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The COVID Project

Industry 04 of 27 · How a typical employer operates

Home Care, Nursing and Senior Living

The functions of the business, its revenue lines, its workforce, its suppliers and counterparties, its seasons, and how the orders reached each of them.

HCin-home visitsSNskilled nursing and assessmentsRSresidential careVSvisitationINintake and referralsICinfection control and staff…TRtransport of aidesDNdining and activitiesHRhiring, screening, training and…OFoffice, administration and…WFworkforce availabilityCBpatients and payers
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How a typical employer in home health, home care, hospice, skilled nursing and senior living operates

This industry sells the physical presence of a trained person at a patient's bedside or doorstep. Every function it performs depends on a person entering a building or a home, touching a patient, sitting with a resident at a meal, admitting a patient from a hospital, or driving from one home to the next. An order that fixes who may enter, on what screening, on what test result, on what vaccination status, who may sit together and who may be admitted on what proof reaches every one of those functions at once. That is why the orders of the period suspended this industry in a manner unlike any other and why the Service's account of an industry that "remained open" describes nothing that existed.

The segments

Home health

Medicare-certified home health agencies deliver skilled nursing, physical, occupational and speech therapy, medical social work and home health aide services in the patient's home under a physician's plan of care, to patients certified homebound after a face-to-face encounter, in thirty-day payment periods under the Patient-Driven Groupings Model that took effect January 1, 2020.1 The conditions of participation at 42 C.F.R. Part 484 fix the initial assessment visit within forty-eight hours of referral, the comprehensive assessment within five days, aide supervision by a registered nurse on site every fourteen days, and the plan-of-care discipline that the 2020 waivers and interim final rules then altered.2 About 11,300 agencies served about 3.3 million Medicare beneficiaries in 2019; the Bureau of Labor Statistics counted about 1.5 million jobs in home health care services in May 2021.3

Home care and personal care

Non-medical home care agencies, personal care agencies and Medicaid home- and community-based services providers deliver bathing, dressing, toileting, feeding, transfer assistance, medication reminders and companion care by aides paid by the hour, most of it under section 1915(c) waivers and State plan personal-care programs, the rest by private pay and long-term-care insurance.4 The States license or register these agencies under names that recur in the orders of the period: "registered health care service firms" in New Jersey, "licensed home care services agencies" in New York, "home care organizations" and "registered home care aides" in California, "personal assistance services agencies" in Delaware, "home care agencies" and "home care registries" in Pennsylvania.5

Hospice

Hospices deliver routine home care, continuous home care, general inpatient care and respite care to terminally ill patients under 42 C.F.R. Part 418, in private homes and in nursing facilities and assisted living communities, where a large share of hospice patients reside; the conditions of participation require a face-to-face encounter before the third and each later benefit period and require that volunteers provide at least five percent of patient-care hours.6 About 4,840 hospices served more than 1.6 million Medicare beneficiaries in 2019, and the Medicare Payment Advisory Commission recorded that in 2020 hospices "reported fewer nursing facility and assisted living facility patients (as many facilities have restricted access)."7

Skilled nursing

Skilled nursing facilities and nursing facilities operate under 42 C.F.R. Part 483, enforced by State survey agencies under agreements with the Secretary through citations at lettered and numbered "F-tags," civil money penalties, withholding of payment for new admissions and termination.8 The National Center for Health Statistics counted 15,600 nursing homes with 1.7 million certified beds and about 1.3 million residents in 2017-2018; the Bureau of Labor Statistics counted about 1.4 million jobs in nursing care facilities in May 2021.9

Senior living and residential care

Assisted living communities, residential care homes, personal care homes, memory care and continuing care retirement communities are licensed by the States under names that vary by State (assisted living residences, residential care facilities for the elderly, personal care homes, adult care facilities, adult foster care, managed residential communities), serve about 918,700 residents in 31,400 communities by the federal survey and about 1.4 million licensed beds by the industry's count, and were reached in the period by the State health department orders that treated them as "long-term care facilities" together with nursing homes.10

Adult day services and intermediate care

About 4,200 adult day services centers served about 286,000 participants in 2017-2018; they were closed by order in the spring of 2020 in many jurisdictions and reopened on conditions in 2021. Intermediate care facilities for individuals with intellectual disabilities operate under 42 C.F.R. Part 483, Subpart I, and received their own CMS directive on March 30, 2020.11

The twelve functions

HC, in-home visits

The aide, nurse or therapist travels to the patient's home, enters it, and performs the visit in the patient's presence. The function depends on the patient's willingness and legal ability to receive a visitor, on the household's screening result, on the worker's own screening, testing and vaccination status, on the availability of personal protective equipment and on the worker's transportation. Orders that confined residents to their homes, that required screening before entry, that required testing or vaccination of the worker as a condition of entering a home or of employment, and that imposed workplace infection-prevention and exposure-control requirements at the point of care, source control in the home among them, reached this function directly.12

SN, skilled nursing and assessments

The initial and comprehensive assessments, the aide supervisory visit, the plan-of-care review and the hospice face-to-face encounter are performed in person by regulation. The section 1135 waivers and the interim final rule of April 6, 2020 permitted remote performance of some of these tasks and altered the timing of others; where the order permitting the remote mode was accompanied by an order confining the patient or the nurse, the order compelled the change.13

RS, residential care

Admission of a resident, assignment to a room and roommate, movement within the building, and the cohorting of residents by infection status are the daily operations of a nursing home or assisted living community. Orders that fixed the proof a hospital had to furnish before discharging to a facility, the test a resident had to pass before admission, the quarantine a new admission had to serve, the dedicated unit a facility had to operate, and the rooms in which a resident with a positive test had to be placed reached this function in every State.14

VS, visitation

A resident's right to receive visitors is a condition of participation and a licensure right in every State, and the visitation function includes the family visits, clergy visits, hairdresser and podiatrist visits, ombudsman visits and admission tours that a residential community conducts daily. The blanket federal restriction of March 13, 2020, the State bans that adopted and extended it, the conditional reopening of September 17, 2020, the State re-tightening of the winter, and the conditional indoor rule of March 10 and April 27, 2021 governed this function on every day of the period.15

IN, intake and referrals

Home health and hospice census depends on hospital and facility discharges; skilled nursing census depends on hospital discharges and on the elective procedures that generate rehabilitation stays. Orders that suspended elective surgery, that barred discharge to a nursing home without a negative test, that barred a facility from admitting during an outbreak or without a State health department review, and that barred hospice staff from entering a facility fixed the industry's intake.16

IC, infection control and staff mandates

Screening of every person at every entry, testing of residents and staff on a schedule set by county positivity, isolation and quarantine of exposed staff, source control, N95 fit-testing, cleaning and ventilation, written plans, logs and reporting, and, in 2021, vaccination-or-testing and vaccination mandates, are the compelled operations of every segment. The federal condition of participation, the OSHA standard and the State and city mandates made each of them an order.17

TR, transport

Aides travel between homes several times a day, by car and by transit; residents and patients travel to dialysis, oncology and physician visits; facilities operate vans. The conveyance order, the airborne-transmission control the Centers for Disease Control and Prevention imposed on every bus, train and paratransit vehicle, the transit reductions, the quarantine orders on travelers and the stay-at-home orders' travel restrictions reached this function.18

DN, dining and activities

Communal dining, group activities, outside entertainers, congregate religious services and beauty and barber services are the daily life of a residential community and a condition of the marketing on which private-pay assisted living depends. The federal direction of March 13, 2020 to "[c]ancel communal dining and all group activities," the county orders that repeated it, and the phased resumption by State order reached this function.19

HR, hiring, training and credentialing

Nurse aide training and competency evaluation, the four-month limit on employing an untrained aide, criminal background checks, out-of-State licensure and the interstate compacts, and the credentialing of hospice volunteers were each altered by waiver or order; single-facility staffing orders and the exclusion of untested or unvaccinated workers changed whom an employer could hire and retain.20

OF, offices and administration

Intake offices, billing, scheduling and human-resources functions were reached by the stay-at-home orders, the telework directives and the county occupancy orders and workplace infection-prevention requirements, and were burdened by the daily and weekly reporting orders of the National Healthcare Safety Network and the States.21

WF, workforce availability

Aides, nursing assistants, licensed practical nurses and registered nurses were confined by the stay-at-home orders except for their own essential work, kept home by school and child-care closures, quarantined by exposure orders, excluded from the workplace by testing and vaccination orders, and, in several counties, barred from working at more than one facility. The Bureau of Labor Statistics counted 13.9 percent fewer nursing-care-facility jobs and 8.0 percent fewer assisted-living jobs in 2021 than in 2019.22

CB, patients and payers

Patients were ordered to stay at home and to admit no one but essential workers; families were ordered out of the buildings; hospitals were ordered to defer the procedures that generate referrals; the Medicare and Medicaid programs changed the rules of payment by waiver and interim final rule, including telecommunications in home health, retainer payments in the waivers, and suspension of the three-day stay. The customers and the payers of this industry were governed by orders throughout the period.23

The regulatory architecture

The federal layer

The Secretary of Health and Human Services declared a public health emergency on January 31, 2020 and renewed it every ninety days through May 11, 2023; the President declared a national emergency on March 13, 2020; those two declarations, together, authorized the Secretary's section 1135 waivers retroactive to March 1, 2020 and the interim final rules that followed.24 CMS directed the State survey agencies and the certified providers through Quality, Safety & Oversight memoranda, enforced through the survey process; it amended the conditions of participation by interim final rule in May 2020, September 2020 and May 2021; and it approved every State's Appendix K amendments to its home- and community-based services waivers.25 OSHA placed every workplace in the industry under an emergency temporary standard on June 21, 2021.26

The State and local layers

Every State licenses nursing homes, assisted living and home care, and every State health department holds communicable-disease powers over facilities and persons. The orders of the period issued from Governors under emergency powers, from State health officers and commissioners under disease-control and licensure statutes, from State boards, from county and city health officers under the same statutes and their charters, and from State occupational-safety agencies under State plans.

The workforce and the referral economy

The workforce

The industry's direct-care workers are aides and nursing assistants paid, in May 2021, at a median wage of $13.77 an hour for the 861,740 home health and personal care aides employed in home health care services and $14.41 an hour for the 471,160 nursing assistants employed in nursing care facilities, disproportionately women, immigrants and workers of color, commonly employed by more than one agency or facility, dependent on public transit in the metropolitan areas and on schools and child care for their availability.27 The single-facility staffing orders of Bexar County and San Bernardino County and the multi-employer testing regimes of New York, New Jersey and the federal condition of participation reached that workforce directly.28

The referral economy

Home health, hospice and skilled nursing depend on the hospital. CMS recommended on March 18, 2020 that elective surgeries and non-essential procedures be limited, and the Governors and health officers of New York, Texas, Utah, Iowa, Alaska, Arkansas and others ordered it, and Pennsylvania ordered a reduction again from November 23, 2020 through August 23, 2021; the Governor of New York on May 10, 2020 barred hospital discharge to a nursing home without a negative test; the Los Angeles County Health Officer on April 24, 2020 and the Minneapolis Mayor on April 23, 2020 fixed the conditions of admission and transfer at every congregate health care facility in their jurisdictions; and the visitation bans excluded the hospice nurse and chaplain from the nursing home for months.29 The Service's picture of an industry whose customers and referral sources were free to come and go describes a period that did not occur.

The counterparty map

Each class of counterparty on which this industry depends was itself under orders, and the layers section below inventories them by class. Hospitals: the elective-procedure suspensions, the discharge-testing and certification conditions, the surge-transfer and crisis-standards orders (the elective-procedure orders; the counterparty layer). Assisted living and nursing facilities as the sites of hospice and home health care: the visitation bans, admission rules and outbreak phases (the State layer; the local layer). Schools and child care: the closure orders of 2020 and the face-covering, vaccination and quarantine orders of the 2021-22 school year (the counterparty layer; the interconnected economy). Transit: the conveyance order and the TSA directives (the federal layer). Households: the stay-at-home, isolation and quarantine orders (the State layer; the local layer). Suppliers of personal protective equipment: the Defense Production Act allocation orders, the FEMA export rule and the State distribution orders (the ecosystem). Payers: the interim final rules, Appendix K and the Medicaid maintenance-of-effort condition (the federal layer; the counterparty layer). Licensing boards, survey agencies and courts: the agency, board and court layer. Landlords and housing: the eviction moratoria on the workforce's homes (the counterparty layer). The immigrant direct-care workforce: the entry proclamations, consular suspensions and land-border notices (the ecosystem).

  1. 42 C.F.R. §§ 409.42, 424.22 (homebound status and face-to-face encounter); 42 C.F.R. Part 484 (conditions of participation); CY 2020 Home Health Prospective Payment System Rate Update, 84 Fed. Reg. 60478 (Nov. 8, 2019) (PDGM effective Jan. 1, 2020). The CARES Act itself, § 3708, permitted nurse practitioners, clinical nurse specialists and physician assistants to certify home health eligibility. ↩
  2. 42 C.F.R. §§ 484.55(a)(2), (b)(3) (initial and comprehensive assessments); 484.80(h)(1) (aide supervision every 14 days); 484.60 (plan of care). Each provision is named in the section 1135 blanket waivers, CMS, COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, at 20-22 (as updated) (Ex. SEC-04-015). ↩
  3. Medicare Payment Advisory Commission, Report to the Congress: Medicare Payment Policy, ch. 8 (Mar. 2021) (2019: about 3.3 million beneficiaries; more than 11,300 agencies; $17.8 billion); Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2021, NAICS 621600 (1,514,860). ↩
  4. 42 U.S.C. § 1396n(c); 42 C.F.R. Part 441, Subpart G; CMS, Appendix K: Emergency Preparedness and Response, template and State approvals (Ex. SEC-04-078) (Pennsylvania's Appendix K, approved for the period Mar. 6, 2020 through May 11, 2023, permitting remote level-of-care assessments, telephonic monitoring and retainer payments). The Kaiser Family Foundation's survey of Appendix K approvals records that all fifty States used virtual evaluations and thirty-eight authorized retainer payments. ↩
  5. N.J. Exec. Order No. 252 ¶ 5 (Aug. 6, 2021) (Ex. SEC-04-030) ("registered health care service firms"); 10 NYCRR § 2.61(a)(1)(ii) (Ex. SEC-04-058) ("licensed home care service agencies"); Cal. State Public Health Officer Order of Sept. 28, 2021 (Ex. SEC-04-037) ("registered home care aides and certified home health aides"); Del. DHSS Emergency Secretary's Order amending 16 Del. Admin. Code 3345, Personal Assistance Services Agencies (Sept. 10, 2021) (Ex. DE-055; Ex. AGY-ST-HEALTH-SUBORDERS-045); Philadelphia Department of Public Health, PDPH-HAN-00363A (Aug. 25, 2021) (Ex. SEC-04-046) ("home and community based care attendants"). ↩
  6. 42 C.F.R. §§ 418.22(a)(4) (face-to-face encounter), 418.76(h) (aide supervision), 418.78(e) (volunteers at five percent of patient-care hours). Each was waived: Ex. SEC-04-015 (Hospice section); CMS-1744-IFC, 85 Fed. Reg. 19230 (Apr. 6, 2020) (Ex. SEC-04-017) (hospice face-to-face encounter by telehealth). ↩
  7. Medicare Payment Advisory Commission, Report to the Congress: Medicare Payment Policy, ch. 11 (Mar. 2021) (2019: more than 1.6 million beneficiaries; 4,840 providers; $20.9 billion; the quoted sentence appears in the chapter's discussion of 2020 conditions). ↩
  8. 42 U.S.C. §§ 1395i-3(h), 1396r(h) (enforcement); 42 C.F.R. Part 488, Subparts E and F; CMS, State Operations Manual, Appendix PP (the F-tags); Ex. SEC-04-001 (F563, F880); Ex. SEC-04-005 (F886). ↩
  9. National Center for Health Statistics, Long-term Care Providers and Services Users in the United States, 2017-2018, Vital and Health Statistics Series 3, No. 47 (Feb. 2022); Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2021, NAICS 623100 (1,407,480). ↩
  10. National Center for Health Statistics, supra (31,400 communities; 918,700 residents); American Health Care Association and National Center for Assisted Living, Facts and Figures (about 41,465 communities; nearly 1.4 million licensed beds). The orders' definitions: Conn. Exec. Order No. 13F § 1(a) (Sept. 3, 2021) (Ex. SEC-04-051) ("long-term care facility" includes "a nursing home, residential care home, assisted living services agency, managed residential community"); Cal. State Public Health Officer Order of July 26, 2021 ¶ 1 (Ex. SEC-04-036) ("Adult and Senior Care Facilities"); Md. Dep't of Health, Amended Directive and Order Regarding Nursing Home Matters (Aug. 18, 2021) (Ex. MD-059) (nursing homes and assisted living programs); Mich. Dep't of Health & Human Servs., Emergency Order, Residential Care Facilities (May 21, 2021) (Ex. MI-072) (nursing homes, homes for the aged, adult foster care facilities, assisted living facilities); Mo. Dep't of Health & Senior Servs., Order (May 18, 2020) (Ex. MO-009) (long-term care facilities, assisted living facilities, residential care facilities). ↩
  11. National Center for Health Statistics, supra (4,200 adult day services centers; 286,300 participants); Minneapolis Emergency Regulation No. 2020-3 (Mar. 17, 2020) (Ex. MET-MSP-003) (adult day care centers added to the closed places of public accommodation; rescinded July 24, 2020); N.J. Dep't of Health, Executive Directive No. 21-007, Adult Medical Day Care (June 14, 2021) (Ex. AGY-ST-HEALTH-SUBORDERS-059; Ex. NJ-081, whose saved text is the Feb. 17, 2023 revision), and Executive Directive No. 21-006, PACE Centers (June 15, 2021) (Ex. AGY-ST-HEALTH-SUBORDERS-060) (each in force to Jan. 11, 2022); CMS, QSO-20-23-ICF/IID & PRTF (Mar. 30, 2020) (Ex. SEC-04-013) (visitation restrictions, screening and group-activity limits for intermediate care facilities). ↩
  12. Cal. Exec. Order N-33-20 (Mar. 19, 2020) (Ex. CA-002); CMS, QSO-20-18-HHA (Mar. 10, 2020) (Ex. SEC-04-010) (directing agencies to identify patients with symptoms or exposure before or upon arrival at the home; staff with symptoms "[i]mmediately stop work, put on a facemask, and self-isolate at home"); 29 C.F.R. § 1910.502(a)(2)(v), (d), (f) (Ex. SEC-04-014); N.J. Exec. Order No. 242 ¶ 13 (May 24, 2021) (Ex. NJ-050) (face coverings in home health settings); Mass. Dep't of Pub. Health, Guidance and Order on face coverings in health care settings including home health (May 28, 2021) (Ex. MA-050). ↩
  13. Ex. SEC-04-015 (Home Health Agencies section) (home health waivers of 42 C.F.R. §§ 484.55(a)(2), (b)(3) and 484.80(h)); CMS-1744-IFC, 85 Fed. Reg. at 19250 (Ex. SEC-04-017) (home health agencies may furnish services "via a telecommunications system, as long as such services do not: (1) Substitute for in-person home health services ordered as part of a plan of care certified by a physician; and (2) are not considered a home health visit for purposes of eligibility or payment"; homebound status clarified for patients whose physician advises them not to leave home because of COVID-19); Ex. SEC-04-078 (Appendix K remote assessments). ↩
  14. N.Y. Exec. Order No. 202.30 (Ex. SEC-04-049); CMS, QSO-20-25-NH (Apr. 13, 2020) (Ex. SEC-04-026) (transfer and cohorting; dedicated COVID-19 units); Los Angeles County Health Officer Order (Apr. 24, 2020) (Ex. MET-LA-066) (admission, cohorting, dedicated staff); N.J. Dep't of Health, Executive Directive No. 20-026 (Aug. 20, 2020) (Ex. SEC-04-043) (Phase 0 for facilities in outbreak: no new admissions); Pa. Dep't of Health, Orders of the Secretary Directing Universal Testing of Residents and Staff (June 8 and June 26, 2020) (Ex. SEC-04-050). ↩
  15. 42 C.F.R. § 483.10(f)(4) (the right to receive visitors); Ex. SEC-04-001 (Mar. 13, 2020); Ex. SEC-04-002 (Sept. 17, 2020); Ex. SEC-04-003 (revised Mar. 10 and Apr. 27, 2021); the State instruments are collected in the State layer below and in the fifty-State table on this page. ↩
  16. CMS, Non-Emergent, Elective Medical Services, and Treatment Recommendations (Apr. 7, 2020, revising the recommendations of Mar. 18, 2020) (Ex. FED-158); N.Y. Exec. Order No. 202.10 (Mar. 23, 2020) (Ex. NY-005) (cancellation of elective surgeries); Utah State Public Health Order UPHO 2020-03 (Mar. 23, 2020) (Ex. UT-003) (elective surgeries and procedures); Tex. Exec. Order GA-09 (Mar. 22, 2020) (Ex. TX-004); N.Y. Exec. Order No. 202.30 (Ex. SEC-04-049); N.J. Dep't of Health, Executive Directive No. 20-026 (Ex. SEC-04-043); N.J. Dep't of Health, Memorandum, Hospital Discharges to Post-Acute Care Settings (Mar. 31, 2020) (Ex. NJ-064). ↩
  17. Ex. SEC-04-004 (§ 483.80(h)); Ex. SEC-04-005 (QSO-20-38-NH); Ex. SEC-04-014 (§ 1910.502(c)-(l), (q)); Ex. SEC-04-030 (N.J. EO 252); Ex. SEC-04-058 (10 NYCRR § 2.61); Ex. SEC-04-045 (Philadelphia Board of Health regulation); Ex. SEC-04-037 (Cal. Sept. 28, 2021 order). ↩
  18. CDC, Order: Requirement for Persons To Wear Masks While on Conveyances and at Transportation Hubs (Jan. 29, 2021) (Ex. FED-020); the metropolitan transit and travel-quarantine orders are collected in the layers section below. ↩
  19. QSO-20-14-NH (REVISED) (Mar. 13, 2020) ("Cancel communal dining and all group activities, such as internal and external group activities") (March 13, 2020 revised text, as recited in Ex. SEC-04-002 and adopted in terms in Ex. MET-MKE-002; the saved Ex. SEC-04-001 carries the March 9, 2020 text); Public Health Madison & Dane County, Order ¶ 2(b)(xi) (Mar. 15, 2020) (Ex. MET-MKE-002) ("Cancel all group activities and communal dining"); Minneapolis Emergency Regulation No. 2020-11 (Apr. 23, 2020; effective Apr. 28, 2020) (Ex. MET-MSP-008) ("All communal dining and activities are to be suspended"); Ex. MET-LA-066 (no communal dining); CMS, QSO-20-30-NH (May 18, 2020) (Ex. SEC-04-012) (communal dining and group activities restored by phase). ↩
  20. 42 C.F.R. §§ 483.35(d), 483.95(g) (nurse aide training and competency; the four-month rule), waived in Ex. SEC-04-015 (Long Term Care Facilities section); N.J. Dep't of Health, Executive Directive No. 20-005 (Mar. 31, 2020) (Ex. AGY-ST-HEALTH-SUBORDERS-058) (out-of-State certified nurse aides at assisted living facilities); Bexar County, Tex., Supplemental Executive Order NW-04 (Apr. 3, 2020) (Ex. MET-SAT-009) (long-term care staff to work at a single facility); San Bernardino County Health Officer, Order for All Individuals Entering Licensed Facilities (Apr. 6, 2020; updated May 8, 2020) (Ex. MET-RIV-022; Ex. MET-RIV-027) (screening, masking, N95 for COVID-19 care, single-facility staffing). ↩
  21. 42 C.F.R. § 483.80(g), added by CMS-5531-IFC, 85 Fed. Reg. 27550 (May 8, 2020) (Ex. SEC-04-006) (NHSN reporting "no less than weekly"; notification of residents, representatives and families "by 5 p.m. the next calendar day"); R.I. Exec. Order No. 20-17 (Apr. 7, 2020) (Ex. RI-011) (daily reporting by congregate-care facilities); Pa. Dep't of Health, Order Requiring Daily Reporting by Skilled Nursing Facilities (Ex. AGY-ST-HEALTH-SUBORDERS-069); St. Louis County, Mo., Residential Living Facilities Order (Apr. 2, 2020), continued as the Residential Living Facilities Reporting Requirement Order (Ex. MET-STL-056). ↩
  22. Bureau of Labor Statistics, Quarterly Census of Employment and Wages, private annual averages, NAICS 6231 and 6233, 2019 and 2021; the stay-at-home, school-closure and quarantine orders are collected in the layers section below; the single-facility staffing orders are Ex. MET-SAT-009, Ex. MET-SAT-035, Ex. MET-RIV-022 and Ex. MET-RIV-027. ↩
  23. Ex. CA-002 (stay at home); Ex. SEC-04-001 (visitors); Ex. FED-158 (elective procedures); Ex. SEC-04-017 (telecommunications in home health); Ex. SEC-04-078 (retainer payments); Ex. SEC-04-015 (Long Term Care Facilities section: three-day qualifying stay waived under section 1812(f)). ↩
  24. Determination that a Public Health Emergency Exists (Jan. 31, 2020) and renewals (Ex. FED-010; renewal of July 19, 2021, Ex. FED-016); Proclamation 9994, Declaring a National Emergency Concerning the Novel Coronavirus Disease (COVID-19) Outbreak, 85 Fed. Reg. 15337 (Mar. 13, 2020) (Ex. FED-001); 42 U.S.C. § 1320b-5; Ex. SEC-04-015 (waivers "retroactive to March 1, 2020"). ↩
  25. Ex. SEC-04-006 (May 8, 2020); Ex. SEC-04-004 (Sept. 2, 2020); Ex. SEC-04-008 (May 13, 2021); Ex. SEC-04-078 (Appendix K). ↩
  26. 86 Fed. Reg. 32376 (June 21, 2021) (Ex. SEC-04-014); id. at 32530 (NAICS 621610, home health care services, among the covered industries), 32562 (home healthcare coverage discussed). ↩
  27. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2021, NAICS 621600 (home health and personal care aides: 861,740 employed; median hourly wage $13.77; registered nurses 173,790; licensed practical and vocational nurses 89,280) and NAICS 623100 (nursing assistants: 471,160; median $14.41; licensed practical and vocational nurses 177,960; registered nurses 131,320); PHI, Direct Care Workers in the United States: Key Facts (2021) (workforce demographics). Each figure is context, stated with its unit and source. ↩
  28. Ex. MET-SAT-009; Ex. MET-SAT-035 (Bexar County, July 17, 2020: nursing home visitation barred and single-facility staffing continued); Ex. MET-RIV-022; Ex. MET-RIV-027; Ex. SEC-04-049 (New York personnel testing twice weekly); N.J. Dep't of Health, Executive Directive No. 20-013 (May 12, 2020) (Ex. SEC-04-042) (baseline testing of all staff by May 26, 2020 and retesting); Ex. SEC-04-004 (§ 483.80(h)(1): "facility staff, including individuals providing services under arrangement and volunteers"). ↩
  29. Ex. FED-158; N.Y. Exec. Order No. 202.10 (Mar. 23, 2020) (Ex. NY-005); Ex. UT-003; Ex. TX-004; Ex. IA-005; Ex. AK-007; Ex. AR-040; Pa. Dep't of Health, Order (Nov. 23, 2020) (Ex. PA-025) (elective-procedure reduction, in force to Aug. 23, 2021); Ex. SEC-04-049; Ex. MET-LA-066; Ex. MET-MSP-008; Ex. SEC-04-001. ↩