As of a March 23 report by CMS, at least 147 nursing homes across 27 states have at least one resident with COVID-19. As we work to protect our residents and staff in response to the risk of COVID-19 infection, providers are encouraged to consider these action items and resources:
General Guidance & Source Documents
- All LTC facilities need to use this CDC check list to prevent the spread – Coronavirus Disease 2019 (COVID-19) Preparedness Checklist for Nursing Homes and other Long-Term Care Settings.
- All LTC facilities should use this LTC Respiratory Surveillance Line List, from the CDC, to track their infection control activities and to track employees and residents with respiratory illness.
- All LTC facilities should have a plan to rapidly implement, or implement now, how they will cohort confirmed or presumed covid-19 patients in their facility. This can be by wing, floor, or if available, by building(s). This should be done with expediency. See this guidance from the CDC.
- Check your state department of health website frequently for local directives and updates
- Follow state instructions on the state department of health website for submitting inventory of PPE in order to be included in the state distribution of materials
- All LTC facilities should limit patient contact to only essential direct care providers (Nurse, CNA, QMA, Hospice, EMS etc.) and should be screening all persons entering the facility per CDC guidelines, and following updated procedures for non-communal dining and no group activities or group therapy.
- CMS released guidance suspending most federal and state surveys, delaying revisits for the next 3 weeks and ending non-IJ related onsite surveys currently in process and exiting the facility. Targeted infection control surveys will continue (see tool in the following bullet for infection control survey content review)
- Review CMS’s infection prevention/control self-assessment tool based on findings at the original facility in Washington State with COVID-19 infections. CMS recommends that facilities use this tool to conduct a voluntary self-assessment of their Infection Control plan and protections. Access the tool here.
- PPE supplies including N95 masks are running very low in many facilities; consider contacting local businesses to request donations including settings where masks are commonly used (auto body shops, cleaning companies, hardware stores, landscapers, manufacturing plants, nail salons, painters.) source: OHCA
- CMS is aware that there is a scarcity of supplies in certain areas. Facilities should not be cited for not having certain supplies (e.g. PPE) if they are having difficulty obtaining these supplies for reasons outside their control. See CMS qso-20-14 here. Follow CDC guidelines for optimizing the current supply, and document your efforts to obtain necessary supplies as soon as possible.
- All LTC facilities should develop specific policies on PPE use including, but not limited to facemask use. Follow CDC guidance on strategies for optimizing the supply of facemasks.
- If national and local supplies are at conventional capacity, then all staff in LTC facilities should wear a facemask per standard recommendations.
- If national and local supplies are at contingency levels, only direct care staff should wear a mask and they should use one mask per shift.
- If national and local supplies are scarce <1 week supply, then only direct care staff should wear a mask and they should use the same mask for multiple days
- If national and local supplies are at crisis capacity, then direct patient care staff should wear a mask if available. If masks are not available, they should use alternative methods to cover their mouth and nose and decrease respiratory droplet spread.
- If allowing the use of homemade fabric masks from the community based on shortages, launder before use. Pattern for sewing masks. (Please follow you state guidance regarding use of homemade mask, as some states are prohibiting their use at this time)
- We recommend completing all laundry in-house in order to reduce the risk of contamination and accepting all external deliveries at a single point of entry, following infection control procedures to reduce the risk of surface contaminates coming into your building
- Please note, there are rampant scams involving phishing email schemes and sales of PPE—stay diligent in protecting your facility against potential fraud. The OIG has released a COVID-19 Fraud Alert to warn about several health care fraud scams that harm patients and the federal programs designed to serve them. This alert has general information about these schemes and how to protect yourself and your community against bad actors.
Management of Suspected or Confirmed Cases
- Review CDC guidelines for managing patients with suspected or confirmed COVID-19 infection. If a resident is symptomatic, implement droplet precautions, move them to an isolated room, shut the door and contact your local health department.
- All LTC facilities need to have updated lists of all residents’ code status. Plans should be in place for how to provide hospice and comfort care to those patients with DNR orders who develop COVID-19, in accordance to their expressed wishes.
- If your facilities have patients or providers who are symptomatic and need to be tested, please contact your designated health department to schedule testing at your facility. Most states have a team available to come into facilities to rapidly test residents and staff who are suspected of having COVID-19 and to provide education on COVID-10 prevention.
- If a staff member has symptoms, have them don a mask and send them home immediately
- Review CDC Return to Work Criteria for healthcare personnel with confirmed or suspected COVID-19 and update facility procedures accordingly
- Review and update your emergency staffing plan. Note that there are various waivers and programs being put in place at the state level to assist in the staffing shortage. Indiana, for example, has approved an 8 hour personal care attendant training curriculum and KY has a program by which you can request that your facility be promoted to those persons filing unemployment claims. Most states have waivers allowing licensed nurses from other states to cross state lines on an expedited, temporary license.
- Many states have now issued some form of an order to “Stay at Home” other than for essential workers and outings. Facilities should prepare a letter or other proof that applicable employees are essential healthcare workers. Inform staff (in applicable states) that they should be prepared to show their badge, a state issued “pass”, or other written proof as needed. A sample letter may be available through the state dept of health.
- The department of labor issued guidance on paid sick leave and expanded FMLA addressing how an employer counts employees to determine coverage, calculate wages and exemptions
- Emergency 1135 Medicaid Waivers have been approved by CMS for 13 states including Alabama, Arizona, California, Florida, Illinois, Louisiana, Mississippi, New Hampshire, New Jersey, New Mexico, North Carolina, Virginia and Washington eliminating prior authorization and opening other emergency solutions. Source: Skilled Nursing News 3/24/20
- MDS and Coding Updates: We have posted blog articles on coding COVID-19, when to complete an IPA, Isolation Considerations, and the 1135 waiver at https://proactivemedicalreview.com/news/
- Review implications of the Medicare 1135 Waiver with key staff and develop interim procedures. The Medicare 1135 Waiver was issued to ensure beneficiary access to care during the national emergency. It is open to SNF providers nationally and temporarily waives the 3-day hospital stay, the 60-day break in spell of illness requirement, and MDS timeframes for completion and submission, among other waivers. Interpretation: This does not mean that there is a blanket license to skill all residents. The waiver should be applied cautiously based on the existing technical and clinical Medicare eligibility requirements. Consider this question: would the patient have qualified for skilled services under normal circumstances had they been able to admit to the hospital? Additional guidance related to MDS interviews, documentation and billing are pending, but as a general rule MDS assessments should not be post-dated. (source: CMS, AHCA, Zimmet Healthcare webinar 3/23/20)
- Review the Coverage and Payment Related to COVID-19 Medicare Fact Sheet issued 3/23/20
- Medicare Advantage plans are not included in the 1135 waiver; however, MA organizations have certain obligations under State-declared emergencies:
Medicare Advantage Plan Requirements during a State-declared Emergency
MA organizations are required to:
During disaster or emergency (declared by the Governor of a state or Protectorate) the following are in effect until the end date identified in the State declaration or for 30 days, if no end date is identified in the declaration.
- Cover benefits furnished at non contracted facilities if the facilities have participation agreements with Medicare.
- Waive, in full, requirements for gatekeeper referrals where applicable.
- Provide the same cost sharing for the enrollee at a non-contracted facility as if it were a contracted facility.
- Changes that benefit the enrollee can be effective immediately without the 30-day notification requirement (examples include reductions in cost sharing and waiving prior authorizations).
Please note that this list is provided as a resource only. Information and guidance regarding the COVID-19 pandemic is being updated frequently and healthcare facilities should monitor CDC.gov and CMS.gov Coronavirus websites regularly.
Blog by Amie Martin, OTR/L, CHC, RAC-CT, Proactive Medical Review