The Centers for Medicare & Medicaid Services (CMS) holds weekly COVID-19: Nursing Home calls, bringing together insights from CMS officials, experts at the Centers for Disease Control and Prevention (CDC), and nursing home staff who have been navigating COVID-19 in their facilities. Here are highlights from the April 8 and April 15 calls:
Expect targeted infection control surveys to continue UFN
CMS will continue to conduct targeted infection control inspections using the COVID-19 Focused Survey for Nursing Homes assessment tool included in the March 23 Quality, Safety, and Oversight (QSO) memo QSO- 20-20-ALL. While that memo set a three-week time frame for enforcement discretion and tiered survey prioritization, “we have not resumed operations as normal, so those conditions are still in effect—and they will be in effect until we communicate anything differently,” stress officials.
Providers shouldn’t assume staff are complying with all CMS and CDC guidelines related to infection prevention and control, suggest CMS officials. “We have observed that, on occasion, this is not the case. If you could set aside just a little time to observe and to train—and to make sure that all of your workers are following the guidelines—it would go a long way to help you, and obviously the residents, as we go along.” For example, training on how to don and doff personal protective equipment (PPE), including gloves, could still be beneficial, they note.
CMS is working with the CDC to develop short training materials (e.g., podcasts or webinars) to help providers. Topic suggestions, as well as other questions and comments, can be submitted to email@example.com. In addition, the quality improvement organizations are providing targeted assistance, note officials.
Review recent policy and guidance changes
CMS and CDC officials highlighted three recent updates:
* Physician visits. CMS has temporarily waived the requirement that all required physician visits be made personally by the physician, permitting physicians to “delegate any required physician visit to a nurse practitioner (NP), physician assistant, or clinical nurse specialist who is not an employee of the facility, who is working in collaboration with a physician, and who is licensed by the state and performing within the state’s scope of practice laws.” Previously, CMS temporarily waived the requirement for physicians and nonphysician practitioners to perform in- person visits for nursing home residents, allowing visits to be conducted using telehealth as appropriate.
The intent is for nursing homes to be able to combine these different waivers to ensure appropriate medical coverage of their residents during the pandemic, say officials.
* Resident transfers. CMS QSO memo QSO-20-25-NH provides guidance for transferring or discharging residents between facilities “for the purpose of cohorting residents based on COVID-19 status (i.e., positive, negative, unknown/under observation).” In general, if two or more certified long-term care facilities want to transfer or discharge residents between themselves for the purposes of cohorting, they do not need additional approval to do so, say CMS officials.
“If, however, a certified long-term care facility would like to transfer or discharge residents to a noncertified location for the purposes of cohorting, they will need approval from the state agency to do that,” they explain. “To assist you in making the proper decisions, we have created a helpful set of diagrams [that] walk you through the process.” Note: When transferring or discharging residents to cohort, it’s critical to keep families in the loop. The Center for Medicare Advocacy noted allegations that the first nursing home to transition to COVID-19-only status failed to adequately notify residents’ children, many of whom did not know where their parent was 24 hours after their transfer to other facilities.
* Nursing home infection prevention guidance. The CDC has updated the Interim Additional Guidance for Infection Prevention and Control for Patients With Suspected or Confirmed COVID-19 in Nursing Homes to include Key Strategies to Prepare for COVID-19 in Long-Term Care Facilities, which generally aligns with and expands upon CMS’s April 2 COVID-19 Long-Term Care Facility Guidance. For example, it promotes universal source control by having everyone entering a facility wear either a cloth-based covering or a face mask, as well as recommending that ill residents be monitored, including their temperature and oxygen saturation, a minimum of three times daily.
Get dedicated therapy staff now
Lynn Care Center has worked with its contract rehabilitation therapy provider to dedicate therapy staff only to its facility, says Crystal Larson, the administrator of Lynn Care Center in Front Royal, VA. “Each of those therapists had to agree to let go of any PRN position that they had at other facilities because the risk of cross-contamination was just too high.” To give therapists extra time, Larson’s team has used them to supplement nursing assistants based on case load. For example, they may do water passes or help residents with showers.
Providers shouldn’t wait to begin that process of dedicating therapists to only one building until they experience a COVID-19 outbreak, stresses John Mielke, MD, a medical director for a nursing home in Minneapolis, MN, and a member of the Minnesota Association of Geriatric Inspired Clinicians. “We're fooling ourselves if we think our community is going to dodge this bullet. It's really important to stop cross-contamination—and the contamination from the community—into each of these buildings up-front. So I would have dedicated therapy staff as much as possible.” In addition, therapists should do all therapy in resident rooms if there are COVID-19-positive residents in the building, he adds.
Explore staff communication options
While e-mail blasts are a classic staff communication option, Lynn Care Center’s health system provides updates to staff via a smartphone app called Poppulo, “We do daily updates seven days a week that let our associates know the changes that are being made through the day,” says Larson. “We also do a little newsletter every day, just for our facility specifically, updating the staff on what's going on every day.”
Prioritize staff morale
To show staff appreciation, “we have established casual days on which team members can wear casual [clothes] or fun scrubs,” says Michelle Hart Carlson, the administrator at Oak Trace, a Lifespace community in Downers Grove, IL. In addition, “food is always a hit, so we do spontaneous food fun, grabbing doughnuts in the morning or deciding to provide fast food for lunch or pizza on the weekends, all while supporting local businesses that have been hit by COVID-19,” she says.
Lynn Care Center’s health system has created a 24-hour employee assistance hotline to support staff, as well as setting up a biweekly call to talk with staff about decreasing stress and improving mental health and wellness during this pandemic, says Larson.
“One of the things that I've been focusing on with my leadership team and with the staff here at the facility is trying to find five things every day to be grateful for,” adds Larson. “Even though this is a very difficult time, there are a lot of lessons that we can learn and some positive changes we can make for our future.”
Plan for sick staff—including how to bring them back
Providers should anticipate seeking “significant support from agency or other staffing routes to back up the staff who are sick,” says Liz Weingast, vice president of clinical excellence at the New Jewish Home in New York. “Our staff started getting sick really [on] the same timeline as our residents. That is something you would certainly want to plan in advance for.”
In addition, the New Jewish Home has established a system for addressing sick calls, says Weingast. “We have beefed up our whole occupational health program, having several nurses call our sick employees encouraging them to seek appropriate care but also to get back to work in a timely manner when their period of illness is done.” Note: On April 13, the CDC updated the Criteria for Return to Work for Healthcare Personnel With Confirmed or Suspected COVID-19 (Interim Guidance).
Go small with staff education
One-to-one and small group education on COVID-19 works best, suggests Hart Carlson. “It allows for social distancing, and we have also seen that it alleviates the fear of asking questions in a larger group.”
Oak Trace has added six-feet space reminders on the floors to remind staff members to maintain physical distancing when they enter the building, “particularly at peak times when team members are coming into work,” adds Hart Carlson.
Think about support staff when preparing to cohort
“Cohorting residents who do have COVID-19 or suspected COVID-19 is very successful,” says Weingast. “It has reduced our drain of PPE because in a fully COVID-19 unit, you can continue to wear, for example, the same gown in and out of other patients’ rooms, and you don’t have to change your mask.”
However, cohorting is a “big drain” on support staff who have to move residents and clean rooms to set it all up, says Weingast. “You do need to ensure that you have the proper support staff in place to make that happen.”
Have advance directive discussions
“We found that having these conversations early on either in the illness or prior to the illness has been extraordinarily important in supporting the residents who have acquired the COVID-19 illness,” says Weingast. “Understanding the resident’s goals of care … has really helped guide how we treat our patients: how we help those who do enter an end-of-life situation and end up dying with us, and help others who would prefer more aggressive care going to the hospital. Those are important conversations to have and need to be integrated into your planning.”
Providers should establish whether the resident’s goals of care include the following, says Weingast:
- Do not resuscitate,
- Do not intubate, and/or
- Do not hospitalize.
Note: The April 13 webinar, Advance Care Planning in PALTC: Even More Vital Now, is available free to anyone who registers at the California Association of Long-Term Care (CALTCM).
Bring on admin and medical staff seven days a week
Nursing homes are used to providing a consistent level of nursing care seven days a week. However, with COVID-19 in the building, it’s just as important to spread medical staff and administrative staff across seven days a week, says Weingast. “We have gotten rid of the concept of the weekend during the crisis, and it is extraordinarily helpful to communicating with families, to really giving the best clinical care, and to supporting the nursing team who are the ones who are always here seven days a week.”
Establish a best practices management support group
At Lifespace, a senior vice president hosts calls twice a week “where we are able to share best practices throughout our 15 communities in eight states,” says Hart Carlson. “If you are not part of a chain, you could band together with local nursing homes and set up weekly calls to share the same.”
“Here in our area in the Shenandoah Valley of Virginia, we do have a small coalition of our hospital partners, skilled nursing facilities, and assisted living facilities that have been meeting at least weekly to talk about ideas for setting up quarantine areas and isolation areas, sharing resources, and just generally supporting each other,” notes Larson. “Facilities that were typically competitive with each other are now working together for a common mutual need.”
Stockpile PPE but oxygen and IV fluids too
Seeking to source the larger numbers of PPE staff need is important, says Hart Carlson. “However, we have found that when ordering small numbers more frequently, we tend to see those get shipped.”
While PPE obviously gets top billing, other supplies could run short as well, adds Weingast. The greater the number of COVID-19 residents in the building, the faster the facility will use both oxygen and IV fluids. “You will want to talk to your vendors to make sure there is plenty of supply.”