• April 8 CMS Call: COVID-19 in Nursing Homes

    Tuesday, April 7, 2020 | CMS

    Please join the Centers for Medicare and Medicaid Services (CMS) for a call on COVID-19 with Nursing Homes tomorrow, Wednesday, April 8th at 4:30 PM EST. CMS leadership will provide updates on the agency’s latest guidance and we will be joined by leaders in the field interested in sharing best practices with their peers. The call will be recorded if you are unable to join us.

    Conference lines are limited, so we highly encourage you to join via audio webcast, either on your computer or smartphone web browser. You are welcome to share this invitation with your colleagues and membership.

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  • COVID-19 Prevention / Management in Long-Term Care: CMS Issues New CDC-Based Recommendations (4-2-20)

    Thursday, April 2, 2020 | CMS

    The new recommendations include:

    ·  Nursing homes should immediately ensure that they are complying with all CMS and CDC guidance related to infection control.

    ·  As nursing homes are a critical part of the healthcare system, and because of the ease of spread in long term care facilities and the severity of illness that occurs in residents with COVID-19, CMS/CDC urges State and local leaders to consider the needs of long term care facilities with respect to supplies of PPE and COVID-19 tests.

    ·  Nursing homes should immediately implement symptom screening for all staff, residents, and visitors – including temperature checks.

    ·  Nursing homes should ensure all staff are using appropriate PPE when they are interacting with patients and residents, to the extent PPE is available and per CDC guidance on conservation of PPE.

    ·  To avoid transmission within nursing homes, facilities should use separate staffing teams for residents to the best of their ability, and, as President Trump announced at the White House today, the administration urges nursing homes to work with State and local leaders to designate separate facilities or units within a facility to separate COVID-19 negative residents from COVID-19 positive residents and individuals with unknown COVID-19 status.

    “The Trump Administration is calling on the nursing home industry and state and local leaders to join us by taking action now to ensure the safety of their residents, who are among our most vulnerable citizens. The Administration urges them to carefully review our recommendations, and implement them immediately,” said CMS Administrator Seema Verma.

    Today’s recommendations will help State and local governments, and nursing homes, as they consider creative ways to stop the spread of the virus, such as designating units within facilities – or entire facilities – solely for residents with confirmed COVID-19. An example of such an arrangement is in Wilmington, Massachusetts, in which a 142-bed facility has been designated as a solely COVID-19-positive facility. Residents across the region who are infected with COVID-19 can be moved to this facility to receive appropriate care and avoid transmitting the virus within their facilities. This approach also eases the challenges of preventing transmission, like extensive PPE usage and isolation practices, for individual facilities. The Massachusetts arrangement, developed in coordination with the state’s government, is a prime example of the arrangements envisioned in the recommendations announced today.

    The recommendations also speak to enhanced screening and transmission prevention practices. Previous CMS guidance, developed with CDC and issued in mid-March, advised nursing homes to restrict all but the most urgent visitors and staff. Today’s guidance builds on this by recommending temperature screenings for all visitors and that all staff utilize adequate PPE when interacting with patients, to the extent PPE is available.

    Nursing homes are unique in the healthcare system because, unlike other healthcare facilities, they are full-time homes as well as settings of care. Importantly, nursing home residents, given their advanced age and corresponding health issues, are at particular risk of complications arising from COVID-19. Because they are large concentrations of particularly vulnerable individuals, nursing homes have been a major focus for the Trump Administration in its aggressive efforts to combat the virus.

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  • COVID-19: Most States Have State-Specific Section 1135 Waivers as of 4/02/20

    Thursday, April 2, 2020 | CMS

    CMS approved additional state Medicaid waiver requests under Section 1135 of the Social Security Act (Act). The waivers were approved within days of states’ submitting them, and offer states new flexibilities to focus their resources on combating the outbreak and providing the best possible care to Medicaid beneficiaries in their states. The waivers were approved within days of states' submitting them, and offer states new flexibilities to focus their resources on combating the outbreak and providing the best possible care to Medicaid beneficiaries in their states.

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  • CDC PPE Burn Rate Calculator (4/20)

    Wednesday, April 1, 2020 | CDC

    This is a spreadsheet-based model that provides information for healthcare facilities to plan and optimize the use of PPE for response to coronavirus disease 2019 (COVID-19). Similarly, non-healthcare facilities (e.g., correctional facilities) may find this tool useful for planning and optimizing PPE use as part of the response to COVID-19. This tool can also be used for planning PPE use outside the context of COVID-19, where PPE shortages may also occur due to supply chain issues related to the COVID-19 response (e.g. manufacturing facilities).

    To use the calculator, you enter the number of full boxes of each type of PPE that you have in stock (e.g., gowns, gloves, surgical masks, respirators, and face shields). This tool then calculates the average consumption rate, also referred to as a “burn rate,” for each type of PPE entered in the spreadsheet. This information can then be used to estimate the remaining supply of PPE based on the average consumption rate. The spreadsheet is open-ended and can also be used to calculate the use of other types of PPE as well.

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  • CMS Adds New COVID-19 Waivers to Address Nurse Aide Training, Other Issues (4/20)

    Wednesday, April 1, 2020 | CMS

    Long Term Care Facilities (Skilled Nursing Facilities and/or Nursing Facilities): CMS Flexibilities to Fight COVID-19

    CMS is empowered to take proactive steps through 1135 waivers as well as, where applicable, authority granted under section 1812(f) of the Social Security Act (the Act) and rapidly expand the Administration’s aggressive efforts against COVID-19. As a result, the following blanket waivers are in effect, with a retroactive effective date of March 1, 2020 through the end of the emergency declaration. For general information about waivers, see Attachment A to this document. These waivers DO NOT require a request to be sent to the 1135waiver@cms.hhs.gov mailbox or that notification be made to any of CMS’s regional offices.

    Long-Term Care Facilities and Skilled Nursing Facilities (SNFs) and/or Nursing Facilities (NFs)

    • 3-Day Prior Hospitalization. Using the authority under Section 1812(f) of the Act, CMS is waiving the requirement for a 3-day prior hospitalization for coverage of a SNF stay, which provides temporary emergency coverage of SNF services without a qualifying hospital stay, for those people who experience dislocations, or are otherwise affected by COVID-19. In addition, for certain beneficiaries who recently exhausted their SNF benefits, it authorizes renewed SNF coverage without first having to start a new benefit period (this waiver will apply only for those beneficiaries who have been delayed or prevented by the emergency itself from commencing or completing the process of ending their current benefit period and renewing their SNF benefits that would have occurred under normal circumstances).

    • Reporting Minimum Data Set. CMS is waiving 42 CFR 483.20 to provide relief to SNFs on the timeframe requirements for Minimum Data Set assessments and transmission.

    • Staffing Data Submission. CMS is waiving 42 CFR 483.70(q) to provide relief to long-term care facilities on the requirements for submitting staffing data through the Payroll-Based Journal system.

    • Waive Pre-Admission Screening and Annual Resident Review (PASARR). CMS is waiving 42 CFR 483.20(k) allowing states and nursing homes to suspend these assessments for new residents for 30 days. After 30 days, new patients admitted to nursing homes with a mental illness (MI) or intellectual disability (ID) should receive the assessment as soon as resources become available.

    • Physical Environment.

    CMS is waiving requirements related at 42 CFR 483.90, specifically the following:

    • Provided that the state has approved the location as one that sufficiently addresses safety and comfort for patients and staff, CMS is waiving requirements under § 483.90 to allow for a non-SNF building to be temporarily certified and available for use by a SNF in the event there are needs for isolation processes for COVID-19 positive residents, which may not be feasible in the existing SNF structure to ensure care and services during treatment for COVID-19 are available while protecting other vulnerable adults. CMS believes this will also provide another measure that will free up inpatient care beds at hospitals for the most acute patients while providing beds for those still in need of care. CMS will waive certain conditions of participation and certification requirements for opening a NF if the state determines there is a need to quickly stand up a temporary COVID-19 isolation and treatment location.
    • CMS is also waiving requirements under 42 CFR 483.90 to temporarily allow for rooms in a long-term care facility not normally used as a resident’s room, to be used to accommodate beds and residents for resident care in emergencies and situations needed to help with surge capacity. Rooms that may be used for this purpose include activity rooms, meeting/conference rooms, dining rooms, or other rooms, as long as residents can be kept safe, comfortable, and other applicable requirements for participation are met. This can be done so long as it is not inconsistent with a state’s emergency preparedness or pandemic plan, or as directed by the local or state health department.

    • Resident Groups. CMS is waiving the requirements at 42 CFR 483.10(f)(5), which ensure residents can participate in-person in resident groups. This waiver would only permit the facility to restrict in-person meetings during the national emergency given the recommendations of social distancing and limiting gatherings of more than ten people. Refraining from in-person gatherings will help prevent the spread of COVID-19.

    • Training and Certification of Nurse Aides. CMS is waiving the requirements at 42 CFR 483.35(d) (with the exception of 42 CFR 483.35(d)(1)(i)), which require that a SNF and NF may not employ anyone for longer than four months unless they met the training and certification requirements under § 483.35(d). CMS is waiving these requirements to assist in potential staffing shortages seen with the COVID-19 pandemic. To ensure the health and safety of nursing home residents, CMS is not waiving 42 CFR § 483.35(d)(1)(i), which requires facilities to not use any individual working as a nurse aide for more than four months, on a full-time basis, unless that individual is competent to provide nursing and nursing related services. We further note that we are not waiving § 483.35(c), which requires facilities to ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents’ needs, as identified through resident assessments, and described in the plan of care.

    • Physician Visits in Skilled Nursing Facilities/Nursing Facilities. CMS is waiving the requirement in 42 CFR 483.30 for physicians and non-physician practitioners to perform inperson visits for nursing home residents and allow visits to be conducted, as appropriate, via telehealth options.

    • Resident roommates and grouping. CMS is waiving the requirements in 42 CFR 483.10(e) (5), (6), and (7) solely for the purposes of grouping or cohorting residents with respiratory illness symptoms and/or residents with a confirmed diagnosis of COVID-19, and separating them from residents who are asymptomatic or tested negative for COVID-19. This action waives a facility’s requirements, under 42 CFR 483.10, to provide for a resident to share a room with his or her roommate of choice in certain circumstances, to provide notice and rationale for changing a resident’s room, and to provide for a resident’s refusal a transfer to another room in the facility. This aligns with CDC guidance to preferably place residents in locations designed to care for COVID-19 residents, to prevent the transmission of COVID-19 to other residents.

    • Resident Transfer and Discharge. CMS is waiving requirements in 42 CFR 483.10(c)(5); 483.15(c)(3), (c)(4)(ii), (c)(5)(i) and (iv), (c)(9), and (d); and § 483.21(a)(1)(i), (a)(2)(i), and (b) (2)(i) (with some exceptions) to allow a long term care (LTC) facility to transfer or discharge residents to another LTC facility solely for the following cohorting purposes:

    1. Transferring residents with symptoms of a respiratory infection or confirmed diagnosis of COVID-19 to another facility that agrees to accept each specific resident, and is dedicated to the care of such residents;
    2. Transferring residents without symptoms of a respiratory infection or confirmed to not have COVID-19 to another facility that agrees to accept each specific resident, and is dedicated to the care of such residents to prevent them from acquiring COVID-19; or
    3. Transferring residents without symptoms of a respiratory infection to another facility that agrees to accept each specific resident to observe for any signs or symptoms of a respiratory infection over 14 days.

     Exceptions:

    • These requirements are only waived in cases where the transferring facility receives confirmation that the receiving facility agrees to accept the resident to be transferred or discharged. Confirmation may be in writing or verbal. If verbal, the transferring facility needs to document the date, time and person that the receiving facility communicated agreement.

    • In § 483.10, we are only waiving the requirement, under § 483.10(c)(5), that a facility provide advance notification of options relating to the transfer or discharge to another facility. Otherwise, all requirements related to § 483.10 are not waived. Similarly, in § 483.15, we are only waiving the requirement, under § 483.15(c)(3), (c)(4)(ii), (c)(5)(i) and (iv), and (d), for the written notice of transfer or discharge to be provided before the transfer or discharge. This notice must be provided as soon as practicable.

    • In § 483.21, we are only waiving the timeframes for certain care planning requirements for residents who are transferred or discharged for the purposes explained in 1–3 above. Receiving facilities should complete the required care plans as soon as practicable, and we expect receiving facilities to review and use the care plans for residents from the transferring facility, and adjust as necessary to protect the health and safety of the residents the apply to.

    • These requirements are also waived when the transferring residents to another facility, such as a COVID-19 isolation and treatment location, with the provision of services “under arrangements,” as long as it is not inconsistent with a state’s emergency preparedness or pandemic plan, or as directed by the local or state health department. In these cases, the transferring LTC facility need not issue a formal discharge, as it is still considered the provider and should bill Medicare normally for each day of care. The transferring LTC facility is then responsible for reimbursing the other provider that accepted its resident(s) during the emergency period.

    • If the LTC facility does not intend to provide services under arrangement, the COVID-19 isolation and treatment facility is the responsible entity for Medicare billing purposes. The LTC facility should follow the procedures described in 40.3.4 of the Medicare Claims Processing Manual (https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/clm104c06.pdf) to submit a discharge bill to Medicare. The COVID-19 isolation and treatment facility should then bill Medicare appropriately for the type of care it is providing for the beneficiary. If the COVID-19 isolation and treatment facility is not yet an enrolled provider, the facility should enroll through the provider enrollment hotline for the Medicare Administrative Contractor that services their geographic area to establish temporary Medicare billing privileges.

    We remind LTC facilities that they are responsible for ensuring that any transfers (either within a facility, or to another facility) are conducted in a safe and orderly manner, and that each resident’s health and safety is protected. We also remind states that under 42 CFR 488.426(a)(1), in an emergency, the State has the authority to transfer Medicaid and Medicare residents to another facility.


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  • CDC: Asymptomatic/Presymptomatic COVID-19 Residents May Up Transmission Risk in Nursing Homes Updated (3/20)

    Friday, March 27, 2020 | CDC

    Asymptomatic and Presymptomatic SARS-CoV-2 Infections in Residents of a Long-Term Care Skilled Nursing Facility — King County, Washington, March 2020

    Early Release / March 27, 2020 / 69

    Summary

    What is already known about this topic?

    Once SARS-CoV-2 is introduced in a long-term care skilled nursing facility (SNF), rapid transmission can occur.

    What is added by this report?

    Following identification of a case of coronavirus disease 2019 (COVID-19) in a health care worker, 76 of 82 residents of an SNF were tested for SARS-CoV-2; 23 (30.3%) had positive test results, approximately half of whom were asymptomatic or presymptomatic on the day of testing.

    What are the implications for public health practice?

    Symptom-based screening of SNF residents might fail to identify all SARS-CoV-2 infections. Asymptomatic and presymptomatic SNF residents might contribute to SARS-CoV-2 transmission. Once a facility has confirmed a COVID-19 case, all residents should be cared for using CDC-recommended personal protective equipment (PPE), with considerations for extended use or reuse of PPE as needed.


    Second related MMWR study: 

    Underlying Health Conditions Among Patients with Coronavirus Disease 2019 — United States, February 12–March 28, 2020

    Early Release / March 31, 2020 / 69

    CDC COVID-19 Response Team

    Summary

    What is already known about this topic?

    Published reports from China and Italy suggest that risk factors for severe COVID-19 disease include underlying health conditions, but data describing underlying health conditions among U.S. COVID-19 patients have not yet been reported.

    What is added by this report?

    Based on preliminary U.S. data, persons with underlying health conditions such as diabetes mellitus, chronic lung disease, and cardiovascular disease, appear to be at higher risk for severe COVID-19–associated disease than persons without these conditions.

    What are the implications for public health practice?

    Strategies to protect all persons and especially those with underlying health conditions, including social distancing and handwashing, should be implemented by all communities and all persons to help slow the spread of COVID-19.

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  • CMS Long-Term Care Nursing Homes Telehealth and Telemedicine Tool Kit

    Friday, March 27, 2020 | CMS
    The Centers for Medicare & Medicaid Services (CMS) has broadened access to Medicare telehealth services so that beneficiaries can receive a wider range of services from their doctors without having to travel to a healthcare facility. CMS is expanding this benefit on a temporary and emergency basis under the 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act. The benefits are part of the broader effort by CMS and the White House Task Force to ensure that all Americans – particularly those at high-risk of complications from the virus that causes the disease COVID-19, are aware of easy-to-use, accessible benefits that can help keep them healthy while helping to contain the community spread of this virus.
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  • Focused COVID-19 Surveyor Training Course and Tools (3/20)

    Friday, March 27, 2020 | CMS

    Training Offering Overview

    Training Name: COVID-19 LTC-Surveyor Training (COVID19LTC)

    Activity Code: 0CMSCOVID19_LTC

    Training Description: A brief training related to a focused COVID-19 survey for Nursing Homes surveyors. This is not mandatory, but is recommended for LTC surveyors.

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  • LTCSP Survey Resources: Surveyor Tools (3/20)

    Friday, March 27, 2020 | CMS
    This ZIP file contains resources for surveyors conducting initial surveys under the Long-term Care Survey Process (LTCSP).
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  • CMS Finetunes Targeted Infection Control Inspections; Tells SNFs/NFs to Complete Voluntary Self-Assessment With COVID-19 Focused Survey Tool (3/20)

    Monday, March 23, 2020 | CMS

    Memorandum Summary

     

    • On Friday, March 13, 2020, the President declared a national emergency, which triggers the Secretary’s ability to authorize waivers or modifications of certain requirements pursuant to section 1135 of the Social Security Act (the Act). Under section 1135(b)(5) of the Act, CMS is prioritizing surveys by authorizing modification of timetables and deadlines for the performance of certain required activities, delaying revisit surveys, and generally exercising enforcement discretion for three weeks.
    • During this three-week time frame, only the following types of surveys will be prioritized and conducted:
    • Complaint/facility-reported incident surveys: State survey agencies (SSAs) will conduct surveys related to complaints and facility-reported incidents (FRIs) that are triaged at the Immediate Jeopardy (IJ) level. A streamlined Infection Control review tool will also be utilized during these surveys, regardless of the Immediate Jeopardy allegation.
    • Targeted Infection Control Surveys: Federal CMS and State surveyors will conduct targeted Infection Control surveys of providers identified through collaboration with the Centers for Disease Control and Prevention (CDC) and the HHS Assistant Secretary for Preparedness and Response (ASPR). They will use a streamlined review checklist to minimize the impact on provider activities, while ensuring providers are implementing actions to protect the health and safety of individuals to respond to the COVID-19 pandemic.
    • Self-assessments: The Infection Control checklist referenced above will also be shared with all providers and suppliers to allow for voluntary self-assessment of their Infection Control plan and protections
    • During the prioritization period, the following surveys will not be authorized: Standard surveys for long term care facilities (nursing homes), hospitals, home health agencies (HHAs), intermediate care facilities for individuals with intellectual disabilities (ICF/IIDs), and hospices. This includes the life safety code and Emergency Preparedness elements of those standard surveys; and revisits that are not associated with IJ.
    • Furthermore, for Clinical Laboratory Improvement Amendments (CLIA), we intend to prioritize immediate jeopardy situations over recertification surveys, and generally intend to use enforcement discretion, unless immediate jeopardy situations arise.
    • Finally, initial certification surveys will continue to be authorized in accordance within current guidance and prioritization.

     Additional Instructions for Nursing Homes

    We are disseminating the Infection Control survey developed by CMS and CDC so facilities can educate themselves on the latest practices and expectations. We expect facilities to use this new process, in conjunction with the latest guidance from CDC, to perform a voluntary self-assessment of their ability to prevent the transmission of COVID-19. This document may be requested by surveyors, if an onsite investigation takes place. We also encourage nursing homes to voluntarily share the results of this assessment with their state or local health department Healthcare-Associated Infections (HAI) Program. Contact information for each state’s health departments is identified on the Centers for Disease Control & Prevention’s (CDC’s) website at:https://www.cdc.gov/HAI/state-based/index.html.

    Furthermore, we remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility, and when and to whom possible incidents of communicable disease or infections should be reported (42 CFR 483.80(a)(2)(i) and (ii)). CDC recommends that nursing homes notify their health department about residents with severe respiratory infection, or a cluster of respiratory illness (e.g., > or = 3 residents or HCP with new-onset respiratory symptoms within 72 hours). Local and state reporting guidelines or requirements may vary. Monitor the CDC website for information and resources to help prevent the introduction and spread of COVID-19 in nursing homes (CDC Preparing for COVID-19: Long-term Care Facilities, Nursing Homes:https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/prevent-spread-in-long-term-care-facilities.html ).

    We urge providers to review the tools and implement actions to protect the health and safety of individuals to respond to the COVID-19 pandemic.

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