person boots on the ground is going to be that water management plan. And for some of you that live all around the country, it’s going to be very different in Texas than it’s going to be in Washington state than it is going to be in Connecticut. And this is in the prevention of Legionella and not Legionella for only your residents, but Legionella for your employees, as well. So, I don’t know how many of you remember, many of you years ago, they are named after legionnaires’ disease, which happened to a group of legionnaires, back I think it was in the 70s. So, now we really look at this. The CDC has a great 36-page guide to stopping the spread of Legionella in a building and it has a questionnaire, you can’t really see it here, but it’s a questionnaire in here. The first question is “Do you care for patients with any immunocompromised system?” and I would say if anybody at your Center is over the age of 55, all of us have a declining immune system. I am almost 55 this year. And so, yes, you do. I really debated this with many of my clients about whether or not they have to do this Legionella water risk management plan and a hundred percent I think it’s the right thing to do.
OSHA Infection Prevention Audits
Donna Nucci: OSHA also has this, if you haven’t seen this and you know, you need to get on that OSHA website and you need to make sure that your program plan is updated because that’s the hierarchy of control. This is very famous. It’s been around for a long time. OSHA talks about what is the most effective thing to eliminate. And this is injury, you can use it. I use it for respiratory or infection prevention or quality and safety, but it can be used in any industry. So, physically removing the hazard is the best thing you could do, the most effective thing, right, but we can’t remove COVID. I mean maybe someday, but I think we’re years away from that. It’s not applicable for COVID, but there’s a substitution for replacing the hazard. Engineering controls, that’s like isolating people from the hazard. Administrative controls, changing the way we work. So, I haven’t eaten lunch with somebody at my work in over a year and I still would not eat at work with somebody in the lunchroom. And then the least effective, but probably what most of our clients as well as our staff members want, is PPE, right? And when I show this slide and I do all my training with what clients and people that work for me, they all want the PPE. It’s actually the least effective in the hierarchy of controls so that most people don’t think about it. Everybody thinks that the n95 is going to solve their problems but it’s actually not.
Staffing and Empowering the “IC Lead” Role
Donna Nucci: So, staffing and empowering the IC Lead role. Okay. So, every organization is going to have to make their own plan for staffing, depending on your unique standard system size, circumstances, size, residential profile, state, and local mandates. I will say that APIC, my national organization does have one for hospitals and hospital beds. I have been a proponent for the last 10 years in my work with long-term care that this has to be a designated registered nurse or LPM, especially if you have over 20 residents living in your facility. If you have any, you know fully catheters, if you have any feeding tubes, anything like that, then you really need to have a designated person and that doesn’t mean a person who is also a charged nurse and this is going to be the challenge. If there’s anything like getting nurses to retire, there is nothing like a pandemic. So, we’re looking at your own programs and evaluating your staff, and see who might have that interest in infection prevention.
Raj Shah: Donna. I am just curious. I know like turning that dial to 11 when we talked about a hospital setting. Can you just kind of give the audience a sense of what a hospital system is doing from an infection preventionist? Just give a brutal scale of the Yale New Haven operation, it is not just a single hospital, right? It’s a whole bunch of facilities. If you can just give them a background, not that assisted living or skilled nursing would have to do anything near what Yale New Haven does but just give a sense of what the extreme number 11 looks like versus a number five.
Donna Nucci: Right, sure. So, in hospital beds, it’s usually one infection preventionist for every 150 to 200 beds. So, we have five hospital systems and we have 11 infection preventionists. When I first started 13 years ago, we had three of us and that’s in 13 years. That’s how much that’s changed. When I’m on national calls and I’ve sat on the board for my education board for my national organizations. We have given many seminars for long-term care and most long-term care, and this is going back 10 years ago would maybe have somebody who spent a few hours sometimes. Now, it’s becoming much more specialized. So, many of you, some of you on this call are working in long-term care and are certified in infection prevention for long-term care. It is a very, very difficult thing to find somebody who’s confident and can meet the challenges that are unique to long-term care and the risks that are associated with it. I would say, I think that if it probably does have some sort of mandate to this in the number of hours that need to be spent, but hospital systems are going, my hospital has 250 beds and we have two infections, full-time infection preventionists and a team of analysts that does all of our surveillance for us. So, I have another three people that support me for my data analytics and data to submit to the Federal Government. So, I mean I’m working with five people for 200 beds. Which I feel very lucky, very very lucky. Many smaller hospitals, I have clients in Wisconsin, I have clients down in South Carolina and many of them really have a challenge in being able to staff for infection prevention. It’s a hard thing to stay up on all the knowledge and training. I consume a lot of, I mean, I’m up sometimes until 9 and 10 o’clock, reading new guidance, reading the new CDC guidance, reading new studies that came out, as much of really kind of really interesting new studies that have come out recently about the vaccine and about the infectivity about the new variants. So, a lot of that we are taking a look at. They have to have the authority to carry out infection prevention programs. So, this can’t be somebody who doesn’t have a clinical background there. There’s not really, there are too many clinical decisions that have to be made about this. So, it has to be, in my mind, a licensed person and then has the resources to manage the program, the time and the tools, know which websites to be going to, which guidance to lead.
Comprehensive Risk Assessment and Program Plan
Donna Nucci: And it’s just an infographic. Here’s APIC and I’ll give you the link in there. That’s the Association for Professionals and Infection Control. And they have a whole membership section and certification for long-term care. I know a few other people have certifications for long-term care, as well. This is going to really tell you how I spend my time. So, I think that you know, again surveillance and investigation. So, in a larger long-term care facility, looking at the surveillance to become a cornerstone, right? How do you identify who is the index patient that maybe got an infectious disease and now two or three other residents or staff members have that infectious disease? Prevention and control of transmissions are going to be about another 15 to 20% and I would say that is looking at that day-to-day. So, walking around every day doing audits, talking to staff members, talking to residents, and talking to family members about how to prevent and control the transmission of infection. Identification of infection. So, any staff members who are coming to them and saying “Hey, I think that I’m sick. I have this.” or a resident that’s saying that. Management and communication. So, lots of communication, emails, coming up with best practices, doing in-services, education. I’d like a great education board. I have like a 40-page guide I give people that have all kinds of printables, so they can print them and then huddle on them every month or two. So, to your point, Raj, when you were talking about that constant continuity, answering questions, and how much the education has fallen off. It’s so important to really stay on it with every huddle, every week. The environment and how clean the environment is. Cleaning and sterilization and this is more for instruments and things like that and many of you might not have that. And then employ occupational health. About two-thirds of IPs work in acute care hospitals, but the other third work in long-term care, outpatient facilities, ambulatory care, and other settings. Only 43% are certified in infection, control, and prevention. I will tell you the state of Connecticut has just passed a new law and I think we’re going to see this around the country, mandating long-term care to have a designated person and certain qualifications for that person. So, 30% of infection preventionist plan on getting certified in their future, and there are some specifics that I think we’re going to see more of. I can’t see a world where we’re not going to have new organizations offering certifications in CEUs for infection prevention and long-term care. I think it’s obviously come under a microscope and scrutiny.
Raj Shah: Donna, I can give you an example of that in the food industry. The mandate became that every processing plant in the food industry had to have a PCQI which is equal to the CIC. It’s Preventive Controls Qualified Individual. You had to have at least one always on duty when the plant was running. So, many plants that have two or three of these folks certified to be able to do that. It’s a 20-hour course to get certified and the exam, your renewal exam, and all that. So, you’re obviously right like it’ll start happening in the coming years, for sure.
Donna Nucci: Right and I think that and again, I think it’s the right thing to do when I talk to my clients, I tell them, I know people can really, we all can have a lot of thoughts about regulation and guidelines but to your point, right it’s consumers as well. And what’s the right thing to do. The food industry had to step up because nobody wants to go to the grocery store and think they are going to die from eating a piece of chicken that night or their child’s going to die. We do a lot of food borne illnesses and a lot of people get hospitalized annually. We track that and report that to the Federal Government. We report many diseases. I have a guy with malaria, you know, you are going to report that and where do they get malaria, did they get in Connecticut, did they get it out of the country. So, we’re always watching all diseases. I think that that’s why comprehensive risk assessment and program plans are important. As I said, there are going to be different risks in long-term care, maybe in a rural section of Texas, Colorado, Utah, then in a more suburban setting, maybe here in Connecticut. And then maybe we’re looking at New York City and they’re going to have different challenges, right? So I think that looking at that comprehensive annual risk assessment and program plan changing it every year and having it improved by a board of directors is very important. It should be detailed and very specific and I go back. I know it’s simplifying it but if I’m going to go on a cruise ship, I want a detailed, very specific program plan of what they’re going to do to make sure I am safe when I’m on that cruise ship. Forever we’ve always had food borne illnesses on cruise ships. So, we get a lot of people coming off of cruise ships with you know, those kinds of GI bugs that can send you to the hospital for days. So, that’s personally why I don’t go on cruise ships, but now we have COVID-19. So because those are so highly transmissible. You’re gonna go to the casino anytime you touch anything is really going to be a problem. So, very specific to your setting long-term care, memory care, adult daycare, or system, all need to evaluate those risks annually. Now, I would contend but if that had been getting done for the last 10 years and many of you did that, so I don’t assume anybody didn’t do that, that we would have had, we could have had less deaths. And so, I think moving forward, you’re going to see that there will be additional templates and help from the Federal Government to try to help people to do this comprehensive risk assessment that we have done. Mine is 20-something pages long in the hospital, my ambulatory care centers, typically, it’s, you know, two to five pages and I would say in long-term care that risk assessments are going to maybe two to three pages with the comprehensive program plan of what your goals are for the next year. You know, what are the goals in 2021.
7 Strategies to Prevent Healthcare-Associated Infections
Raj Shah: Donna, one of the things we recommend is actually every three months, quarterly to do the assessments. The COVID-19 assessments for skilled nursing, from the ones that we build as CareSafely is 79 different risk factors. It’s pretty comprehensive. So you’re right. It’s like, but I don’t think it’s even annual, it’s much more quarterly right now, maybe eventually from semi-annual and eventually annually. But right now, things are changing so fast that if you did an assessment for COVID or last year, there wasn’t one really, right? Last February. So, our recommendations are typically much more frequently right now and for COVID specifically, but environment care and things like that, probably more on a semi-annual or quarterly basis, instead of the annual. I think annual is becoming, it’s just too long a time, things are changing too much to wait for that part.
Donna Nucci: And I think that doing that initial risk assessment and program plan in January. I usually finish it up in December, kind of looking at that year forward having it approved and to your point, then monthly really going through it and making sure there’s nothing to add or subtract to your program plan. But every year in that January getting a really comprehensive one reviewed and then updating and I completely agree. And again, these are some of the strategies that we look at and these are all that can be included in a program plan and we look at risk assessment. You know, what is the risk that maybe employees are not going to perform hand hygiene all the time that they’re supposed to? What is the risk that the environment might become contaminated and transmit disease? What are the risks of screening and cohorting patients together? We know that was a huge risk in long-term care in 2020. Surveillance. What kind of surveillance is going on? What kind of testing is going on? I know many of you are testing weekly now and what you know with maybe the antigen test. What does that look like moving forward? Antibiotic stewardship. I think a hot topic in some long-term care sectors in the prevention of C. diff. Following all kinds of guidelines, right? So, that’s another strategy, what guidelines we should be following and what kind of guidelines are changing so that we can see a lot of things in the news, and sometimes I really have to stop by my centers to say like “Don’t follow or chase that butterfly. Let’s look at what the guideline was.” Just nothing to change right now. A lot of centers went to cleaning and over-cleaning. There was no reason to clean every single surface all the time. So, really looking at the good quality studies and guidelines. And then overall anybody who is an identity Six Sigma or IHI training. It’s creating that safety culture where people feel like they can go to the CEO. They can go to the nursing supervisor and say “Hey, you know what? I saw this gap or I saw this missed opportunity and I’m wondering whether or not we can do something about it.” So they are creating that culture of safety so that everybody feels empowered to report things they feel might not be safe.
‘Ingredients’ for Successful Cleaning and Disinfection
Donna Nucci: This is just one thing and green is for successful cleaning and disinfection. I’m going to say like the environment or durable medical equipment. So, maybe it’s the patient’s bed. It’s a side table. It’s a wheelchair. It’s the tables in the lunchroom. People are eating. It’s the craft room. It’s the gym. It’s the art studio. Whatever it might be. This is just one section. So this is why it becomes time-consuming for the infection prevention lead. They have to have real clear specific things right based on what the risk is. They have good effective annual trading. If not, as you said, Raj, more monthly training documented in the line of accountability. Who’s accountable when we bring residents from one section to the other, from one place to the other, and making sure that somebody is accountable to ensure that the environment is safe and the client is safe. Involving the patients. So, nowadays we actively ask patients to tell us if their doctor did not wash their hands and let the doctor know. So, we give out handouts that say “If your provider does not perform hand hygiene before touching you, please remind them. We want you to remind us. We’re all busy.” All staff recognizing the responsibilities, audits to drive improvement, closing rings with infection. So really looking with infection prevention and control, nursing leadership being engaged, and having board-level supports. And this is adapted from that National Patient Safety Agency back in 2007. So, like I said, this is like my bread-and-butter, from when I started infection prevention, but I think sometimes there’s a lot of catching up to do in some other sectors.
Infection Preventionist Monitor Data: Trends Nationally and Locally
Donna Nucci: Again, you don’t have to really understand these slides but just know that infection prevention can be a really comprehensive, typical thing to monitor all the time. So, I recently have been looking at the weekly deaths above normal which in the country we’re looking at about 21%. So, you know, what we say is like “Who normally at this time in March would, what was a normal death rate last year, compared to this year?” And we’re still seeing about 21%. So, you know, COVID deaths we can all debate again on how they are reported but did you not go for your mammogram? Did you not go into the emergency room because you had chest pain? There’s a whole host of other, sort of, secondary deaths to COVID-19, but I think, overall with those ones where the patient comes in with acute respiratory distress and dies or ends up on a ventilator, we really say it is COVID. Right now, we’re still looking at about 20%. Patients with the immersive diagnosis are just, kind of, stuck in there because many of you are going to be familiar with MRSA and assisted living adult daycare MRSA. Kids who are in high school who do wrestling have a chance of MRSA. So, again not monitoring this that closely just yet, I could anticipate that these multiple drug-resistant organisms will be monitored more quickly and more intensely after COVID is over. So, people can become septic from this and get pneumonia, they can get cellulitis and skin ulcers, and they can have complications in their medical care. So, this is something that we look at all the time at community-acquired MRSA. So if somebody comes into my hospital from an SNF and ends up with a surgical site infection related to MRSA. You know, we’re always going to kind of relate it back maybe to that “congregate setting”.
Training is the Cornerstone of Competency
Donna Nucci: Again, I am not going to read through this, but this is just the education theories through APIC, which is kind of talking a little bit about long-term care and getting, you know, CEUs because there’s a lot of changes with CMS.
Modernizing IPC Program Management
Donna Nucci: Modernizing your infection prevention program management. Raj, do you want to speak on this slide?
Raj Shah: Sure. Actually, we’re going to be running out of time, Donna, because we got a few more minutes. So, why don’t we just skip a few more slides down and move to Q&A?
Raj Shah: I know we’re running out of time so if you have any questions, just go ahead and put them in the Q&A section. Just at a high level in terms of modernizing the IPC plan, you know. One was of course dialing that up from if you’re at four before you got to turn to six, if you are six and that turned into eight. That’s clearly the sort of the overall message I got from listening to Donna and she’s up at the extreme 11 end of all of that. The second part of this is continuous improvement. That’s the key takeaway I took. It is like this is not a one and done. We just gotta get through COVID and somehow it will magically disappear. This is a long-term continuous improvement approach that one has to take. It’s not something that will just go away. Because there’ll be other issues that will come up. There’ll be more regulatory scrutiny and another scrutiny that’s coming up. In the last part, I just wanted to mention is more about a shameless plug I guess about CareSafely. But if you think about all the things that one has to do related to infection control and safety and quality, if you’re using spreadsheets, paper-based assessments, and emails to chase people down to do action plans and corrective actions. If you’re doing all those things that are the manual process, you may want to consider something that’s much more an automatic workflow that makes this whole process a lot easier. The example I’ll give you is the COVID-19 assessments for skilled nursing or assisted living. We’ve actually gathered all the information from CDC, CMS, and all the different state public health departments and end up having a 79 question assessment just for COVID-19 for those kinds of facilities. Most folks I talked to, say that they don’t know the answer or they’ll think “Oh, we do about 20 or 30 different questions related to our assessment.” So anyway, if you’re interested, we’d be happy to have a conversation with you about CareSafely and how we help manage that entire process. So with that, Kate, we are going to turn back to you and I know we’re running out short on time but for Q&A.
Kate Wallace: Yes. So, we have a few minutes for Q&A. Thank you so much, Donna and Raj. The first question “Would you recommend having other clinical personnel involved in the risk assessment and if so, who?” This is for Donna.
Donna Nucci: I would definitely recommend having your medical director involved. I deal with a few medical directors in long-term care in Connecticut. And I get phone calls all the time from them. I’m quite good friends with a few of them who have questions about that isolation. So, I think a physician is a good one to have onboard and then somebody from nursing and certainly can be multi-disciplinary. So, if you have a great manager, that for your environmental services or anyone else you can make it multi-disciplinary, but pretty much I would say working with that medical director and the director of nursing, and then whoever the liaison is. In some of the long-term care, quite frequently, I see that the director of nursing also takes on the infection prevention role.
Kate Wallace: And Donna, one more. Someone asked if you have your basic guide available that you had talked about during the presentation. Do you?
Donna Nucci: It is geared towards ambulatory, but sure, why don’t we get somebody’s contact information. It wouldn’t be on the website because I have it actually outside of my website, it is just, you know, the advertisement for myself and then I have a back portal for clients. But certainly, get the person’s contact information.
Kate Wallace: Okay, perfect. And, Raj, for you “Does the CareSafely platform include infection control elements and assessments?” You touched on this a little bit with the number of assessments involved. Is there anything else that you can tell this person about the platform?
Raj Shah: Yeah. So, it’s a software platform that also provides all the pre-built content meaning the assessments and the audit. So, we have assessments for every type of senior care facility for COVID-19, for MRSA, for C. diff, for environment care. About 25 different assessments are pre-built. But one of the cool things we do is we enable our clients to actually take our assessment and clone it and then make it their own and they can add questions and take questions out. So, they can make it exactly fit their specific organization depending on their profile, where they’re located, etc. So, that is the ability, they can configure it to their specific needs. Same thing with staff competency audits. We’ve got about a dozen different staff competencies. Our research shows that if you hire somebody and then just put them on the floor or on the job training, it’s about 68 percent compliance to the safety standard, infection control standard. If you do really good training, you get 82 percent compliance. If you do three staff observations in the first two months of their employment, you get 94 percent compliance. So, we recommend you don’t just do once a year staff competency checks and that’s all great for your five-star ratings and things like that. But if you’ve got a system where you can very quickly do hand hygiene observations, Medpass observations in a very quick way, you can get compliance all over 94% with just three quick observations. So, that’s the way we think about as much more, not just cross-disciplinary, but just a broader approach to it, rather than just patient or resident focus, it’s everything around, including things like dining assessments.
Donna Nucci: And how I am going to be using it as a consultant. I know some people that were signed up for the conference were also a consultant, was to individualize it for each one of my clients. And then what I like about it is that then you can turn around and say you know “Mary, at New York City Surgery Center identified on a visit that I went to that the instrument-room was cluttered.” I can tag her and then the follow-up will be designated to her. So, I do like that part of it is having a stakeholder who now has to own whatever the deficit might have been. I think that’s important.
Kate Wallace: Accountability. Right, Donna?
Donna Nucci: Yeah. Absolutely.
Kate Wallace: And speaking to that, we have another question. “Do you think assisted livings will be required to have more nurses?” Raj talked about this a little bit with the Congress giving more money, having greater expectations. Do you think assisted living is going forward, post-pandemic even, will it be required to have more nurses on staff for potentially residents with a little bit of a greater acuity?
Donna Nucci: Raj, I don’t know if you want to speak to this? I definitely follow this nationally, I think staffing ratios and things like that. I would only anticipate and like we said – who’s aging up? I’m the one aging up in 10 years, I’m going to be your client maybe with the way the pandemic has been going, I am going to be your client next year because I feel like I’m beginning to really need to have somebody take care of me every day. But anyway I feel as if absolutely the consumer is going to say what good quality care looks like. If there’s one fall in assisted living and they’re going to say “What did you do to prevent that?” or somebody took their meds the incorrect way. So, I can only see where, as the acuity changes, absolutely and the only way to evaluate that is through that good risk assessment. And then that ongoing quality care. I tell clients all the time “I’m here to keep you out of the courtroom room, as well. Because I feel as if people can go back five years from now and say like “Oh, I never thought about that, but maybe that’s why that happened.” It’s because they didn’t have a good quality program, they didn’t really watch out for that. They expect us to all know everything in healthcare and be able to participate in every hospital and many of you might even be in the midst of litigation because employees expect us to evaluate all risks and prevent any kind of harm to them. And I would say the same thing about assisted living, memory care, anything is that the consumer is saying and the price tag is not inexpensive. So, if I’m paying $4,000 a month, if I am paying $2,000 a month, my expectations are high. So, it’s just like a cruise ship. If I take a cruise ship and it is a $10,000 cruise, I better be getting a filet mignon every night for dinner. If I take a cruise ship and only cost me $500, I might let you, you know, serve me chicken fingers instead. So, I don’t know why I keep going back to the cruise ships. I feel like it’s because I really don’t like cruises, right? So I’m using them as a scapegoat. It is terrible for me.
Raj Shah: Either way, Donna. I think it was an interesting point you made. You may not want fillet mignon for your 10,000 and just chicken fingers. But you want safety regardless. Safety is not negotiable. You’re not going to want to get sick, no matter what kind of ship you’re on. Right?
Donna Nucci: And I think that this has torn off the band-aid of assisted living in long-term care. So, I think everybody was going along their way. And now when I talk to CEOs and managers and people who are working in long-term care, the stress and struggle and the no sleep and that I mean, these are wonderful people. I have a weekly call and they are stressed because families are really demanding answers. They are demanding answers to why there’s been an outbreak maybe of COVID. Now they are trying to look at every other thing or they’ve heard about, even if your center doesn’t have a problem. They’ve heard about a friend’s center in California where three residents died of COVID or somebody got sick or three people fell last week. Everybody starts to talk to each other. I think not being able to see that family member is very difficult. So, I hundred percent anticipate there being some regular regulations surrounding staff ratios and expectations of licensed care within the facility. Hundred percent.
Kate Wallace: Donna, thank you so much. That’s going to wrap it up for us with the Q&A. If you have any other questions, you can feel free to email me at email@example.com and I can forward them to Donna. Also, there’s Donna’s email right there, as well as Raj’s. As soon as you log off, you’ll have a survey pop up and it really helps us if you could fill that out. Give us some insight into how you liked the webinar and give us some other topic ideas that you’d like to hear about going forward. Thank you so much for all your hard work. We know that it’s been a very challenging year and keeping everyone safe and healthy. So, thanks for your hard work and continue to stay safe. We’ll see you next time.
Raj Shah: Bye, everyone.
Donna Nucci: Thank you.