NC care facilities, counties inconsistent in reporting outbreaks

Early Thursday morning, Tabor Commons Assisted Living in Columbus County announced it had 40 confirmed cases of COVID-19 — more than a quarter of the county's quickly growing total of 153 cases.

The announcement came in the wee hours, after the county health department had announced a new outbreak of the virus at a congregate care facility the previous day but did not say where.

Instead of providing details, the county had alluded to a new outbreak in a press release, saying 27 of the county's surge of 38 cases in one day were from a congregate care setting.

But, until early Thursday morning, county residents and those with loved ones who lived at Tabor Commons were left in the dark about the details of the outbreak.

The reporting of that outbreak in Columbus County is the latest illustration of the various ways in which county health departments are tracking reported outbreaks at group living facilities across the state.

A survey of counties by journalists from six newsrooms across the state found that reporting of COVID-19 cases at facilities varies and the way in which that information is then transmitted to the state is inconsistent.

That means the public can still be left unaware about an outbreak of the virus at a facility, even as the North Carolina Department of Health and Human Services started releasing specific information about outbreaks at congregate care facilities early this week.

In light of the new disclosure policy announced by DHHS on Monday, reporters asked county health departments to provide documents showing when individual care facilities reported outbreaks to their agency and how those reports were then transmitted to the state.

The response to that request has largely been silence.

County health departments still reluctant to identify facilities

In Columbus County, the initial lack of information about the outbreak at Tabor Commons stemmed from a decision by the county’s health director to let the facility announce the outbreak itself — ahead of DHHS releasing its updated list of facilities with outbreaks every Tuesday and Friday.

Daniel Buck, a spokesperson for the county health department, said the county's policy would be to let facilities make public announcements on their own or wait for the state's release.

"The decision to give the congregate living facilities the opportunity to discuss outbreaks was decided by the county health director, Kim Smith, with the understanding that if the facilities did not release the information on their own, the state would," Buck said.

But according to records obtained by reporters, Tabor Commons knew it had a growing number of cases days before its first announcement on April 26, when the facility posted to social media that it had identified its "first" positive case.

Records show the assisted living facility actually discovered its first case nearly three weeks before, when an employee tested positive on April 6. By April 24, three residents had been diagnosed with COVID-19, prompting the facility to conduct mass testing.

The state defines an outbreak as two or more positive cases.

Mass testing at Tabor Commons started Monday, and the local health department learned of the growing number of cases over the next three days. By Wednesday, county health officials announced their totals.

But until Thursday morning, Tabor Commons’ leadership refused to confirm its facility was the site of the outbreak.

When contacted by reporters Wednesday afternoon, the president of the group that owns Tabor Commons declined to confirm it was the involved facility, and referred reporters to the new DHHS bi-weekly disclosures.

Hours later, the facility posted about the outbreak on Facebook.

Even with the new disclosure from Tabor Commons, the number of reported cases and outbreaks confirmed in Columbus County does not match state totals.

​Buck said numbers reported locally could easily not match those reported by state, as reports of cases "sporadically get reported to us at all times of the day and night."

All but a handful of county health departments refused to provide records or did not respond to requests regarding COVID-19 outbreaks at congregate living facilities reported to their agency.

Greene County Health Director Joy Brock responded to a request for records from congregate care facilities to her health department with a link to an entirely different record: the state DHHS website with the overall state tally of COVID-19 lab-confirmed tests, hospitalizations and deaths.

“Please look under the congregate living tab,” Brock said.

Halifax County Health Director Bruce Robistow also directed a reporter to the information state officials began releasing this week. DHHS currently lists no outbreaks in the county's long-term care homes, and Robistow said his department hasn't received any reports of positive cases at the facilities.

The state Department of Public Safety is tracking more than a dozen positive cases at Caledonia Correctional Institution in Tillery, N.C.

"Caledonia Prison has reported only a couple of positive cases to us," Robistow wrote in an email April 30. "Providing those redacted forms would basically provide you with a blank form."

Notifying public ‘not a top priority’ for top state health official

In Burke County, a spokeswoman for the county health department declined to provide any records showing how the staff tracks reported outbreaks of COVID-19 at congregate living facilities without more guidance from the state.

“The N.C. Local Health Directors Association has directed this type of request to state leadership to give guidance on addressing this request and we are waiting on their response. As soon as we hear back from them, we will get back to you,” a county spokeswoman said.

An email request for additional information and comment from the N.C. Local Health Directors Association sent early Thursday afternoon went unanswered.

As of late Thursday evening, DHHS said it had provided no such guidance to county health departments. But the agency did make the state epidemiologist, Dr. Zack Moore, available for an interview for this story.

When asked about what guidance his agency was providing to county health departments, Moore said he didn’t have an answer to the question.

“We work with them, supporting them, on all the steps that need to be taken. We are now posting these data on the DHHS website and you’ve seen local health departments post their own data on their own websites as well,” Moore said. “I don’t know that I have anything specific on guidance to them on that topic.”

During the interview, Moore downplayed the importance of notifying the public of an outbreak at congregate living facilities.

“I think that the public notification piece is not, in my mind, a major component of the response. The residents are aware, staff are aware and they are taking, you know, those precautions. So, it’s not, in my mind, a major component of the outbreak investigation and response,” Moore said.

When pressed by a reporter, Moore said notifying the public of an outbreak takes a backseat to putting in measures to prevent further spread.

“That’s not the top priority,” Moore said of county health departments notifying the public of a reported outbreak. “What they’re actually doing with the residents and with the staff is the top priority.”

Moore’s comments are at odds with the Centers for Disease Control and Prevention’s field epidemiology manual, which includes an entire chapter devoted to communicating with the public during a public health investigation.

“From the beginning of an event to its resolution and follow-up, public health authorities are expected to provide the news media with timely, accurate information and answers about the outbreak’s effects,” the CDC manual says.

The manual goes on to say that communicating during a public health investigation is key to gaining and maintaining the trust of the public. That trust may determine whether the public follows the advice and guidelines of health officials going forward.

“Trust and credibility can greatly influence your ability to persuade affected persons to follow public health authorities’ recommendations during an outbreak or public health response,” the manual says. “The ability to contain and stop the outbreak might hinge on established relationships and coordination with key partners and stakeholders.”

Records show some counties offering mass testing at nursing homes

Not all counties needed guidance from the state before responding to reporters’ requests for records. It took Moore County health officials just a day to turn over 56 pages of records in response to the collaborative's request.

DHHS data released this week shows Moore has one outbreak of 65 COVID-19 cases at Pinehurst HealthCare and Rehab, where three people have died from disease.

After learning of an outbreak at the Pinehurst Healthcare and Rehabilitation Center, Moore County Health Director Robert Wittmann ordered testing for all residents and staff at the facility and prohibited new admissions on April 3.

Wittmann's order — along with news of the Pinehurst Healthcare outbreak — was first reported by The Pilot, one of the North Carolina newsrooms that threatened to sue the state over its refusal to release nursing home outbreak locations in mid-April.

The nursing home alerted its own employees in a letter on April 5 that several workers had been diagnosed with COVID-19. One was already hospitalized. While testing for residents would begin the next day, the company said all employees would receive tests April 7 in a drive-up operation run by the county health department and local hospital.

Days later on April 10, Wittmann wrote in a press release shared directly with top long-term care administrators that further testing at the facilities was no longer necessary due to broad asymptomatic spread of the virus. It was highly likely, Wittmann wrote, that COVID-19 was present in all Moore County nursing homes.

“Without complete and continuous testing with rapid results, we have no way to truly get a handle on virus transmission," Wittmann said in the statement. "At this time, we do not have the testing capabilities for such an undertaking."

Less than two weeks later, that changed after the county received federal funding to expand testing.

Wittmann wrote again to the top leaders of the county's nursing homes on April 24, noting that the health department was required to test residents and staff in cases of outbreaks. Thanks to a newly signed $96,600 contract with Mako Medical Laboratories, the county could do it at no cost to the facilities.

"I am offering you an opportunity to test your facility before you experience an outbreak," he wrote. "I can furnish you the testing materials, consulting service, and the transporting of the test samples to the laboratory."

As of Thursday afternoon, Moore County spokesperson Matt Garner said although some nursing homes have expressed interest, no facilities had committed to taking the health director up on the free testing offer.

Records show Pinehurst Health and Rehab nurses have reported new COVID-19 deaths and cases directly to Moore County's nursing director by email in some cases. But even this reporting shows that attributing deaths to the disease can be tricky.

Pinehurst Health and Rehab on Monday reported two deaths for COVID-19 positive residents under hospice care – one who had been in gradual decline and another suffering from cervical cancer.

"Please review the two cases with your medical director or patient's physician to determine if the deaths were caused by COVID or if their underlying illness was more likely the cause of death," Moore County nursing director Melissa Fraley wrote on April 27. "Please let me know what is decided."

Path for reporting cases from facility to state unclear

The limited information counties did provide in response to reporters’ inquiries shows each county handles reporting cases of COVID-19 differently.

Some counties, including Burke, Chatham and Wilson, take reports of COVID-19 cases from congregate living facilities over the phone.

"The records that you requested do not exist. We utilize phone confirmation or the state’s surveillance system. We update our congregate information on our dashboard at wilson-co.com," an assistant county manager in Wilson County said in response to a request for records documenting reports of COVID-19 from congregate living facilities.

A spokesman for the Chatham County health department said the agency tracked reported cases in a state database but declined to produce those records, citing federal privacy laws. The spokesman did not respond to a follow-up question from a reporter asking for the specific part of the law that prevented release of the requested records.

Wayne County responded to a public records request made by the collaborative, saying “no records, such as you requested, exist.”

Wayne County Director of Public Affairs Carol Bowden referred to both the county and state’s COVID-19 dashboard for more information.

Granville Vance Public Health Director Lisa Macon Harrison said she wasn't aware of any records that would be responsive to a reporter’s request, aside from what the two-county partnership reports on its website.

That’s because public health staff there get information in real-time through the statewide N.C. Electronic Disease Surveillance System, a database administered by DHHS. Labs conducting tests enter positive cases in that system immediately, often at the same time they’re reporting them to the physicians and nurses who order the tests for their patients.

That means her staff knows about COVID-19 cases before nursing homes do, and can report to the facilities first.

“Right now, we're working so fast and we're doing so much heavy lifting on data management that there's not a lot of written documentation,” Harrison said.

The state is reporting no nursing home outbreaks in Granville County, but it’s identified 10 cases and one death at Pelican Health in Vance County.

Consistent with the governor's April 9 executive order, which requires long-term care facilities to notify local health departments immediately about "any resident with new, confirmed or suspected COVID-19," Harrison said nursing homes and hospitals do report suspected cases by phone so her staff can be on the lookout for the results.

When rapid tests for COVID-19 are more widely available, she said it might make more sense to hear directly from nursing homes and providers about positive tests. But for now, there’s a lag between sampling at the various providers across her two counties and the results processed and entered into NC EDSS by at least a half dozen labs.

“I'm grateful we at least have that system to keep us connected,” she said.

Other counties, including Iredell and Moore, rely on facilities sending local health departments an email to update their cases.

An email provided by the Iredell County Health Department shows the report comes with little fanfare.

The email from Autumn Care of Statesville nursing home to the county health department regarding a positive case at the facility simply said “New +.”

“We had a patient test +. We have implemented our protocols and call me with any questions,” the nursing home’s director of nursing wrote to the health department.

A spokeswoman for the Iredell County health department did not respond to a follow-up question from a reporter asking how the county agency then notifies DHHS of the facility’s report.

In Johnston County, health department staff said they communicate daily with Springbrook Rehabilitation and Nursing Center in Clayton. The health department typically informs the facility of new positive cases, rather than the other way around, said public information officer Lu Hickey.

That’s because positive tests are usually reported to the health department first, Hickey said.

“Some laboratories feed their lab results directly to the state, while others do not,” Hickey wrote in an email. “For the labs that do not report directly, health department staff enter the information manually into the state’s electronic system (NCEDSS).”

In Johnston, when a positive test result is identified, it’s counted in the county’s COVID-19 dashboard that day, as long as the information is received before 4 p.m., Hickey said.

Springbrook first contacted the health department on April 1 to communicate that someone from its facility had been sent to be tested. An outbreak was identified three days later.

Dr. Zack Moore, the state epidemiologist, said it should typically take about a day between the time in which a facility reports an outbreak to a county health department and that agency relays the report to DHHS.

Moore said county health departments typically report new cases and outbreaks by calling one of two phone numbers staffed around the clock by DHHS personnel.

Sometimes, though, a county health department’s notification to the state could be delayed.

“Many of our counties are very adept at dealing with these situations and, unfortunately, with COVID-19 they’ve had a lot of practice now. So, oftentimes, they’ve already started their outbreak investigation and response before they notify us at the state,” Moore said.

This story was jointly reported and edited by Kate Martin and Frank Taylor, of Carolina Public Press; Gavin Off, Ames Alexander and Doug Miller, of The Charlotte Observer; Lucille Sherman and Jordan Schrader, of The News & Observer; Nick Ochsner, of WBTV; Emily Featherston, of WECT; and Tyler Dukes of WRAL.