Transcripts For CSPAN3 House Ways And Means Subcommittee Hearing On COVID-19 And Nursing Homes 20240712

Nursing homes. We are joining this hearing in progress. Youre watching live coverage on cspan3. As one basis for work authorization. U. S. Cis has used deferred action in medical and humanitarian cases for decades. The idea is longstanding, and, in fact, customary. In one data set i received in 2011, nearly half of the cases i could identify involved serious medical conditions. And many of the cases involved more than one factor. For example, deferred action was granted to a 47yearold schizophrenic who overstayed his visa, was the son of a lawful perm resident, and had siblings who were u. S. Citizens. Over 100 of these cases involved people whose homes were destroyed by an earthquake in haiti. In another data set, a 578 cases obtained from u. S. Cis in 2013, 336 were based on medical issues. One case involved a mexican female who entered the United States without inspection and had two u. S. Citizen children. One of her children had down syndrome, and the other child had serious medical conditions. I received a third data set from u. S. Cis in 2016. Again revealing that many deferred action requests were based on serious medical conditions. The data set included a child with burns on over 65 of their body, and parents of usc children with cerebral palsy. U. S. Cis has a long history and the expertise of handling cases for vulnerable populations and should continue to process humanitarian deferred action cases. Preserving an affirmative deferred action process at u. S. Cis allows a person to request what is often a lifesaving protection without having to undergo removal proceedings. And also saves the government resources. Further, nearly every legal opinion from ins and dls on prosecutorial discretion instructs officers to exercise prosecutorial discretion at the earliest stage of the enforcement process. Stripping u. S. Cis of jurisdiction over deferred Action Forces a noncitizen to instead exhaust the enforcement process. Who has served by placing a cancer patient who might ordinarily request deferred action at u. S. Cis into the removal process . No one. Finally, u. S. Cis has improve transparency by publishing statistics about deferred action and providing greater notice and information to the public. Thank you, doctor. I believe your time is up. Well have further time for questions. Dr. Donaher . Ranking jordan, chairman raskin, ranking roy, and distinguished members of the committee, thank you for the opportunity to testify before you today. I am dr. Fiona daneher, pediatrician at Massachusetts General Hospital for children where much of my clinical work focuses children and immigrant families. I have come here to express the profound concerns that i and my colleagues share over u. S. Cis potential termination of the medical Deferred Action Program. Our hospital cares for children program, including a young child with a rare genetic condition that causes seizures and developmental challenges. In the country of origin, this childs condition is stigmatizing and deemed unworthy of care. The family was told the child would suffer from intractable seizures and die within a year. Refusing to accept that nothing could be done, the family left everything behind to seek a Second Opinion at mass general specialized clinic devoted to this genetic condition, one of only a handful of such clinics in the world. Thanks to the familys determination and the care of a dedicated clinical team, this child has lived a longer and much richer life attending school and achieving some social skills. None of this would have been possible without the medical Deferred Action Program. Now the childs status is due for renewal at a time when the program may arbitrarily end jeopardizing much hardwon progress. When pediatricians care for medically complex children, we often do so with bated breath. These children are by 6n definn vulnerable. Whether they suffer from cancer, cystic fibrosis, muscular dystrophy, cerebral palsy, or one of any number of other diseases they require care from a Multidisciplinary Team of specialists. Depending on their underlying condition, an error as simple as a missed dose medication, a dislodged breathing tube, or a poorly covered sneeze could spell catastrophe. For many of these children, their health is so tenuous as to make travel unsafe, and their clinicians would hesitate to even transfer them to another hospital within the United States, never mind overseas. Should these children be forced to return to their home countries, their care may be impeded not only by stigma and misunderstanding, as an n our patients case, but by lack of basic resources. Access to safe food and water is not a given in many parts of the world, and chronically ill children routinely die from malnutrition or infection as a result. Unreliable electrical grids talent the health of children who depend upon inpatientventions such as pumps, ventilators, or medications that spoil without consistent refrigeration. Particularly frail children can die from heatrelated complications for want of access to air conditioning. Severe air pollution in developing countries poses a dire hazard for children with underlying lung disease. Immunocompromised children are poorly equipped to handle exposure on endemic fin effect us to diseases such as malaria, diarrhea, measles, and pneumonia. Health care systems in many lowincome countries are in their niceens. Simply transporting a child to an hospital can pose a challenge in areas without ambulances or safe roads. Supply chains are inconsistent, so should the child make it to the hospital the medications and equipment he or she needs may prove unattainable. As may the skilled personnel needed to administer them. It is sadly not high bushily to say that sending medically fragile children to such environments amounts to issuing them a death sentence. Adding insults to injury, such children could find themselves unable to access even the most rudimentary Palliative Care to ease the anxiety and physical pain of their passing. Perhaps no intervention is more racial to minimize the suffering of a severely ill child than maintaining the presence of a loving Family Member at the bedside. Terminating the medical Deferred Action Program would leave some medically complex u. S. Citizen children struggling not only with the physical burden of their disease but with the Emotional Trauma of forced separation from their immigrant parents. No child can be expected to heal under such circumstances. There is not just badinhumane. The u. S. Department of health and Human Services building here in washington, d. C. , bears an engraved quote from its namesake, hu burt h. Humphrey, it reads the memorial test of government is how it treats those who are in the dawn of life, the children, those who are in the twilight of aged, and those in the shadow of life, the sick, the needy and the handicapped. My colleagues at mass general and i respectfully rnurge you t embrace the moral impertive po allow our young patients to heal and thrive. Thank you, dr. Danaher. Mr. Marina. Chairman raskin, Ranking Member roy, Ranking Member jordan, distinguished members of the committee, thank you for inviting me here today and for hearing these stories. Im here today in my capacity as the director of Legal Services at the irish immigrant secenter where we provide legal, wellness and Immigration Services to those from ireland and 120 countries around the world. In our Legal Program we represented dozens of families facing horrific circumstances that always accompany an application for deferred action. Majority of deferred action cases ive seen, fell ill, was gravely injured or received a terrifying diagnosis. Sometimes the illness or injury makes travel impossible. Sometimes lifesaving treatment is not just available in a home country. And the vast majority of cases we handle, its a child whose life is at stake. We represent children with cerebral palsy, muscular dystrophy, a child blinded by the cancer in her eyes, a child whos suffering multiple seizures after day. We represent children confined to wheelchairs, connected to feeding tubes and tracheostomy tubes. In each of the cases desire to any law but cannot leave without putting life in danger. The government has always provided a relief valve, a process by which a family could come forward rather than ko cowering in the shadows over a sick child and lay out their circumstances, explain to uscis why travel would become impossible, even deadly, and the government would allow them to continue their childs care. I know that lives have been saved by this program. Ive sadly also known children weve represented to die in this program. But even in nothose cases the brief reprieve by the government bought those families precious time. This longstanding Legal Program is what protects people from government actions that would shock the conscience and betray our fundamental values as a nation. I was shocked then three weeks ago when i received the first denial notice and over the course of the next two weeks about a dozen more. They all contain the same boilerplate language. Uscis field offices no longer consider these applications at all. Leave in 33 days or we may initiate your removal. The decision to terminate the program was done in secret. No prior notice. No opportunity to advocate for the program and no opportunity to prepare my clients for those denial letters. We immediately reached out to all the families who were applying or were in the program already. And ive had some of the most Difficult Conversations of my life over the past few weeks. Clients have asked me what the government expects them to do, to disconnect a child from lifesaving support, to put them on a flight that they may not survive. Theyve asked me what i would do. And we found many applications for parents whose u. S. Citizen children suffer these lifethreatening diseases and in these cases the termination of the program threatens yet more family separation. There are parents right now having conversations about whether to orphan a child in order to extend his or her life. The terrible reality of what they have done became public, usciss initial response to the media was to deny that they eliminated the program. They claim they had simply transferred it to i. C. E. And, of course, our clients wanted to know what that meant and how much danger their families were in. Media outlets were contacting our center trying to get us to explain it to them and i had to tell them that the only information i had i was getting from them. But the transfer to i. C. E. Appears to have just been false. Theres no new procedure. Theres no new program. And i. C. E. Officials have since confirmed again through the media that they have no program in place and no plan to implement one. After usciss latest press alert last week, we began receiving notices that some cases would be reconsidered. We still dont know what that might mean for those families. The press alert References Department of state regulations and its unclear if this means theyre applying the same standard they always have or if they made up some new standard that we dont know. And the press alert and these reconsideration notices we received still indicate that the program has been terminated moving forward. It leaves no option for families in these dire circumstances now or in the future. Because the program was terminated in secret, people didnt know, they kept filing. We filed applications as recently as august 16th. And we have no idea what it means for that case. Deferred action is a critical, literally, lifesaving program that impacts a small number of families but in an absolutely immeasurable way. And ultimately uscis hasnt backtracked so much as doubled down. Theyve delayed the consequences of their decision for a handful of families, but thats it. And unless congress or the courts can either convince or compel uscis to reinstate the program, everyone in it and everyone that would otherwise benefit from it is in a horribly worse position today. Thank you very much for your testimony. Mr. Humman. Chairman raskin, Ranking Member roy, distinguished members of the subcommittee, thank you for the opportunity to appear here before you today on this very important summibject. My name is tom homan. I retired in 2018 after serving more than 34 years in forced immigration law. As you know, im passionate about this issue. Im glad to be back to testify in a different aspect of it today. Before i delve into the details pertaining to the subject of todays hearing, i would also like to pause to reflect on this being 18th anniversary of 9 11 terrorist attacks on our homeland. May god have mercy on those innocent victims who lost their lives and their families. May we continue to protect this country against those who want to destroy us and the freedom we enjoy in this country. I also want to salute and honor the Fallen Soldiers that took the fight to those who attacked us and made the ultimate sacrifice. I for one will never forget. Id like to start by clearing up what appears to be a common misunderstanding. Its not lawful to have a Deferred Action Program at any federal agency. The word, program, conjures the idea an entire class of aliens if they meet certain criteria 9re entitled to a benefqdw thats simply not the case. You break it down to the most underpinnings of the law, deferred action is exercise of prosecutorial discretion and prosecutorial discretion may only be exercised, one, on a casebycase basis, not far class according to a set of criteria, and, two, by Law Enforcement agencies. Again, prosecutorial discretion is rightfully only exercise bl on a casebycase basis and only then only by the relevant prosecuting agency, Law Enforcement agency, that has a Statutory Authority over those laws. Im here to answer those questions about that program today. Its an important hearing. Tease are important questions well be talking about today. I want to change the course here for one minute. I understand this hearing is very important. Thats why i accepted the offer to come here today and discuss it we apologize for the inconvenience. We took you to the wrong hearing. We now take you live to the correct hearing on how covid19 is impacting Nursing Homes. We are joining this hearing now in progress. Unwilling to work in these conditions. We hear a lot about the heroes working in hospitals, but these individuals working in Nursing Homes, many of whom are making close to minimum wage and risking their health, are heroes, too. Nursing homes have been underfunded for many years and struggled with staffing and other issues prior to covid. ÷]8 in many respects covid is, to quote a colleague, a crisis on top of a crisis. So what do we do about all of this . Well, first, we need to determine why covid has entered certain Nursing Homes and not others. Some are suggesting covid is a bad apples problem and are quick to point fingers at ineffective state policies or poor nursing home practices. This is not what my research or the independent research of other academics suggest. Indeed, three of us published a washington pos Washington Post opped on exactly this issue earlier today. We find that cases are concentrated wherever covid is present in the community. The secret weapon behind covid is that it spreads in the absence of any simpymptoms. Visitors have not been allowed in most facilities since march. But staff unknowingly bring the virus from the community into the facility. As a result, if covid is in the community where staff live, covid is soon to be in the nursing home where they work. This suggests covid is not just a bad apples problem, but rather a systemwide problem and can impact any nursing home in any state. This is a time to support all our Nursing Homes. So, what should we do . Staff and residents are in desperate need of covid testing. Until we get rapid and accurate testing for all staff and residents, we wont be able to contain covid. This cant just be a oneoff. We need a Surveillance Program that regularly tests staff and residents in order to identify new cases as they emerge. The virus also spreads because staff lack ppe. Theres a huge shortage of masks, goggles, gloves, and gowns that has led to staff reusing these supplies or simply going without. Rather than pushing the logistics and costs of testing and ppe to states and Nursing Homes, the federal government needs to take ownership of this issue. The federal government should set a consistent policy across all u. S. Nursing homes and provide states and Nursing Homes with the resources to achieve it. And if we have testing and ppe in place, we would be able to move safely toward opening Nursing Homes again to Family Members. Another issue is supporting and growing the direct chair workforce. Nursing homes need higher reimbursement for covid cases to prevent layoffs and maintain Staffing Levels. Staff also deserve a wage that is commensurate with the risk they are taking. The federal government needs to put dollars in place to directly flow to workers in terms of hazard pay and other benefit. I want to conclude with a simple statement. It didnt have to be this way. Much of the negative impact of covid in Nursing Homes could have been avoided. However, rather than prioritizing the safety of the 1. 3 million spriindividuals whoe in Nursing Homes and staff who care for them, we fail to invest in testing, ppe, and the workforce. We allowed a problem that could have been contained to now grow into a National Crisis. Now that we are here, its time for the federal government to make the necessary investment to mitigate the spread of covid across all u. S. Nursing homes. We owe that to our parents and our grandparents and the individuals that care for them. Thank you. Miss kennedy . Thank you. Chairman, Ranking Member nunes, and members of the subcommittee, my name is dana marie kennedy. Im the state director for aarp arizona. On behalf of 38 million members and all Older Americans nationwide, aarp appreciates the opportunity to testify. We are calling on congress and the administration to take immediate action to stem the continued loss of life and improve conditions in longterm care facilities. Youve heard the high number of nursing home and other longterm care facility deaths and the share of the overall covid19 deaths. In arizona 65 of deaths in Maricopa County are from people who lived in longterm care facilities. These were moms and dads, grandmas, grandpas, uncles, and aunts. Aarp has heard from thousands of families across the country. Heres just one story from an arizona family. Nor jn ma moved to a nursing home after having a stroke. Her son, damon, visited his mom regularly. In march he thought his mom look tired and a little sick. He reported the symptoms and three days later was denied access to the facility. For more than a month he tried to see his mom or call the facility but mostly got voicemail. Normas family only learned she was gravely ill when the hospital called. Unbeknownst in them, she had been transferred and put on a ve ventilator. The hospital asked permission to kp normas son denied the request. She died a week and a half later. Aarp urges action on a fivepoint plan to slow the spread and save lives. One, care facilities must have the ppe and testing they need to cases. In arizona assisted living facilities still report they dont have adequate ppe. This is 15 weeks after not allowing families to visit and this is unacceptable. Testing is also not available or happening in many Nursing Homes and longterm care facilities. In arizona Skilled Nursing facilities have done one round of tests of staff and residents and do not plan to do any more preventative testing. Assisted living facilities have yet to do even one round of testing. This is outrageous. The only way to truly protect residents and staff, health and safety, is to have regular testing in accordance with the cdc guidelines. Two, there must be adequate staffing to provide necessary care and longterm care ombudsman must be allowed to visit in person. Many of these facilities struggled can staffing before the pandemic. Ombudsmen play an Important Role voekting for residents and families but are currently unable to conduct inperson visits. We urge this restriction to be lifted. Three, care facilities must report publicly on a daily basis if they have confirmed covid19 cases. Residents and family need information. The Community Need information. When there are discharges and trance fers. Aarp long called for increased transparency in longterm care facilities and appreciate seeing the action that takes steps toward more transparency, however more must be don, more. Reporting is still not happening consistently, and reporting generally does not include demographic data. We need oversight accountability, as billions of taxpayer dollars are distributed to Nursing Homes. We urge congress to establish guardrails and transparency to ensure such funds are used for testing, ppe, staffing, virtual visitation, and other items that directly relate to resident care, wellbeing, prevention, and treatment. Four, virtual representation must be made available and facilitated regularly between residents and their families. Congress must require virtual visitation using readily Available Technology like were using right now. We also urge congress to provide funding for technology, equipment, and support for virtual visits. Thats why aarp supports the bipartisan access act. Five, proposals to grant blanet immunity related to covid19 for longterm care facilities must be rejected. The pandemic has put residents health, safety, and quality of care at unprecedented risk. We know that staff in many longterm care facilities are doing heroic work. Putting their health on the line for others. But sadly, many families who have contacted us have loved ones who were not treated with the compassion or dignity they deserve. Aarp strongly urges congress to protect the safety of residents including by maintaining their rights of residents and their families to seek legal redress to hold facilities accountable when residents are harmed, neglected, or abused. Litigation is an option of last resort. At this time of limited oversight and accountability and horrific death tolls, congress should not strip away the rights and protections of residents. Families nationwide are looking to congress and the administration for swift action to protect the health and safety of their loved ones in longterm care facilities. Thank you, and im happy to answer any questions. Thank you so much. Thank you for allowing me to come together and share our unique perspective. We are a 25bed critical access hospital that also has 120bed Skilled Nursing facility attached so were a little bit digit situation than some of the stories youve heard here today. And actually our situation is a little different being in new york, too, than some of the things ive heard here today. I did want to let you know about the hardships were facing here. So being in a nursing home administrating position, the changing regulations have been difficult for us to keep up with. The regulations have been changing constantly and with a limited number of staff and resources to be able to implement those changes, it is difficult to comply with them. The penalties for noncompliance in new york state equal a misdemeanor or loss of your operating certificate or for a misdemeanor would mean loss of your ability your career, basically, in the future. And so the other thing that happened here on march 25th, 2020, Governor Cuomo and the new York State Department of health issued an executive order that prohibited Nursing Homes from denying patients admission or readmission to a nursing home based on the confirmed covidpositive diagnosis. We were very thankful and lucky here to be part of a health system, part of cuba health system, we partner with cuba Medical Center. We knew from the beginning that could have a devastating impact on our nursing home. We worked together in order to ensure wed actually never admit a covid19 patient in our nursing home and think this is something that actually could be regionalized in new york state and possibly other states as well. So we worked together to ensure that our any covid19 patient that was positive that came to our facility was actually transferred to cuba Medical Center. If they were going to be admitted to a nursing home, we kept them in a swing bed stay to confirm they were not Covid Patients. Im happy to say, as of today we have not had a positive covid case in our nursing home. Another issue weve faced thats been talked about already here is staffing. Even prior to covid19, we had a nationwide shortage of registered nurses as well as cnas. Pay is part of the reason that we talk about that, but that weve had to reassign those Critical Resources we have to other duties. Rns have been reassigned to swab staff. Cnas have been reassigned to man tables, screen people as day come into our facility. ÷dh÷ this leaves residents with less facetoface time with caregivers who provide services to them and could lead to quality issues in other Nursing Homes are Staffing Levels are not as adequate as ours are. Resident quality of life is another issue that has been faced here and although we do understand the need for the measures that have been put in place, such as swabbing staff, on a weekly basis, we would respectfully request that perhaps metrics be developed to allow visitation in some Nursing Homes such as our county where we have only had 14 cases of covid to date. And do not have any active cases in our county today. Because this puts the no socialization rules that have been put in place by executive order here are causing our residents to face anxiety and depression. I round in the nursing home regular ly and i have one of th residents grab my arm and say to me, can this last forever . Can i really not see my family again . These family are just distraught. We need to Work Together to find a way to work with administration and the department of health to figure out how we can allow safe visits in our Nursing Homes. Reimbursement is the last issue that i wanted to talk about here. I am happy that we do have staff testing in our facility and that we are being able to detect people that have covid in our hospital. But there is a cost and a price tag that comes along with that. So for us, it is 100 for the processing of each covid test that we send to be processed. That does not include the ppe cost. That does not include the courier cost. That is costing our facility 28,500 a week. That is 114,000 a month. Or if you did this for a full year, that would be 1. 4 million. Nursing homes run on very thin margins which is why we have such staffing needs because we cant afford to pay somebody like our competitor, like target does, so its hard to retain those staff providing such an important an Important Service but its also hard. Its not easy work. And so we do need fair wages for those people and in order to do that, we need to see increases in the rates that we receive. We have received i do want to be fair, we have received some ppe testing. Ppe, limited testing supplies from our state, but we have received no funding directly for the testing regulation that have been imposed upon us. So i do want to reiterate that we are lucky that we have not faced some of the challenges that others have talked about here today. And we do want to provide a safe, caring environment and we do want to comply with the regulations that have been put upon us, but i did want you to understand some of the other challenge s that we do face in our roles in caring for these the vulnerable population directly. Thank you for your time. Thuank you for your insightfl testimony. Without objection, each member will be recognized for five minutes to question our witnesses. Well do it in seniority, switching back and forth between majority and minority members. Members are reminded to unmute yourself when youre recognized for your five minutes. And to, particularly important to direct your question to a specific witness so that witness can unmute and respond. I will begin by recognizing myself and direct my first questions to dr. Gwabowski. Doctor, would you describe what the effect has been of having a fragmented approach where the Trump Administration really relinquished its responsibilities and told the governors to go out and compete to get the ppe that they needed . Yeah, its been a little bit like a game of hot potato. The federal government took that responsibility and pushed it out to the states. The states in turn pushed it to the Nursing Homes. To one has owned this issue. 1pg the federal government, to their credit, did say we would provide two weeks of personal protective equipment to every nursing home in the country. However, as was already stated, many Nursing Homes are still waiting on that ppe and many other Nursing Homes thatpmhb received ppe that isnt even usable. So i would say that the federal government has not taken care of this issue around personal protective equipment. We should nationalize the supply chain. We should need ppe available to all u. S. Nursing homes. Thank you. Its my understanding that cms has created an Oversight Commission and that their version of oversight was to hire a contractor which may want to do continued business with cms to select that commission. Is that correct . I so as you said when you introduced me, im on that cms commiscss et they did right. And i should note that im speaking for myself today. Of course. Not for and. And that commission, i understand, has had its first meeting. Have those meetings been open like our meeting today or have they been closed . Our first meeting was closed. Has there been any indication the commission will be open to the public . There hasnt been any indication the meetings will be public. Im pleased youre on it. You have an important view popo to convey. Looking for any reason why cms would be unwilling to participate todayns7t other tha unwillingness to defend its sorry record. There was a suggestion that they have their own Oversight Commission, but i can see that while that commission may make a contribution, its not the kind of public airing of concerns that we really need. And some of that, the best of that public airing, has come from investigative journalism. Without objection, i will make a part of our record the New York Times article about the removal and eviction of medicaid residents from Nursing Homes as well as a separate article concerning some of the problems with ppe and other staffing issues in austin by Margaret Nicholas of the austin chronic chronicle. Id like to ask you a little more about that. I must say, ive tried to follow activities in Nursing Homes for years. I was shocked to read that people are being evicted from Nursing Homes and placed in homeless shelters. As if we didnt have a big enough homeless problem. Placed there without anyone to help them with their medications and surroundings that may be unsafe for them. Have you seen this, yourself, and heard about this in california . Thank you, sir. Yes. This is a longstanding practice where facilities who have potentially residents theyve had for a long period of time that are homeless, that they feel they will attempt to discharge them to alternative care sites. Homeless shelters being one of them. A longstanding practice. Ombudsman receiving this in a language they upnderstood. However, thats not happening. It was exacerbated in california where we have a program to get individuals who are homeless into hotels. I saw Skilled Nursing facilities exploiting that project Room Key Program and discharging residents they did not want hoping no one would notice. And there is a requirement that they notify the ombudsmen when this happens but youve seen that not occur. Not occur, but it also changed. As ms. Gould said, theres been a drastic reduction in regulations everchanging thats very challenging to keep up and i think an attempt to try and sort of prevent hospital impaction, Skilled Nursing facilities, some regulations are waived. That being one of them. That is one that needs to be reinstated immediately. Between march, april and may the discharge notices we receivedxwy reduced by 50 going from approximately 6,500 to 3,000. Thats a significant reduction. I believe it indicates there are residents being discharged in appropriate care settings. During that period of timing have you had any means of communicating with people within your jurisdiction as ombudsman . Yes. My team members are particularly ingenio ingenious. We have used phone, we have used zoom, we use google hangout, we use facetime. For those residents who are able to connect that way, it is useful, but we know that there are so many who are not. And like the Family Member stated earlier, it has been many months without any contact. This has significant harm for residents and i think actually aids in their decline. So not having them there has an impact in terms of social contact with a loved one, but does it also have an effect on the quality of care that they are likely receiving in some of our Nursing Homes . Absolutely. Not only do Family Members aid in care and know their individual and help provide assistance, but they also are on the lookout, and without eyes and ears in the facility, no one knows what is happening. And while i believe many facilities are . ui doing their , i think there are some thatbu[ be using this time and not providing the best of care and residents are unable to speak for themselves. Thank you very much. Ms. Kennedy, why not grant these Nursing Homes immunity . Understand this has been a top priority of Mitch Mcconnell and some of the people, senator graham, everybody, immunity. Granting blanket immunity to Nursing Homes is just wrong. It stops residents from holding longtermcare facilities accountable for harm caused by substandard and dangerous care including care that results in a residents death. And many nursing facilities had safety violations before the pandemic. And according to o recent study office, eight out of ten Nursing Homes were giving citations for not following even basic Infection Control practices. So, many facilities were not staffed adequately before this pandemic leading to devastating ulcers and worse. Lastly, ms. Edelman, you have made reference in your testimony to the possibility of establishing a medical loss ratio for Nursing Homes. How would that work and what benefit would have . Thank you, congressman. Oh, i think we lost you again, ms. Edelman. Sorry. There you are. This is a very important issue to make sure facilities actually spend a designated portion of the reimbursement medicaid on actual care for residents. There isnt any obligation now that they spend the care spend the money on care, even know thats what t though thats what the expectation is. We do have experience with this kind of requirement. The Affordable Care act. Must spend a designated portion of their money, care for their plan participants. We think that would also be very useful in Nursing Homes. Okay. Thank you. Thank you very much. Mr. Nunes. Thank you, mr. Chairman. I want to yield my time to mr. Reed whos been really focused, laser focused on this issue, doing a lot for the state of new york. So i want to yield my time to him if thats okay. Surely. I thank mr. Nunes for yielding his time to me. As indicated, this has been a priority of our office since the beginning of this crisis. The nursing home situation. And i will just tell you, what we really need to be focusing on today is there needs to be accountability for the and leadership and action for the past mistakes that happened during the course of the pandemic crisis. Most importantly, as we move forward, we must protect the loss of life from occurring in the future like weve seen, in particular, in new york state. Since this virus first hit our shores, we have known our nations parents and grandparents were particularly at risk. While many states, 45, in fact, mr. Chairman, chose to follow cdc guidance, cms guidance, regarding nursing home 0 directly exposed the elderly to covid19 and placed our most vulnerable population in harms way. Governor andrew cuomo in my home state of new york enacted a series of disastrous policies that directly led to thousands of our states parents and grand pare grandparents. We know this virus is not going away any time soon. If were to ensure our nations parents and grandparents are protected Going Forward, we need to fully understand why Governor Cuomo and the four other governors ordered covid19positive seniors to be forced into Nursing Homes, exposing the entire nursing home population and staff to death. Mr. Chairman, im asking this is a copy of the march 25th executive order from Governor Cuomo, which i ask unanimous consent be included in the record. Thank you. I assume thats a yes. I didnt hear you, mr. Chairman. It was muted. Yes, sir. Its without objection. Thank you. I find it particularly important because as you indicated in your opening remarks, mr. Chairman, transparency is important and this order has been deleted from the public records on the internet for the state of new york. I want to also note, mr. Chairman, immediately after Governor Cuomo imposed this order to force covid19positive patients into Nursing Homes, the society for longterm care sent a direct written letter warning to the governor, and i quote, the mandate was overreaching, not consistent with science, and beyond all, not in the least consistent with Patient Safety principles. And particularly indicated that the order caused significant risk of fatality to nursing home patients. Awould also like to seek unanimous consent to enter into the record, march 26th, the day after without objection. Thank you, mr. Chairman. Instead of working together with us, the medical community and advocates on solutions, Governor Cuomo is focusing on lying to the American Public as evidenced by independent Fact Checkers who ruled the governor did not follow federal guidelines even though he said it was the fault of the Trump Administration. Even now he continues to refuse to take responsibility for the states errors. It is offensive to those who have lost a parent or a grandparent and who just want answers like myself. Our investigation in this committee should serve as the foundation of future nursing home policies and decisionmaking. The results should be a comprehensive strategy, mr. Chairman, to keep our nations parents and grandparents safe from what i fear will be a return to a crisis level of nursing home deaths in the fall as the virus potentially reemerges. Congress must ensure that state leaders follow the proper best practices tailored to meet the specific needs of the community moving forward. We should be fighting for people like donna who reached out from our district to our office who recently shared her story with us after failing to hear from a single new york official in response to her plea for help. She is extremely concerned about her dear aunt rita who has been isolated and unable to interact with her family for months. And as donna said, im pleading with you to address this. We cannot have a onesizefitsall approach. We need someone who cares enough to speak up for those who cant. We should also stand with doreen from our district whos been unable to see her 95yearold mother for weeks and has described the whole situation as a nightmare for the family. The American People need our help, and they are relying on us to act because they have lost faith in their states confidence and ability to roll up their sleeves and put a plan of action in place. I join with the witnesses here today that say we owe it to our parents and grandparents to do better. Mor we shall not cast blame, we should demand justice, ction demand justice, that makes sure that tens of thousands of seniors do not face death sentence that they faced in new york state in regards to the march 25th order sending covid19positive seniors into Nursing Homes without any scientific or data to support such an egregious policy decision during the course of f1 osion during the course of and with that thank you, mr. Reed. Thank you very much. Mr. Thompson. Thank you, mr. Chairman. Thank you to our excellent witnesses that are with us today. My condolences to mrs. Saderwhite for the loss of her brother. I want to thank, in particular, nico Nicole Howell whose work in my district in Contra Costa County has been incredibly important. Thank you for all that you and your team are doing. This is an important hearing. A tragic one, mr. Chairman, but its an important one. Covid19 has ravaged every part of our society but nowhere has it hit harder than in our Nursing Homes. And its been exacerbated as pointed out by mr. Grabowski, ms. Kennedy, and ms. Gould by the fact Family Members arent allowed to visit their loved ones. And they are, themselves, ombudsmen for this industry and for the patients who are there. I have a woman in my district who quit a very lucrative job and took a job in a Skilled Nursing facility so she could be close to her parents to be able to watch over them. So this is really an important issue. As ms. Howell notes, Contra Costa County had 18 deaths last week. 16 of them were in Nursing Homes. My conversations with local Public Health officials and nursing home operators, themselves, few things have become clear. First, theres still not enough ppes. Second, once covid appears in a nursing home, its basically impossible to stop. And third, wages for nursing home employees are way too low. Fourth, the measures required to contain and mitigate covid in Nursing Homes are too expensive for many Nursing Homes to implement. They need our help. Id like to ask ms. Howell a question. You recommended in your testimony that Nursing Homes and longterm care facilities increase wages for employees. And in my district and other places cant hear. Can you hear . No, im sorry, you cut out for a second. Okay. The low wages as exacerbated the problem because employees have to work in two or three different places. Two different Skilled Nursing facilities or Nursing Homes. They so bring in the infection and spread it in their many places of work. So can you talk a little bit about that and how important this is . Thank you, sir. I appreciate that. no raised what is the critical issue which, again, is the gasoline to covid19s match. I want to say i dont think this is just a byproduct. I think its part of the system is designed is the way longterm care pays for its employees at the lowest possible rate and the same time says we cant receive, get staff. You have to pay appropriately for what youre trying to get which is someone whos been trained, has received appropriate training and personcentered models of care, lgbtq issues, as well as others and effectively recruit staff. So when we have Staff Members that are working at multiple facilities that we know where there are active infections, we cannot be surprised when the disease spreads. I submit to you that you as a congress did provide additional compensation and did encourage facilities to use that for staffing members but that has not been done. It may have been done on a modest level, maybe 1 more an hour, but that does not significantly compensate for the risks that they are taking. So i understand when Staff Members are saying, no, i will not come to work. Thank you very much. I also have a ppe question and i think dr. Grabowski is probably the one that i should direct it to. I still have Skilled Nursing facilities who are trying to track down ppe material and equipment and this is this is like way too long into the process for this to be happening. Dr. Grabowski, did the Trump Administration implement a clear, comprehensive, plan for distributing ppe . Thanks for that question. No, they didnt. We really should have nationalized the acquisition of ppe from the beginning of this pandemic. Unfortunately, Nursing Homes and other longterm care providers were left at the back of the line. So hospitals and other systems were bidding up the price of ppe and Nursing Homes just simply couldnt afford it, so its not enough to simply give them the dollars to purchase this. We actually in some cases need to help them acquire the ppe because they just cant afford it at the going going rates. So we could be doing a lot more and, unfortunately, the administration didnt kind of connect the dots there in terms of providing the resources and getting the ppe to the Nursing Homes and protecting our ca caregivecar caregiv caregivers. Thank you very much. I yield back, mr. Chairman. Mr. Buchanan. Verne . Can you hear me now . Yes. Go right ahead. Thank you, mr. Chairman, for this critical important hearing today. I appreciate all our witnesses. Very thoughtful. Im in florida and we talked about the amount of deaths across the country for seniors. Nationally 50 , or 40 , as someone said. In our region, the deaths weve had, its been 85 seniors so its a huge, huge issue. I have the seventh oldest district in the country, so im very sensitive about these issues. The seniors, many of them in thursd Nursing Homes and other facilities, have been lock ted down for three months. The impact is enormous in terms of mental health. As we look forward i assume we might have another package id like to think that congress is going to do more in this space in terms of mental health. Mrs. Gould, is that your thought . What more should we do in this space to be more helpful Going Forward . Thank you. So, this is a complicated question. I think it depends on your geography and whats happening in your area and i dont think theres a one size fits all. In new york state what weve been doing for phasing of reopening is designating a set of metrics and criteria to determine if its safe to have visitation. So i think if thats something you could do, possibly in the summer months maybe have it outside, i think theres a lot of things that could be thought about. We have tried utilizing the telemedicine option or the tele, you know, telecommunication. We actually purchased ipads for our residents. But the facts are that a lot of them are not even with assistance, theyre not able to use them. They dont really understand what is happening in that space because its different than what theyve experienced in their life. And so i thing its going to take a group of people coming together and coming up with common sense metrics and, you know, working together as a team but also looking at whats happening in your region because whats happening here is not the same of whats happening in stork citnew york city. I think thats important to remember. Thanks for that comment, and let me just say in terms of i want to talk to mrs. Kennedy and get her thoughts. I mean, the focus is on Nursing Homes, primarily, but we do have a lot all our states, especially florida assisted living facilities, memory care facilities, continuing care retirement communities. So as we look toward ppe, making sure they have the proper resources along with Nursing Homes, whats your thought . You know, theres 65 members i think that have signed on to a letter including myself and asked the secretary of hhs, 175 billion for ppe dollars, but we want to make sure these dollars are also going to these other facilities that are critical to florida and im sure a lot of digit pa different parts across the country. Id like to get your thoughts on that, mrs. Kennedy. Thank you, chairman doggett, and representative buchanan. In arizona when i talked to the assisted living facilities, theyre not getting p per intin. Theyre not securing it. Skilled nursing facilities were able to but will run out. 30 days that they had it. Really prioritizing your funding to make sure that at the very beginning these facilities are getting adequate ppe. Its just essential to being able to stop the spread. What about, you know, in terms of assisted livings and memory care, do you think it seems like theyre getting a token amount, seems like they need some additional dollars. Is that what youre saying . Absolutely. Thats exactly what ive been saying. Level, if theyre getting resources, are there guardrails to make sure that those resources are being spent where they should be spent . This should have been the very numberone priority is ppe and testing in our, all longterm care facilities, not just here we go. Yeah, mr. Chairman, can you hear me . I can, but i cant hear the witness. Okay. Lets see if she well go ahead, vern. Can you hear me . Okay. Yeah. I think i i think i had some connectivity problems. I dont know what you heard or what you didnt hear. You want to repeat so he gets his full answer . Yes. I mean, you asked regarding the distribution of ppe to assisted living facilities. I think that is an extremely major priority and, you know, the Skilled Nursing facilities are getting some resources but the assisted living facilities because theyre not regulated under cms, theyre getting left out. And we have 147 Skilled Nursing facilities in arizona and we have over 2,200 assisted living facilities. So theyre not getting what they need so, therefore, the spread is just immense. Thats why our numbers are so high. Yeah. So, again, thank you, mr. Chairman. I yield back. Thank you very much. M mr. Blumenaur. Will you unmute, earl . Still cant hear you there. There you go. No, we lost you again. Youre on. Okay. Sorry for the im sure a show of hands would probably recommend staying on mute and being able to collect peoples thoughts and get caught up. Mr. Chairman, i really appreciate the hearing you put together. I appreciate you and chairman neil have a long abiding interest in this. I find the more we get into this, the more unsettling i find it. Number one, it appears as though that the federal responsibility for resources that we provide and for a function where we ostensibly have some oversight, have some legislative and policy guardrails, it appears as though the Trump Administrations in the process of weakening them and the circumstances where there is virtually no oversight, in part, there are challenges in the midst of the covid19, but given the challenges, and given what the administration has done, i find this extraordinarily disconcerting. I wuonder, first of all, if our witnesses, dr. Grabowski, perhaps you have a sense on this or ms. Edelman, in terms of having some standards, you mentioned having some requirements that the resources are actually provided from the federal government resource, provided on actual care. If there is some standard that you would recommend, i see the data that suggests the facilities that have been taken over by private equity institutions that are very good at engineering financially appear to not be very good in terms of providing care. Is there an area here where we should have a special degree of standard that is imposed that you can outline in some specificity . Yeah. How about i start and then ms. Edelman can pick up after me. So i very much believe that we need to put more resources into this sector but those resources dont need to go to private equity. They dont need to go to ceo salaries. They need to go to the workforce. So i really like what ms. Edelman described earlier about a medical loss ratio. Thats one approach.  appro previously is using wage youre putting medicaid dollars directly into direct care staff. Directly into wages. So i would very much encourage the congress to earmark those dollars for . iq staffing. Thats where the money needs to go. Not to the private equity groups. Not to the ceo salaries. We want to make certain this gets to our caregivers. Thanks. I dont know if ms. Edelman has other thoughts. I think you provided part of the framework that i want in terms of where the money goes to a specific purpose. It appears that we are also still shy in terms of providing the necessary protective equipment and theres a serious problem of testing. Do you or ms. Edelman have ms. Howell a sense of what we should be doing in terms of mandating these key functions of testing and and the necessary equipment . Just do it directly . This is toby edelman. I think we do need to have a mandate for testing and we need to make sure the tests are done on all residents. We know from the kirkland facility when everybody was tested in that facility, the majority of residents who tested positive for covid19 had no symptoms at all. They dont have high temperatures. They dont have coughs or other respiratory symptoms. So it is essential that we test all residents them we can target protective equipment where its most needed, not just sending it randomly around. The other point thank you. I want to make is that i just want to conclude here because my time is almost up. Okay. Mr. Chairman, i think that is very, very important. That we put the resources there. We have 2. 5 Million People who go in and out of who are in these facilities either working or as residents and thats before we restate the opportunities for families to visit. I hope we can bulk up the support for testing and put the resources directly where we want it. And not let it leech out. But its on the ground where people need it. Appreciate it, mr. Blumenauer. Mr. Smith. Thank you, mr. Chairman. Thank you to all of our witnesses. This hearing topic is very timely. I want to begin by saluting workers on the front lines of health care, especially those in Nursing Homes and facilities housing our elderly, seniors, that are, unfortunately, so exposed to covid. And i think we are were learning a lot. You know, were compiling data and i hope that we can use that instructively looking and moving forward. I know that the hardships placed upon families and seniors, themselv themselv themselves, are many, as has been mentioned already here. I know, though, the Emotional Distress, i hope does not actually outweigh or overcome even the or that the impact of the Emotional Distress i hope is not worse than the covid, itself. And so as we do sort through aco of the data and information moving forward, i know that video applications have been helpful, certainly they do not replace the family interaction and so forth, but im glad that video and telemedicine can be, i think, part of our answer in treating patients in place. I know ive been working for some time now on what we call the rush act. Reducing unnecessary senior hospitalizations act wrihich wod expand the usage of telehealth in facilities with the goal of treating seniors in place so we can reduce the risks facing seniors and also improve outcomes. So in addition to new technologies, i know that we here in congress on both sides of the aisle work with the president to quickly allocate resources to the areas hardest hit by covid and in the pandemic and interventions that were vital to protecting our seniors and slowing the spread of the disease. One of those actions involved the creation of the Provider Relief Fund thats been mentioned here earlier today. It distributed billions in aid to providers throughout our Health Care System including nearly 5 billion to Skilled Nursing facilities. As the remaining funds are dispersed, i think its important to note i believe that the assisted living facilities should be helped with these funds. They have been facing a huge burden because of the pandemic and certainly the scope of bther care is very important during this pandemic and even beyond. Ir so the challenges posed by covid19 require significant expansions in the use of telehealth, especially for seniors and vulnerable populations. Because of the highly infectious nature of the disease that has included a new emphasis on treating vulnerable patients in place when possible rather than transporting them to a hospital or clinic, i was wondering what lessons weve learned so hard regarding telehealth and treatinplace initiatives that can continue to be an assetmiai covid crisis and beyond. How important will telehealth be for nursing facilities and seniors after the pandemic subsides . Mrs. Gould, would you like to start with that question . Mr. Chairman, i think you are still on mute. Im very sorry about that. I wanted to say that, yes, this is actually something that we actually implemented. We stood up and implemented during the covid crisis. Medicine was currently in our primary care centers as well as our field nursing facility. And it is a great option to protect the residents but also make it convenient for them so that they dont have to leave their space and i think that its going to be here to stay. I think were going to see this long into the future. I think it serves a great place for residents and for people who visit clinics, the like. I think telemedicine is going to be invaluable. Yeah. And, i mean, obviously, this video interactions to treat someone medically is far different than Human Interaction with families. Yeah. How much longer do you think we can do basically excluding Family Support from the human presence that is that is absolutely vital . So, my dad suffered with chronic pain from Rheumatoid Arthritis for many years. One of the things he always talks about is quality of life. When you cant do things anymore how difficult it is to enjoy life. What im seeing in our residents when i walk down there and the conversations that im having with them is that they are feeling this very much right now. To have someone, you know, grab my arm and express to me how they need to see their family is incredible, and we were trying to do the telehealth visits and some of the residents have actually had the Family Members have decided they dont want to do the televisits with them because it makes the resident more agitated. Theyre actually more upset that they cant actually see their Family Member. So were trying to do something good, but were finding that sometimes the reaction is actually adverse. And so i think its resident dependent, but i think the sooner we can make common sense approaches to be able to bring people into the Nursing Homes, the be better but we need to do in a safe way so no ones loved one is infected, or worse, fatal from that type of visitation. Right. Its taking a huge toll on the residents. Yes. Thank you. Uhhuh. Mr. Chairman, i couldnt hear you. Go ahead. I believe your time is expired. And calling on mr. Higgins. Thank you for your questions and for the comments. Thank you. Thank you very much, mr. Chairman. As we all know, there are 120,000 americans dead from covid19. Theres no treatment. Theres no vaccine. Despite the that our nations s our nations third coronavirus outbreak in nearly two decades. The federal government failed to protect its people. The United States government response to covid19 was late, sloppy, and adversarial, and in the absence of strong federal response, the nation looked to new york and its governor, andrew cuomo. The nation looked to new york because Governor Cuomos response to covid19 was early, strong, and unified. Nursing homes and longterm care facilities are most vulnerable to covid19 because most of the people that live there have preexisting conditions. During this pandemic, the president is trying to kill the only law that protects people with preexisting conditions. Now, let me turn to the states in nursing home deaths. Nationally, onethird or a little over 33 of all covid19 deaths are in Nursing Homes and workers who work in those Nursing Homes. In north carolina, it was 63 . In new hampshire, its 77 . In minnesota, its 81 . In new york, its 20 . 13 lower than the national average, 43 lower than north carolina, 57 lower than new hampshire, and 61 lower than minnesota. Dr. Grabowski, can you speak to new york states response and its effectiveness relative to covid19 versus or compared to the federal governments response. Yeah, so, to answer that question really supports this idea that as you just described, the rates in these different states is really reflective of whats happening in the Community Around them. So, as we look at new york and we look at other states, communities in new york where we saw really big outbreaks in Nursing Homes, there were similar outbreaks in the communities around those Nursing Homes where the staff lived, so its really about where the staff lived bringing it into the Nursing Homes, and so i dont as i said in my opening remarks, i dont point fingers at new york state. Not every decision the state made was great, but on the other hand, the onus for this nonresponse on the part of our government really lives with the federal government. Yeah, dr. Grabowski, let me ask you this. Do you believe that there will be a vaccine by the end of this year . I think were putting a lot of eggs in that basket. Id rather put those eggs in ppe and testing. You know, i dont want to speculate about a vaccine but i know we can invest with certainty in protecting our nursing home residents so i think its highly uncertain whether there will be a vaccine, but we can know with certainty whether our staff and our residents are protected. Do you know how long it took to develop a vaccine in response to ebola . Probably a lot longer than a few months, i would imagine. It took five years. Typically, a vaccine is 10 to 15 years before its fully clinically trialed for both safety and efficacy and then scaled to the number that is needed to deal with a pandemic, which, you know, means all of us. Were all in this. Let me also ask you this. Had the federal government invested back when the coronavirus, in 2003, was declared to be the cause of Severe Acute Respiratory Syndrome 17 years ago, had we made an investment in the development of a vaccine, would we have a vaccine that could be that could be developed much earlier because of the base basic science that we would have relative to a new break outbreak of the coronavirus . I think its fair to say behind on our response with covid for a long time, and you know, often further than i do, but i would go back to even when it was we were seeing these outbreaks in asia and europe, we werent making any steps to protect our Nursing Homes. We saw kirkland. We still werent making steps to protect other Nursing Homes. Its now june. Have we really put the protections in place for our Nursing Homes and individuals that live and work there . I dont think so. So, youre right. This has been a long standing problem, but even over the last four to five months, we havent been ahead of this. Thank you very much, sir. Thank you, mr. Higgins, and mr. Higgins, just to make our record complete with reference to a point you made earlier, without objection, ill make a part of the record a map, a chart that is prepared by the ways and means democratic staff, the share of Skilled Nursing facilities, covid19 deaths as a share of total covid19 deaths actually, im afraid that my home state of texas was about twice as worse as new york. We had 43 of the share of deaths in the state were in skilled Nursing Homes, and new york was at 20 . So, i offer that into the record along with an explanation of it. And with that, and ready for comment further on new york, im sure, i would call on mr. Reed on his own time thank you, mr. Chairman. Dr. Grabowski, let me just cut to the chase. Are you advocating as an expert in this field that covid19 positive seniors should be ordered to go into nursing home facilities like the march 25th order of new york state . No, ive been pretty clear, congressman, on that issue, that i think that was a mistake. But i did want to clarify a couple things. I appreciate that. No i appreciate acknowledging a mistake. Has the governor ever cuomo ever acknowledged or the four other governors ever acknowledged that was a mistake to your knowledge . To my knowledge, no, he has explained it was consistent with cms guidance. So youre also misrepresenting the fact on that issue, that the independent Fact Checkers indicated was mostly false if youre aware of that, correct . So they cms was at fault for this . The cms guidance was pretty clear on that from march 13th and i can read from it. Nursing homes should admit individuals they would normally admit to their facility, including individuals from hospitals where to case of covid19 was is present. Now, was it a good policy . I just said no, i think it was a mistake, but was it i appreciate you acknowledging it. Trying to sugar coat d dr. Grabowski, to try to sugar coat the 6,300 deaths that happened in new york and i think that number, in my personal opinion, is twice that, to somehow say because were going to play with percentages that we did a great job in new york is appalling to me. Its offensive to me. Its offensive to those 10,000plus seniors and their families that died as a result of that order in my humble opinion that were trying to sugar coat and whitewash this conclusion. And so, i want to get to the order itself, because its critical to me that we understand why that happened. Because we have been demanding answers on this question and the four other governors and our whip is doing it at the National Level so ms. Gould, you lived this. You were on our daily hospital calls. You and i were talking every day for seven days a week during this crisis. With the march 25th order from new york state was issued, had you or any of your colleagues in the Health Networks that you represent that you work with, that you talk with, that we had on our calls on a daily basis, were you in any way consulted in regards to the issuance of that march 25th order that sent 6,300 seniors to their death in our Nursing Homes in new york . No, i was not. And when you heard about that order that came out, it appears you took unilateral good faith action because your expertise said, we shouldnt follow that rule, i believe, in your opening testimony, you referenced how your hospital worked with other hospitals to protect those seniors as a result of that situation. So, when you got that order, how did you respond to it . So, we had actually talked about this before the order had came out. We were actually prepared for what we were going to do if someone came to our facility with a covid19 patient. Like i said, we becky, youre breaking up there. I think were having some technical difficulty, mr. Chairman. I believe we are. Can you hear me now . Can you hear me now . Yes, go ahead, ms. Gould. Im sorry about that. We had made a decision that the best place to care for those types of patients, covid19 patients, would be at the larger Hospital Medical center and we also knew that by bringing any covid19 patient into even our hospital would be risky because we have so many shared service departments, so people who work in dietary also work in the nursing home, people who work in housekeeping also work in the nursing home. So we had decided right off the bat that we were going to have a different strategy and try to keep covid19 patients out of our facilities so they would not infect our nursing home patients. And why was that, becky . Why were you so concerned about having that covid19 come into your nursing home facility . I think it was all of the early reports about the people that were on the cruise ship who had all contracted the virus, and so we were very concerned about the layout of a nursing home. So, nursing home layout is very institutionallike, kind of like classrooms that you would see in a high school. And so, it would be very difficult. You have one cna who is in charge of three to five residents at a time, and when people are already low staffed, its hard for them to use proper ppe techniques to make sure theyre adhering to Infection Control, and we just felt like it was too risky. And as you did that analysis, what im hearing you testify to, that you were really trying to separate out separate facilities because you just could not manage the covid19 population in a situation where there are negative patients who are Senior Citizens that are highly susceptible to this, so you were concerned about the location of all of this in one location, were you not . That is true, and we also felt that the best care for covid patient would be at the Medical Center for their care as well but also to protect the nursing home residents. And why was that, because of the expertise in the Medical Center that they have . Yes. And so, Going Forward, if i am surmising your testimony accurately, one of the recommendations im hearing from your reallife experience is that we should make sure that when the virus comes back, that we get the seniors isolated in separate facilities and that we get our parents and grandparents the best care that they possibly can by the medical facilities that can deliver that care to them or that those personnel, is that fair input . Yes, i think it would be wise for us to make Regional Networks where we can actually have the Covid Patients taken care of in the proper setting and try to keep them out of the Nursing Homes if possible. And would you recommend ever that we consider an executive order like march 25th directing covid19 positive parents and grandparents to be forced to go into a nursing home . Would you ever support an order like that ever again . I would not, and i dont believe Governor Cuomo would either. Okay. And i would hope he doesnt, but as he indicated to the today show and National Press that he felt your time has expired. Correct order then and correct order now Going Forward. Thank you, mr. Chairman. Thank you. Ms. Sewell. Ms. Sewell . Well, we either have technical difficulties there or some problem. Let me call ms. Chu and well come back to ms. Sewell. Well, thank you. The covid19 pandemic is far from over and nowhere is that more evident than in my home state of california where cases have jumped nearly 70 in 2 days. Los angeles county, where my district lies, is a hot spot with 41 of all the new cases in the last two weeks. Despite making up only a quarter of the states population. And that means that the nursing home residents in my district are facing an especially high risk at this moment as cases climb in the Community Around them. And what is really disturbing is that so much of its related to staffing. An upcoming study from the university of california San Francisco has shown theres a direct correlation between nursing home Staffing Levels and the likelihood of covid19 infections. This study found that Nursing Homes with total nursing Staffing Levels under the recommended minimum were twice as likely to have residents with covid19 compared with those that met or exceeded minimum nursing Staffing Levels. So, i was horrified by the conditions that you described. I cannot believe that there would be such a lack of ppe and lack of information on who had covid19 in the facility, and i would like to ask you, what are the practical issues that arise when a nursing home does not have sufficient staff . Thank you, ms. Chu. What happens is the cnas on average, on a good day, if were staffed properly, they have anywhere from 9 to 10, 11 residents. When theyre short staffed, they can have up to 15, maybe 16. As the nurse on the floor, i can have up to 30. So, sometimes the acuity is not looked at, at these residents, because they may have their acuity. They may have to have two cnas sometimes, three Staff Members due to possibly behavior. There have been plenty of times where i have had to stop my own med path to help, regardless of maybe giving that resident a shower, helping that cna, give personal care, be in that room with that other staff member. Theres a lot of times we dont get a break. Theres times that we miss our lunches. Theres been many times where i have my normal hours are 7 00 to 3 00. Theres times ive left at 7 00 in the evening. Yeah. And thats what you describe is why i am an original cosponsor of the quality care for nursing home residents act of 2019 which would institute minimum staffing and care levels for Nursing Homes under medicare and medicaid. So, ms. Edelman, how has cms, under the Trump Administration, weakened the ability to enforce sufficient staffing for Nursing Homes, including during the covid19 pandemic, and why is it necessary for Nursing Homes to resume submitting staffing data through the payroll based journal system . What would be the downside to making the cms waivers related to staffing permanent . Thank you for that question. Its complicated and extremely important. The staffing information that is submitted by facilities now through the payroll based system are much more accurate than the information we had before when they were selfreported. And what theyve really shown is that there are very inadequate numbers of staff in facilities, particularly nights and weekends. But even so, the federal staffing standard is pretty minimal by itself. Its a requirement for one registered nurse, eight hours a day, eight consecutive hours a day. Otherwise, some licensed nurses around the clock, but sufficient staff and thats not a standard that is enforced. And so the if cms does not let us know how many staff were actually in the facilities, if they do not require facilities to give the payroll based data, we will never know how many staff were there. We will never know how many of the residents were assessed. We wont be able to figure out what went wrong and how to fix it. So, we need to have essential, Important Information and best to be accurate and comprehensive. I know dr. Grabowski had been concerned about the information that was released june 4th about the numbers of cases of covid and the numbers of deaths. Those numbers are also extremely inadequate and inaccurate. We need accurate information. Thank you for that. Appreciate it and i yield back. Thank you very much. Mr. Kelly. Mr. Kelly . Okay. Lets see. Mr. Holding. Thank you, mr. Chairman. As we all know, this virus has created unprecedented challenges to providing healthcare services. Elective procedures have been canceled and americans, especially Senior Citizens, have been cautioned to avoid hospitals and clinics as best as possible to create a major disruptions to the vital routine procedures and checkups. And as some of you, including my colleague, mr. Smith, from nebraska, have hit on today, these disruptions have forced us to rethink our providers can most effectively treat patients and has also spurred major innovations throughout the healthcare space and the institution of telehealth provisions especially has not only got vulnerable individuals safely out of waiting rooms but has expanded access for many of my rural constituents who otherwise face Major Barriers to basic care. Im proud to say that in north carolina, many healthcare stakeholders have already begun to embrace telehealth expansion and are working to improve its implementation. Blue cross blue shield north carolina, for example, has announced an extension of its expanded reimbursement policy for telehealth visits through the end of the year to continue collecting data for further improvements. Going forward, we must continue working to refine these services so that groups like Senior Citizens that rarely face access barriers can take full advantage of them. Likewise, i believe the immediate telehealth expansion during this emergency is vital to protect Nursing Homes which house our most vulnerable population. Rather than risk exposure to infected individuals, seniors in Nursing Homes should be able to receive an array of care of services virtually, which is why access act that provide Grant Funding to facilitate the development of telehealth capacities in Nursing Homes. So, ms. Gould, you spoke favorably about your experiences with telehealth and using it in your facilities. So i wonder if you could expand a little bit on that and tell us, you know, what are the barriers to you using telehealth even more in your facility. Tell us anything that you think that we could be helpful with in reducing those barriers, whether it be reimbursement rates or regulatory hurdles that you got to face for using telehealth. Id be interested in hearing your thoughts. Okay. Thats a good question. So, i think one thing you have to remember about telehealth is that the patient is not in front of you so it has to be used in the right setting, so depending on what the patient or resident is being seen for, it may not be appropriate for telehealth. Reimbursement is definitely an issue with telehealth. Can you guys hear me . My whole screen went blank there. Yep, we can hear you. Reimbursement is definitely a hurdle and has actually been a barrier for some to moving towards that, and i think that weve enjoyed the cms, thank you very much, has increased the reimbursement during this time. But i think that there are other tools. I think other people have more robust telehealth systems than what we probably have being a critical access hospital. You know, our pockets arent really deep and so i think having programs where you could buy additional tools to be able to do telemedicine more proficiently would be helpful. Right. Thank you very much. Mr. Chairman, i yield back. Thank you very much, mr. Holding. I will go back to ms. Sewell, and as is our ordinary practice at this point, in order to maintain balance, well go to two to one, so ill do ms. Sewell and mr. Evans and then go back if mr. Kellys available. If he is not, then to m devastating impact of covid pandemic on our Nursing Homes. Its become abundantly clear that we as policymakers along with cms, hhs, and other states must take responsibility for fixing our deficiencies so that our Nursing Homes are better equipped with what they need now and into the future. My Congressional District in alabama has been disproportionately impacted by the covid19 pandemic. While the 14 counties of my district make up 26 of the states population, we account for 40 of the states covid deaths. The pandemic has laid bare the historical inequities that exist in our Healthcare System for black americans. My constituency is painfully aware of the pervasive, systemic, and institutional influences that have contributed to their disparities. We have also seen studies, study after study, over our nations Nursing Homes are not immune to these trends. They are largely segregated, and Nursing Homes serve higher minority populations that serve higher minority populations are more likely to be overcrowded and to have lower quality ratings. Id like to thank our guests who have spoken so eloquently about the disparity the disparate impact this pandemic has had on communities of color, specifically the black community and the need for National Demographic data. We need this data. Its critically important. We know that too often, our covid deaths are concentrated in our Nursing Homes, and ive spoken with the nursing home administrators in my district in alabama, and its clear to me that too many of them are not equipped with the resources they need to stop the spread of the virus. They will continue to struggle if we do not provide more resources like those in the heroes act. I join representative pascal and panetta in addressing a letter, underlying the dire need for Nursing Homes to have support and guidance. It asks whether cms plans to study the relationship between race and Health Outcomes in Nursing Homes that have had covid19 outbreaks. As a representative to have a minority majority district in alabama, i cant stress enough how crimin critical it is to figure out why there are disparities and what these Nursing Homes can do better to protect our constituents. If cms doesnt have a plan to db so, i ask that we, mr. Chairman, must have the leadership from the congressional leaders in order to do something about it. Weve seen too many disparities and enough is enough. I think its critically important that we address it now. The heroes act includes a provision to direct hhs to allocate money for strike teams to help facilities manage these outbreaks, which i think is a good first step. Outside of collecting more data to underscore what we already know is true, that this pandemic has disproportionately impacted minority communities, what can we do or what recommendations would these witnesses provide congress to do about this health disparity, in particular, id like to ask mr. Grabowski if he would address the workforce side of this. Ive heard from too many of my nursing home administrators that staffing shortages are an issue and so, my question is, what recommendations would you make to address these workforce challenges as we continue to endure the covid19 pandemic . First to dr. Thank you. This is a great question about workforce shortages. Weve seen this around the country. We had this before covid but its been magnified. I would point towards several things that we can do. The first is upping the pay. Thats pretty obvious. We need to put more dollars in the pocket of those caregivers. Two, we need to make certain they have the right benefits, like sick leave and Health Insurance and life insurance, just making sure they have those benefits, and then third, we need to recruit new individuals into this workforce and then retain them and ive been advocating really strongly that we need to go out, we have lots of individuals right now that are unemployed, we need to match those unemployed individuals with jobs in Nursing Homes and get them trained and ready to work such that they can help out, because were going to see only more shortages as this pandemic continues. Would any other of the witnesses like to address the workforce challenges and recommendations that they could make to congress . This is toby edelman. I think we need to require specific staffing ratios in Nursing Homes. We have seen for 30 years now the standard of sufficient Nurse Staffing and its not enough. And what we see a lot is that nurse aides have not just 15 people but 20, 25 residents that theyre responsible for. And a typical problem that i have read about in cases is a resident who needs two people to be transferred and the aide is looking for another person but theres nobody around. The aide tries to transfer the resident from the bed to the wheelchair independently, all by herself, they both go down on the floor, the resident breaks a hip, the aide gets fired. Its considered her fault, although the reason she did it is there was nobody else around. We need more staff, and we need to mandate those staffing ratios and the professional staff, the registered nurses, to make sure that residents get the care they need and that theres enough staff to provide that care. Thank you, mr. Chairman. Thank you. Thank you, ms. Sewell. Mr. Evans. Thank you, mr. Chairman. Appreciate this opportunity. Dr. Grabowski, youre probably going to think that my good friend from alabama and i are tag teaming you, but i represent a district in philadelphia, and theres some commonality with what she was describing with what i want to also talk about. I wanted to talk about the issue of disparity with race and income when it comes to nursing home care or have you talk about it. And really the question is, as inaction at the federal level helped to deepen the disparities . Thats first and foremost. Secondly, doctor, with all of this discussions about safe openings, how exactly, particularly this Committee Conducted a hearing not too long ago and talked about how the virus was affecting people of color. Can you just take some time and talk about the issue of disparities of race and income in the nursing home areas . I know thats been a lot of discussion. And has the federal government added to the problem . Sure. Thank you for that question. So, we have had longstanding disparities in nursing home care in this country with Nursing Homes treating higher numbers of black residents having fewer resources and worse quality outcomes. And weve just seen that exacerbated under covid, and indeed, when we did research trying to determine which to have covid in the building, as i said earlier,mrx] it was largely about location and the size of the facilities, but the other factor that was predictive of having cases was your share of africanamerican residents, and thats because of, once again, location, and we know that blacks have been particularly hard hit by covid in the community and then thats led to staff bringing it into Nursing Homes, so this issue has been really critical right now, and i dont think this administration, by taking on covid, has really helped dampen these disparities. In fact, if anything, its magnified it. When you dont provide personal protective equipment, when you dont provide testing, the Nursing Homes that are least able to get those resources are going to be those lowest resource facilities. And so so in other words, no matter if its alabama or philadelphia, theres no huge difference there. Thats right. And if its in the community, its going to be in the nursing home, and we found that, youre right, in all sorts of states all around the country and all sorts of communities. Is there any specific kinds of strategies or do you have the ability to recommend things that you think need to happen . Absolutely. So, i would go back and i know we keep beating this drum, but its so important. Our secret weapon against covid is personal protective equipment. It sounds so simple. Its almost like weve had the answers to this test now for three months but we dont want to use them. We know what works. Lets get every nursing home in the country adequate ppe. Testing of staff and the residents is also a must, and we just talked about workforce support. I also think cohorting is very important and how do we keep when Nursing Homes have outbreaks, how do we keep covid positive residents separate from covid19 negative residents, thats really important as well, but you started at the most important thing, supporting our workforce and getting them ppe and testing. I thank you, mr. Chairman. Yield back the balance of my time. Thank you, mr. Evans. Ms. Bolarsky. Thank you, mr. Chairman, and thank you so much for allowing me to sit in on this incredible hearing. I appreciate your allowing me to come and be a part of it. Glad to have you. So, the pandemic has affected the whole world but theres no question its impact is felt more severely in some population than others. Nowhere is that more evident than in Nursing Homes and longterm care facilities. The foundation for research on equal opportunity estimates that make up only 0. 6 of the u. S. Population, they account for 43 of coronavirus deaths. Some put that percentage even higher. The u. S. Is not alone with its relatively small percentage of the population accounting for 49 of coronavirus deaths in sweden and 82 in canada. Its easy to see why there is such a challenge. Coronavirus spreads most easily indoors at close quarters and is deadliest among the elderly and those with underlying conditions. Nursing homes and longterm care facilities are at a perfect storm of the biggest risk factors and thus require a higher level of care. New York Governor Andrew Cuomo likened the spread of coronavirus in these facilities to, quote, fire through dry grass, which makes it all the more puzzling that his state forced Nursing Homes to admit patients who tested positive for coronavirus. This policy effectively ceded burning embers. New jersey, michigan, pennsylvania, connecticut, illinois produced some of these policies too with devastating effects. These seven states account for 60 of our nations nursing home deaths. According to a recent propublica article, michigan has lost about 5 of its total nursing home residents to coronavirus. In new jersey, that figure was a staggering 12 . By contrast, california has a forced transfer policy but reversed it in two days as it was able to limit its steps in Nursing Homes to 2 . Florida banned these transfers from the start and has lost 1. 6 of its nursing home residents. Regardless of the state, each and every one of these deaths is a tragedy, but its clear that some states mismanaged the response and ignored the warnings. These misguided policies deserve close scrutiny and the leaders who put them in place have a lot of tough questions to answer. Pennsylvanias Top Health Official took their mother out of a nursing home as she was state enforcing into nursing home to take these positive patients. Thats insane. Three days after michigan reported its first coronavirus case, the state Nursing Home Association recommended to governor fritsgretchen witmer t the state use empty facilities. That was ignored. Governor cuomo manipulated new york data to understate the true scope of the deaths and at every step tried to wish away any responsibility for thinks failure. Now is not the time to look the other way. Now is the time to look closely at the response and figure out what went wrong. Ms. Gould, i sit on the select subcommittee of the coronavirus crisis. A few weeks ago, the subcommittee held a briefing on the topic of coronavirus and Nursing Homes. Some of my colleagues contended that new yorks nursing home problem wasnt a result of forcing facilities to take positive patients. Since youre on the front lines, i want to know what you think. Do you think forcing facilities to take patients that tested positive for coronavirus did more to put patients and employees at risk than any other issues your facility has seen during this pandemic . So, i do think that forcing facilities to take covid positive patients is definitely risky. We did have plans to cohort patients as dr. Grabowski talked about. Lack of ppe is also a concern. But from my perspective, because covid is so low in our area, i think the biggest risk is somebody who works at a different facility actually bringing it into the facility. Doesnt know that they have it, is an asymptomatic carrier bringing it into the facility. I think governors cuomos order for all of us to wear face masks whenever were in the facility was a good order and i think it does help and it does prevent the spread. But i cannot agree that covid positive patient in a nursing home is a good idea. I appreciate that and i just want to throw this out really quickly. I know weve all talked about ppe today. In the state of indiana, so, many, many manufacturers are making domestic produced ppe inside of indiana. Our governor pulled x amount of percentage off those and for every Company Going back to work and opening up in the state of indiana, they were able to purchase through whats called the marketplace now, set up by the state of indiana from manufacturers in our state a lot of them in my district, that are running extra amount of ppe specifically for the Companies Inside of indiana and i would lend that model to any governor in this country who is trying to open up, thinking of opening up or hopefully would take this information, open up, and provide whats actually being produced inside the state into a marketplace for that state and for their employees w. That, mr. Chairman, again, thank you, and i yield back. Thank you. Ill be calling on mr. Scneider now, mr. Horsford, mr. Kelly, mr. Davis. I want to thank our witnesses for staying with us today. As youve all discussed, we have a National Crisis raging through our senior care facilities. Serious problems existed before covid, but as was eloquently set, this is the match that lit the gasoline. My home state of illinois, more than 50 of the covid related deaths have occurred in our Nursing Homes. Lake county, 47 different senior care facilities have reported an outbreak, totaling more than 1,500 positive cases and tragically 250 deaths. Lake county isnt even the hardest hit in illinois. Ive spoken to Nursing Homes and Public Health officials and the number one issue, the number two and number three barrier they cite for effective Infection Control is lack of adequate testing and ppe for patients and staff. The supply chain broke early in this crisis and remains broken today. According to a recent survey, more than 50 of senior care facilities have less than a weeks supply of masks and gowns and that number has only gotten marginally better over the last few weeks. The facilities that are able to get supplies are paying exorbitant prices. A gown that cost 31 cents can cost up to 17 and an n95 mask that cost 65 cents now costs upwards of 6. Thats 10 to 15 times the price and that increase is costing billions on a national scale. Worse, its costing lives for the people who cannot get the protection they need. Our administrations response has failed to meet the moment with tragic consequences. For instance, fema recently distributed care packages with the two week supply of ppe to 15,000 nursing facilities around the country. Its one issue that the administration celebrates, sending two weeks of critical supplies at a time when were in the middle of a monthlong pandemic, but its worse when those supplies arrive, theyre unusable, theyre not medical grade, theyre of no use. Staff described surgical gowns more like tarps than gowns and masks billed as n95s made of cloth. Both are useless in a medical environment. These issues arent new. I raise these concerns in february and march with secretaries azar and mnuchin. Our supply chains broke down early in the pandemic. If i can ask ms. Haschek, can you give us a brief description of how the supply chain has affected or the lack of access to ppe has affected your role. Thank you, mr. Schneider. We have had to you saw my testimony. We have had to i personally obtained my own ppe. There have been times where some of my coworkers were wearing ponchos just to cover themselves. Were wearing our n95 masks weeks and weeks at a time. We have to sign for them each time we get a mask. The residents, theyre starting to recently allow them to come out of their rooms to im considered a cleaning at this time. They need their masks, and theyre its just very frustrating and difficult because we have to fight with them. Staff members have gone to administration as far as where is the ppe . You know, where your were trying to protect ourselves. Were trying to protect our residents, and i think thats most important. We just its frustrating. It really is. Its like were not having a winning battle. I understand. Its awful and the fact that youre buying your own is even more dr. Grabowski, can you discuss the administrations response as well as what you think congress should be doing today to ensure that we have the ppe we need in the Current Crisis this summer and as it looks to have a spike in the fall. Absolutely. We need, as you suggested, nationalize the supply chain. We cant have Nursing Homes or states bidding against each other, bidding against hospitals. We need to basically consolidate and purchase collectively. I would prefer even a process where the federal government was doing the purchasing and then providing the Nursing Homes directly as they were going to do for those two weeks, which unusable ppe, even in one case, i read in the wall street journal, glorified garbage bags. That should offend all of us. We need to make certain were getting top ppe to Nursing Homes. This is where covid is at its strongest. This is where it is at its most dangerous. Lets get our nursing home workers, the ppe that they need and deserve. Right, thank you, and i think you used a keyword. We should all be offended. The greatest nation in the world should be able to do is this. I will share that with my colleague, ive introduced legislation that was also included in the heroes act designated a medical supply chain coordinator, centralize that function to make sure were getting the supplies, where we need, what we need as we need it. With that, mr. Chairman, i yield back. Thank you. Thank you, mr. Schneider. Mr. Horsford . Are you with us . Yes, thank you, mr. Chairman. Good. Its this is such an important hearing. Impact to thank you, chairman doggett, for leading this hearing and to all of our witnesses for sharing your expertise. Ive shared with this committee before in the past that providing quality care to seniors is a deeply personal issue for me. When i was just nine weeks old, my grandmother suffered a debilitating stroke that put her in a coma for six months and left her paralyzed on the left side of her body when she came out. She needed around the clock care and relied on Longterm Services and supports provided through medicaid. Because of her stroke, she spent 27 years of her life in a nursing home until she passed away in april of 2000. I spent much of my childhood and early adulthood in those Nursing Homes, visiting my grandmother every week. And i remember, as a boy that probably wasnt more than eight years old, i told her that one raise the issues about the lack of care for so many people that are in Nursing Homes, and today is that day. I can only imagine how heartbreaking it is for families who have loved ones in Nursing Homes who are not able to make those weekly visits during the coronavirus pandemic. Just yesterday, i conducted a telephone town hall in my district, and i spoke with debra from las vegas who before coronavirus visited her brother in a nursing home five or six times a week. Now, it has been four months since she last saw him in person. Debra shared that she constantly is worried for her brothers safety and health, and i have heard the stories from seniors across my district who express how leanly aonely and depressin experience has been. To the frontline doctors, nurses and healthcare workers, i have heard how trying this time has been to meet the challenges of obtaining ppe, testing, and staying healthy and with all due respect to my colleagues on the other side of the aisle, there has not been a strategy from this administration and in fact, the ppe that was delivered has been hoarded by many of the very facilities and have not trickled down to the frontline workers who have needed it the most. So, to all of those healthcare workers on the front lines, i just want to say, thank you. Thank you for adhering to these very tough guidelines and for fighting for our Family Members in these situations. I know you are working hard, and i know that we can Work Together to address the troublesome changes discussed in this hearing, and it is, quite frankly, outrageous that our Family Members and those who are living in Nursing Homes are in these conditions. But i want to begin with the question for ms. Howell, who im thrilled to see as a fellow native nevadaen and graduate from the university of nevada whos on our panel today, so, go wolfpack. But in your testimony, you shared the facilities with the significant number of africanamericans and latinx residents irrespective of facility size rating or location are twice as likely to have Coronavirus Infection as those facilities whose residents are white. So, can you discuss some of the longstanding Health Disparities these populations face and how covid19 can impact their Life Expectancy and Health Outcomes . And further, can you touch upon the reporting challenges faced in those facilities . Thank you, sir. I, too, had a grandmother who was on medicaid who spent time in a Skilled Nursing facility, and i would say what happens is we have individuals who have depended on a Healthcare System for years provided by medicaid and they simply do not have the money, and so for that reason, they are sent to Healthcare Facilities that put them directly in line with the disease, yet there are less expensive and more enriching places that they could live through the use of home and Community Based waivers where someone could be supported in the home. And i think what happens is these individuals have a builtin distrust for the system that has not served their needs and so inherently, these folks are told that they are going to have to be discharged or, no, we cant take care of you or youll have to stay in x facility that maybe doesnt actually have a great rating because it was the only facility that would take medicaid residents. And i think that we have built and deepened the structural system where folks who are native american, latinx, and i would also add africanamericans are really do not have the care that they deserve and because of the continued entrenchment of the social determinants of Health Outcomes, they already had the diseases such as diabetes and other vasculars that just put them at risk for this disease. So what i think is were talking about sort of reimbursement and care strategies, i think we need to look at the disparate ways in which the state and federal government create unnecessary competition to incentivize certain kinds of residents versus other residents. Thank you. Chairman doggett, i just want to conclude by saying as you know weve introduced the nursing facility quality reporting act of 2020 and its included in the heroes act. I look forward to working with you and any other member of this committee and the senate in advancing these important measures. Our Family Members and those in these nursing home and longterm care facilities deserve nothing less. Thank you for your leadership, and i yield back. Thank you for your work on that legislation, and mr. Kelly. Chairman, can you hear me okay . Yes, sir. Okay. All right. Im never sure whether im hitting the right button. First of all, thanks for having the hearing. I appreciate it. One of the things that makes it tough when we have hearings like this is it turns into a political issue as opposed to a really good policy issue. If we had had this meeting in july of 2019, i wonder if we would have had the same concerns about an administration not reacting to a pandemic that nobody saw coming, and i listen, at this point in my life, i know that hindsights always 20 20, and i know its easy to blame the previous administration. I dont think there was too much preparation going back several administrations for the idea that we may have a pandemic some way. It just wasnt on the charts, and nobody saw it coming. It happened, though. Now, change does take place during a crisis or a tragedy, so for all the members or the panelists that came in, and i mean this sincerely, thank you for taking time out of your life to come in here and talk with us or at least come on the screen with us, but in your own in your own operations that you are theyre doing right now, the whole gamut of what it is were trying to do, i know in pennsylvania, 67 of the deaths from covid are taking place in the facilities, the nursing home facilities. And early on, it was really hard to understand. Our governor told Governor Wolf told people, listen, you Nursing Homes have got to take these people in, even if they are covid positive. It is a must. You have to do that. Then, they backed it off after they saw what was happening. They said, well, you can kind of decide for yourself, kind of figure out for yourself what you have to do. So, it was one of those things where directing people to do some kind of a ship without a rudder and letting people decide what they should do, even our department of health, the secretary of health, took her own mother out of a nursing home and put her in a private hotel once they had made this decision that you had to put people in Nursing Homes even if they were covid positive so this is just across the board. I dont want this to be political. We waste so much time bashing whatever administrations in office. Lets talk positively, what could we do Going Forward because id rather know what it is we can do, why we have to do it, and how we would then do it. From each of you, if you can just do us a brief summary of what you would do now, knowing that we have this pandemic and the possibility that there could be a relapse and the possibility that there could be Something Else released into the world again that we didnt know about until january, february of this year, had no hint of it happening. I dont really want to blame it on the previous administration, this administration, but any administration Going Forward, we should probably have an idea that we need to have stores of product in place that we can use. The fact that weve used other producers around the world for production, that was a policy that we took because we like buying things that were cheaper, so if you can, each of you, if you can just take a couple of seconds, what would you do from this point on as opposed to blaming somebody in the administration for not doing something that nobody saw coming, an impossible thing, but i know were in a political world and november 3rd is not that far off. So, anyway, becky, why dont you talk a little bit about what you could do up there in new york. So, i think i said some of this already, and i dont want to repeat myself, but i think coming up with strategies, Regional Strategies where hospitals can Work Together to keep covid19 patients out of Nursing Homes would be a first strategy. Obviously, if theres nowhere else to place individuals, you may have to put them in the nursing home. Thats a reality that we have to accept. I think understanding the difference between the burn rates of what staff use for ppe when they do not have Covid Patients versus what the rate the burn rate is of ppe when you do have Covid Patients, is really important because its drastically different based on what type of patients you have in your facility, and so we need to be prepared for that worst Case Scenario, so how much ppe do we need to have if we do have the worst Case Scenario of having cohort patients within our facilities. And i do think ensuring that we have enough staff in order to care for those patients and provide proper care and proper training, there needs to be proper training of how to don and doff ppe, of how to use proper Infection Control inside the facility. All those things are going to be majorly important, not only to the fall but also to any type of outbreak in the future of any type of droplet precaution that we might encounter here in the United States. Very good. Very good. Anybody else . One of the things ive always heard is that our emergency rooms, we are woefully this happening, biological warfare that would take place, theres very few hospitals equipped to handle any type of large numbers of inpatient, so im sorry to take up any time but anybody else, please dana, anybody that wants to weigh in, please weigh in because youre the experts in this. Thank you. This is dana. I dont know if you guys can see me. Im having connection problems, but i can see some of you. The one area that you would also say is we need to publicly report on a daily basis whether a facility has covid19. I mean, that goes back to the community spread, and not sharing that information and not being transparent, i think, has led to i know we had one facility when i went on to google maps, and saw that there was other three other facilities. I knew it wouldnt be long before those facilities also had covid in them. So transparency is critical. Thank you. Great point. Thank you very much. Thank you, mr. Kelly. Thank you, mr. Chairman. Mr. Pasquale. Thank you for putting this together, mr. Chairman. I think its excellent. The members have been really great on both sides. The arc of the moral universe is long but it bends towards justice. Thats the second time i quoted Martin Luther king jr. Today. I think its so, so appropriate here. Nursing homes have been devastated by the virus. Nearly 30,000 residents across the country, including more than 6,000 in new jersey, have died. This is not a drop in the bucket. There are now over 123,000 covidrelated deaths in the United States. No hoax, mr. Chairman. No hoax. Longterm care deaths are disproportionate. Nursing facilities comprise only 11 of the cases. They comprise 1 in 3 covid deaths. These guys have gotten away with murder, and were here talking about partisan politics . You got to be kidding me. Onethird related deaths come from nursingzno homes. And i want to be clear. This was not only because our elderly are more vulnerable to covid19. This goes, i think, deeper. The fact that too many facilities across our country have been mismanaged for many years. Who is in jail . Nobody. Like the bankers in 2008, nobody. These glaring deficiencies were made worse by this administration, yes, rolling back nursing home protections. That is a fact. That is a fact. You didnt do it, members. They did it. An administration. They rolled back the regulations. Ill cite them if you want me to. In 2017, cms gutted standards in nursing facilities for Infection Control, facility assessments, and transfers and discharges. If we would have that record, and if we followed up on it as the administration was supposed to under the law, we would have known which places were more vulnerable to the disease. We didnt do that. The administrations guilty of this. The administration recklessly disregarded the health and safety of our most vulnerable neighborhoods, our most vulnerable Nursing Homes. Cms even as a proposal to eliminate requirements that Nursing Homes employ Infection Prevention specialists during this pandemic. You cant make this stuff up. What the hell are they doing over there anyway . So, i have a question for dr. Grabowski, and i would like to say to melinda haschek, you are truly a first responder. Thank you so much for what you do day in and day out on the front lines. Dr. Grabowski, many are responsible, dr. Grabowski, for the outsized impact covid has had on nursing facilities, including Nursing Homes themselves. Yet, this administration has doubled down on its crusade to make Nursing Homes less safe. What are the most harmful impacts of deregulation on nursing facility residents, dr. Grabowski . Yeah, we need strong regulation here. We have a lot of residents in Nursing Homes that cant monitor their own care. They cant advocate for themselves. We need soombudsman, we need regulators, we need family keeping eyes on this so when those eyes arent on the buildings, bad things happen and we have heard already during this hearing about low staffing and other bad outcomes that can happen. So, we need to maintain strong oversight and accountability. Well, toby edelman, senior policy attorney. Yes, sir. I agree completely that we need strong regulations, and they need to be treated seriously. Cdc talked about what to do for covid and what they said is our guidance is identical to what we say for all infections. These requirements are not new. These guidances are not new. Staff need to wash their hands. That is the number one violation cited in Nursing Homes, hand washing. They need to have and use personal protective equipment. They need to disinfect equipment between residents, medical, do it correctly. They need to isolate and identify residents who have an infection or seem to have an infection. These are essential, basic Infection Prevention and control requirements for covid, for any infection. Theyve been around for years. This is the number one violation cited in Nursing Homes. Thank you. Mr. Chairman, can i say this . Before i sign off. Thank you, ms. Edelman. Mr. Chairman, can i just make one more comment before i sign off . Yes. Go right ahead. If there are reports and oversight where the cms is coordinating oversight with the states, with the individual states, so each of these homes each of these Nursing Homes gets a report card. What has been done with these report cards . Where are they . How have they been acted upon . Want to know i want to know within the next week from cms, give us what youve done about these report cards, or else every one of you should be fired from the top to the bottom. Ive had relatives that have been killed in these Nursing Homes, and i am not going to leave this alone, mr. Chairman. And you should not either. Thank you. Thank you very much. Mr. Davis. What about what he was talking about . Thank you very much mr. Chairman for the opportunity to participate in this hearing. Anything that has to do with health is always of great interest to me even though im not a member of the committee. Ive got a question id like to ask mr. Elderman. Illinois department of health recently posted data that over 52 of the States Coronavirus deaths are tied to longterm care facilities, assisted living establishments and other homes. The highest number of deaths have occurred in cooke county. There are multiple agencies in illinois that inspect and certify Nursing Homes in the state including the Illinois Department of Public Health, the u. S. Department of health and Human Service center, the medicare and Medicaid Services. Mr. Elderman, could you speak to where the gaps are in inspection, surveillance and enforcement, education and guidance . Well, thank you for that question, congressman. For the last three months, cms has said to states do not do any surveys. Do not do any surveys except for immediate jeopardy deficiencies, which is 1 of the problems, or targeted targeted Infection Control surveys. They did Infection Control surveys spoededly. On june 4th, they released 5,700 of them. They called them no harm. How in the middle oof a pandemic when so many people are dying from infections every day do we find facilities not having any problems . This is the number one problem in facilities, the gao said last month its the number one problem, widespread, persistent, way before the covid19 problem. So, we do not have good oversight. We dont cite the problems. And even if we do cite problems, we dont do anything about them. And thats the real problem. That is the real problem. We just let these issues fester. And now we know the number one issue, hand washing. Hand washing isnt just a trivial matter. People are dying in Nursing Homes because the staff are not washing their hands. And i would say part of the reason theyre not doing that is that there arent enough of them. People try to cut corners and do as much as they can as quickly as they can when they have a lot to take care of. We need to have better enforcement of these important standards. Thank you very much. And doctor, could you discuss the separate of the ownership of Nursing Homes on the quality of care received . And i ask that question because there are some who believe that private Equity Investment in health care does not always benefit the patient and that it has the opposite effect, impact. Could you explore that for us . Sure. Thank you for that question. This has been a trend in Nursing Homes to separate the real estate from the operations and weve seen with covid how that can be a really risky separation. From an assets perspective, the most valuable part of the nursing home is the real estate. So, the operator still has to pay their lease to that owner while theyre not taking in patients like they were before covid. And so its become really challenging for a lot of Nursing Homes, basically operators to pay their bills right now. So, the private equity groups are kind of protects while the operators are really challenged. So, i think exactly as you described, congressman, we all worried about the accountability and the transparency of these deals and ultimately the quality. I think weve really seen that come to light here with covid where its a really risky proposition to separate ownership from operators and thinking about whos accountable all the time but especially during a pandemic. If i could just ask you quickly, ive always had some affinity for operators of Nursing Homes. There are a number of them in the community where i live. I used to be on the board of one that is notforprofit built and we operate it for a number of years. And i must tell you we caught holy hell trying to operate it and maintain the standards that we wanted to have which is saying anyway that perhaps the Nursing Homes have been underfunded, or the reimbursements that they get have attributed to the quality of care that they sometimes provide . Absolutely. Are there some bad Nursing Homes out there . Definitely. But its hard not to argue that low medicaid reimbursement hasnt contributed to low quality. Weve done a lot of studies supporting that link. And Going Forward we need to make certain that were adequately funding Nursing Homes. And as we stated by settlement and others, we need to get those dollars in the pockets of the workers, not ceos, not those private equity groups you just asked about. Thank you, mr. Chairman. I yield back. Thank you very much. Mr. Winster. Thank you mr. Chairman. Thank you everyone for being here today. I really appreciate it. Im glad were having this hearing to address this crisis. Weve faced this pandemic. I think in ohio weve had a lot of people very committed to taking care of our seniors in our facilities. Interesting story, staff at two assisted living facilities in ohio even moved into their facilities for 65 days to keep their patients safe. Thats incredible. They sacrificed being away from their family for over two months to make sure theyre protected. That speaks a lot to the care gives which obviously we need more of at every level in health care today. But they put their own safety at risk and out there protecting the the most vulnerable. And, you know, i even spoke to one ohio nursing home provider who spent time one morning buying rain ponchos on ebay to serve as ppe for his providers. This isnt acceptable. We can take a look at these things. We should do an afteraction review, find out where were short, what our challenges are and how we can do better. And pointing blame, i guess thats bound to happen. Washing ones hands of something, none of those things are solutions. And thats what i really prefer to work on. I have written secretary azar asking for additional funding from the Provider Relief Fund for Skilled Nursing facilities, and im glad to see that secretaries have dedicated 3. 9 billion of that fund to over 13,000 Skilled Nursing facilities. But, you know, speaking as a doctor, the process of isolating sick patients isnt new, and governors in some states as we know mandated that covid19 positive patients be sent back to Nursing Homes. 1 in 10 nursing home patients have died in new jersey. New jersey is one of those states. New york had access to the u. S. Naval ship comfort and the Javits Center and still cent patients back to Nursing Homes. We have to understand why that happened. Send them back to the most vulnerable. These werent federal mandates to do that. These were state mandates. This is a federal, state and local problem that we have to deal with. I challenge anyone to ask themselves if they would want to comply with the government mandate to send covid19 infected patients home to their home or to an extended family especially if their Family Members is among the most vulnerable. Im curious where the advice came with that. Did you consult with Infectious Disease before making that decision . And the ppe problem, let me touch on that. That is a problem, and i dont know that that problem was better under the last administration or the administration before that. I shutter to think that any of them would have been in a better situation. We were in a bad situation. And why . Because we dont have enough domestic source of these types of things. And im working very hard on identifying what our critical needs so that we can be ready. And we have to find ways as congress and do our role in making sure we can produce these things domestically and have the minimal amount required and certainly the manufacturing capability for a reserve when called upon in ha moments notice. In my hometown of cincinnati, we had a Health Collaborative in hospitals. They were ready to go to the Convention Center to build the hospital there, and all the hospitals had had a role in addressing this. These are the type of things we need to be ready for. These are the types of things we need to talk about. But, you know, we see that majority of covid deathsona occurred in poor performing Nursing Homes with quality ratings scores of 1 to 2 stars. And theres universal precautions for infection. There always has been. And cms required fa sulties adding Infection Control programs in place. I was part of a Surgery Center with other doctors. We had our Infection Control program in place. And before i got to congress, i served on our board of health and we would commonly evaluate and share best practices amongst those in our community that are taking care of people. So, we need to take a look at Nursing Homes and see what succeeded with Infection Control. Why did some not have a problem and others did . This i think is the path forward and quit pointing fingers and come up with solutions and make we are addressing problems that we are facing as a nation that affects everyone. And you know, there are Things Congress should do. I want to ask ms. Gold. Ill choose you. As i said, this is federal, state, local. What do you think congress should do in order to improve the quality of the poor performing nursing home . I yield back. Was i heard . Im not sure she heard. I guess well let her give her answer for the record if theres further answer, and ill call on mr. Byer. Thank you very much and thank you for this really, really important hearing. The first thing to call our attention, the Life Care Center in kirkland in washington, that was back in february, and we knew at the time it was going to disproportionately affect older adults, the older, the more dangerous. Its one reason we were having so much trouble having the young people take it seriously. But it wasnt until midmay that finally that cms started requiring a collection of nursing home data. 2 1 2 months in and i know we were talking to our governor every single week about whats happening in the Nursing Homes. Let us know. The families want to know. It was just a complete shutdown of information. In a country with government and democracy completely dependent on transparency, do you have any sense of how this delay in data transparency has meant to the situation that developed in the Nursing Homes . Yeah, thanks for that question. Its really caused two problems. The first is that it didnt allow us in a timely way to know the extent of the problem. We now know that a number of the cases and the fatalities are located in Nursing Homes. But i really dont think we obviously had the situation in kirkland. But we didnt have the broader data to tell us this is where we should be directing a lot of our resources. The other problem with not having early data was not being able to learn as the prior congressman said about which facilities have cases, which dont, whats working in term of best practices, Infection Control, Public Health, infrastructure. This is just good Public Health that you have data that youre learning from both your successes and your failures. And this really prevented us from any type of learning. Thank you very much. Your testimony was fascinating. You get the sense that trump has been doing the bidding of any industry his entire administration, eliminating any regulation on industries wish lists and were paying for that behavior right now. 2013 the center for medicare and Medicaid Services updated emergency preparedness. You go through your testimony m step by step all the things that were rolled back. Can you tell us concretely how much the rolling back of these regulations may have had an impact on this crisis in the Nursing Homes that weve seen . Thank you, congressman byer. I think the rollback of the standards of care, the complete lack of information and no oversight. There has been nobody in Nursing Homes for three months. Not the families, not the only budsmen like ms. Powell. Thaw do such a great job advocating for Nursing Homes and not state and federal regulators. Now were seeing the results of what happens to rolling back or not enforcing nursing care standards weve had in place for decades. Assume that theres ive been a Small Business person all my life. So, im very sensitive to ms. Goulds talk about the cost burdens of ppe and testing employees. How do you sort out how much of this cost pressure in the Nursing Homes is because of two small medicare reimbursement payments versus the private equity takeover of what used to be family run, Small Business run homes . Well, private equity involvement has been a very serious problem. What private equity firms did was immediately cut staff in hay number of facilities. And that was good for investors butter ableo5n for the care of residents. What private equity firms have also done is sold the real estate. Thats the most valuable part of the business. And theyve sold the real estate to the Real Estate Investment trump. Then they raised the rent so the reimbursement paid to Nursing Homes was not as available for staff anymore or food or supplies or all the things that residents rely on. Instead, the money went to the Real Estate Investment trust and they kept raising the rents. Facilities went into bankrupt. Thats been a terrible situation. Generally we dont require facilities to be accountable for the money weve given them. Medicare is the highest payer. At present the average rate is 525, 550 a day up to a thousand. In 2014 the Inspector General looked at all the residents admitted to Nursing Homes under medicare in a one month period and found that more than a third suffered an adverse event or harm. They had medication errors, all kinds of problems. There were hospitalizations and deaths that had not been anticipated at all. This is with the highest payer. This is why our concern is not just to give money but to make sure the money goes where we want it to go. Medical loss ratios, the other efforts to make sure that money is spent on care for residents and not just taken out by the owners for profits, management, overhead, whatever they want to take it out for. Thank you very much. Thank you. Thank you. Thank you very much mr. Byer. Mr. Panetta. Thank you, appreciate that. Thanks to both of you for holding this hearing. I want to thank the witnesses for providing your testimony, your preparation, and your experience and sharing your experiences with all of us and with the nation. So, thank you very much. Obviously our nations Nursing Homes, their residents and their staff clearly have been at the epicenter of this crisis. As someone who grew up with a loved one in a nursing home, im familiar with the General Dynamics of a nursing home. Im familiar with the care that is provided for residents thats necessary. Im familiar with the love shown by many of the employees at these Nursing Homes for the residents. But also and sometimes im familiar with the lack of love and lack of care that can be shown to residents as well as the isolation that residents can feel as well. Now, i believe this pandemic did more than take advantage of these types of conditions at our Nursing Homes. I believe it ravaged our residents and went after the employees. As weve heard and as you know, as many as 9,600 Nursing Homes and other longterm care settings in the u. S. Have had at least one covid19 case. Theres been more than 50,000 residents and workers in longterm care settings that have died from covid19. And as my good friend said thats one thursday third of all deaths nationwide. And the administration decreased oversight for the facilities, and limited access by families who seek justice. Its those types of decisions that have exacerbated the vulnerability of nursing home residents and staff and left many Nursing Homes miserably illprepared. Thats why i urge congress to continue to lead, protect these people so they can continue to love and be loved. I introduced the the sos act, the legislation that would fund teams, teams for additional nurses to go into facilities at the request of the facilities during the covid19 pandemic and assist with staffing and cares for residents. This concept is already working the in several states in response to spikes of covid19 and is deployed mainly from Nursing Homes that have had a hard time finding Nursing Homes in the first place, not just during the pandemic. Doctor, im not going to ask you a question because youve been getting a lot of questions, so dont worry about it, all right . Im going the ask ms. Kennedy this question. Prior to getting to this point of having strike teams come in, is there Anything Congress can do to help increase or incentivise staffing at Skilled Nursing facilities . Thank you chairman and representative. I do believe some facilities are offering hazard pay and i think that is something to consider and i think that in time of crisis being able to offer incentive for staff to get a little bit of extra money is helpful in times of crisis. All right. And doctor, dont take it personally youve just been doing a really good job and theres a lot you know. I appreciate it. Trust me. I want to get to someone who hasnt talked much and i think she should talk more. Thank you very much for what youve said and i appreciate you being here and obviously sorry to hear what happened to you and your brother. What should Congress Know about your experience with your brothers nursing home, as we consider when to prevent Nursing Homes moving forward during and after covid19 . Well, thank you for the question. I think that if we could get more testing done. Here in texas theyre not testing like they should be. I know that the nursing home where my brother was at, they just tested the staff and the residents a few weeks ago. My brother did not get tested until he was running a fever and coughing. So, testing is definite must in these Nursing Homes. They need ppe. The workers need to be protected. They cant do their job if they get sick. And the residents cant take care of themselves. So, they need the workers there to help them. But testing definitely has to be done more frequently for the workers and the residents. Thank you. Thank you, thank you, again. Mr. Chairman, i yield back. Thank you, mr. Panetta. Mr. Estes, thank you for waiting, and please proceed. Thank you, mr. Chairman. And thank you to all of our witnesses for joining us today. This is a very important topic that we need to talk about and address and help support our most vulnerable citizens. Everyday medical professionals put themselves at risk to serve our community and battle against the current Public Health crisis. Ive heard from Health Care Providers in my district. They need support now more than ever and Nursing Homes need assistance as they determine how they prevent the quick spread of the virus of covid19 in the future while maintaining the high quality of care of their residents. Our medical community should be prepared for the future epidemic and its imperative Nursing Homes have better ability to protect seniors. Nursing homes and assisted living facilities have unacceptably high numbers of cases and deaths. Weve seen troubling actions from public officials. Im concerned at several governors actions including Governor Cuomo that insisted Nursing Homes take covid19 patients. Its one of those issues that stands out as whats made it worse for so many people. Nursing homes dont have the tool or capacity to handle the patients leading to devastating consequences. I want to step away from placing blame. Lets focus on how do we fix the issues in front of us . In my district, Nursing Homes have a voice of this crisis has exacerbated existing problems, especially inadequate staffing numbers. Nursing homes must send Staff Members home when they exhibit symptoms of covid19. This forces Nursing Homes to work longer and frequent shifts. The nursing homework force and quality act addresses this problem. Representative evans and i have introduced this bill to ensure the quality standards of Nursing Homes are upheld allow for additional oversight of Nursing Homes be systemic problems and address critical shortages of certified nursing assistants. Specifically legislation allows Nursing Homes inhouse cna Training Programs to resume such programs when the secretary of health and Human Services certified that all quality concerns cited and fined have been addressed. This allows Nursing Homes to continue to meet high standards without losing Staffing Levels which we know are critical to the quality of care that a patient receives. Ms. Gould, youve given current staffing shortages and distancing return work due to some additional unemployment payments. Would it be beneficial to remove barriers to inhouse training for cnas and Nursing Homes . And do you believe this ability to train and make more staff available is consequential in helping prevent the spread of covid19 in Nursing Homes . So, thats a twopart question. I do think that staffing is key to prohibiting the spread of covid19 in the nursing home. And like i said earlier whrks youre running short or in a hurry, you make mistakes. So, having the appropriate staff on hand definitely would be an advantage. We do run inhouse cna Training Programs in our facility. We do that and it does help with retention. I think where we see a real issue really is in the compensation rate. So, being a cna is hard. Cnas are required to bathe people, to feed people, to change them effectively. And so when you can go someplace like target or burger king and earn a wage thats similar, its hard to complete. And i know in our facility we are about 90 medicaid. I hear a lot of talk about medica medicare dollars. Its hard to continue to give increases when the medicaid rate youre receiving doesnt cover the majority of your costs. I think what youre saying for facilities is true, having cna program in house is beneficial. It allows you to train the people on sight. It makes them comfortable and it is easier to retain them. I think removing barriers in other states in order to have a cna Training Program inhouse is valuable. Thank you. You know, ms. Gould, earlier you talked about being able to vac ppe and recognize we have a different burn rate if you have an infection of covid19 versus not. Do you have any ideas in a short time about how we can more accurately capture that data . So, in new york state, we are completing data set every day. Its called herds reporting. On there we do list our current burn rate and current rate on hand. There should be two different, one for what is your current rate youre using and another one for what you would have on hand if your burn rate was that of having covid positive patients because there is a large disparity. I think its somewhere between 3,000 to 5,000 masks a week difference between if you have a covid positive patient in your facility and not having a covid positive patient is no your facility. It is a lot. Youre required to change the mask every two hours if you have a patient in your facility. I think thats a great question. Every state should be looking into that and looking in your stock piles you are prepared to move if a facility comes down with a covid crisis in their facility. Great question. Thank you for all your information. Mr. Chairman, i yield back. Thank you very much. I believe that concludes our questioning. I want to thank all our witnesses for an lengthy hearing, an outstanding panel. I particularly want to thank, again, ms. Satterwhite for being here. I know you made special efforts to get off work in order to be able to do this. And i saw the excellent profile on you that avery travis did on kxian yesterday. Shes done great work yesterday in exposing these problems. Your personal story adds meaning to what were doing today. Every witness paid a big contribution and members should be advised that they have two weeks to submit written questions to be answered. If you arent able to get all your questions in today, those questions and answers will be made part of the formal hearing record. And with that, i believe our business is concluded, though our work to respond to this hearing is only beginning. So, thank you each of you, and that concludes our hearing. First ladies influence and image on American History tv examine the private lives of the nations first ladies through top historians. Monday night we look at Edith Roosevelt and taft. She became the first lady to travel abroad while in office. And helen taft was the first first lady to ride with the president in the inaugural parade. Watch first ladies influence and image monday at 8 00 p. M. Eastern on American History tv on cspan3. Members working on the George Floyd Justice and policing act Police Reform package, House Speaker nancy pelosi and congressional black chair karen bass k spoke about the legislation