CMS has released QSO 20-30 NH, which gives states guidance on the reopening of visitation, communal dining and activity programs, as well as restarting of survey activity.  CMS states they are providing recommendations to help determine the level of mitigation needed to prevent the transmission of COVID-19 in nursing homes. The recommendations cover the following items:

• Criteria for relaxing certain restrictions and mitigating the risk of resurgence: Factors to inform decisions for relaxing nursing home restrictions through a phased approach.
• Visitation and Service Considerations: Considerations allowing visitation and services in each phase.
• Restoration of Survey Activities: Recommendations for restarting certain surveys in each phase. 

CMS is encouraging State leaders to collaborate with the state survey agency, and State and local health departments, to decide how these and other criteria or actions should be implemented in their state. LeadingAge WA is currently working on a plan with Washington Health Care Association, the Adult Family Home Council and representatives from Residential Care Services and the Governor’s office on the phased resumption of all services and activities in long term care.  CMS has given specific examples of how a State may choose to implement these recommendations and include: 

• A State requiring all facilities to go through each phase at the same time (i.e., waiting until all facilities have met entrance criteria for a given phase).
• A State allowing facilities in a certain region (e.g., counties) within a state to enter each phase at the same time.
• A State permitting individual nursing homes to move through the phases based on each nursing home’s status for meeting the criteria for entering a phase. 

 Factors that CMS urges states to consider before reopening visitation and communal dining and activities include:

• Case status in community: State-based criteria to determine the level of community transmission and guides progression from one phase to another. For example, a decline in the number of new cases, hospitalizations, or deaths (with exceptions for temporary outliers).
• Case status in the nursing home(s): Absence of any new nursing home onset of COVID-19 cases (resident or staff), such as a resident acquiring COVID-19 in the nursing home.
• Adequate staffing: No staffing shortages and the facility is not under a contingency staffing plan.
• Access to adequate testing: The facility should have a testing plan in place based on contingencies informed by the Centers for Disease Control and Prevention (CDC). At a minimum, the plan should consider the following components:
  • The capacity for all nursing home residents to receive a single baseline COVID19 test. Similarly, the capacity for all residents to be tested upon identification of an individual with symptoms consistent with COVID-19 or if a staff member tests positive for COVID-19. Capacity for continuance of weekly re-testing of all nursing home residents until all residents test negative;
  • The capacity for all nursing home staff (including volunteers and vendors who are in the facility on a weekly basis) to receive a single baseline COVID-19 test, with re-testing of all staff continuing every week (note: State and local leaders may adjust the requirement for weekly testing of staff based on data about the circulation of the virus in their community);
  • Written screening protocols for all staff (each shift), each resident (daily), and all persons entering the facility, such as vendors, volunteers, and visitors;
  • An arrangement with laboratories to process tests. The test used should be able to detect SARS-CoV-2 virus (e.g., polymerase chain reaction (PCR)) with greater than 95% sensitivity, greater than 90% specificity, with results obtained rapidly (e.g., within 48 hours). Antibody test results should not be used to diagnose someone with an active SARS-CoV-2 infection.
  • o A procedure for addressing residents or staff that decline or are unable to be tested (e.g., symptomatic resident refusing testing in a facility with positive COVID-19 cases should be treated as positive).
• Universal source control: Residents and visitors wear a cloth face covering or facemask. If a visitor is unable or unwilling to maintain these precautions (such as young children), consider restricting their ability to enter the facility. All visitors should maintain social distancing and perform hand washing or sanitizing upon entry to the facility.
• Access to adequate Personal Protective Equipment (PPE) for staff: Contingency capacity strategy is allowable, such as CDC’s guidance at Strategies to Optimize the Supply of PPE and Equipment (facilities’ crisis capacity PPE strategy would not constitute adequate access to PPE). All staff wear all appropriate PPE when indicated. Staff wear cloth face covering if facemask is not indicated, such as administrative staff.
• Local hospital capacity: Ability for the local hospital to accept transfers from nursing homes.

State Survey Prioritization (Starting in Phase 2 ) States should use the following prioritization criteria within each phase when determining which facilities to begin to survey first.

For investigating complaints (and Facility-Reported Incidents (FRIs), facilities with reports or allegations of:

• • Abuse or neglect
  • Infection control, including lack of notifying families and their representatives of COVID-19 information (per new requirements at 42 CFR 483.80(g)(3))
  • Violations of transfer or discharge requirements
  • Insufficient staffing or competency
  • Other quality of care issues (e.g., falls, pressure ulcers, etc.) In addition, a State agency may take other factors into consideration in its prioritization decision. For example, the State may identify a trend in allegations that indicates an increased risk of harm to residents, or the State may receive corroborating information from other sources regarding the allegation. In this case, the State may prioritize a facility for a survey higher than a facility that has met the above criteria.

For standard recertification surveys:

• Facilities that have had a significant number of COVID-19 positive cases
• Special Focus Facilities
• Special Focus Facility candidates
• Facilities that are overdue for a standard survey (> 15 months since last standard survey) and a history of noncompliance at the harm level (citations of ”G” or above) with the below items:
• Abuse or neglect
• Infection control
• Violations of transfer or discharge requirements
• Insufficient staffing or competency
• Other quality of care issues (e.g., falls, pressure ulcers, etc.) For example, a facility whose last standard survey was 24 months ago and was cited for abuse at a “G” level of noncompliance, would be surveyed earlier (i.e., prioritized higher) than a facility whose last standard survey was 23 months ago and had lower level deficiencies. CMS recognize that there are many different scenarios or combinations of timing of surveys and types of noncompliance that will exist. They will defer to States for final decisions on scheduling surveys consistent with CMS survey prioritization guidelines.

CMS has also released 5 pages of FAQs with the memo.  LeadingAge WA will continue to update on you on the state’s plan for resuming visitation, communal dining, and activities.  We will be holding Nursing Home and Assisted Living Cabinet Meetings to discuss the state wide testing of all residents and staff and other criteria to consider as we lift restrictions. 

Questions?

Contact:

Laura Hofmann, MSN, RN – Director of Clinical and Nursing Facility Regulatory Services

LeadingAge Washington
c: 324-231-4804