CMS released a memo and new FAQ document on April 24, addressing a number of questions collected over the past several weeks. Little new information is available, though this FAQ document may help providers in decision-making. CMS states that the information in this document should be used to make decisions based on:

  1. The needs of the resident,
  2. Actions needed to prevent transmission of COVID-19, and
  3. The circumstances of each situation.

LeadingAge recommends that nursing homes utilize this framework in decision-making and be able to provide information for each of these considerations in justifying decisions. Many questions remain, but information available at this time is below.

Five Star Quality Rating System on Nursing Home Compare

The regular monthly update of the Five Star Quality Rating System on Nursing Home Compare is scheduled for Wednesday, April 29. CMS has announced that effective this update, the Health Inspections domain will be held constant, or “frozen.” CMS is affecting this move due to the re-prioritization and suspension of survey activity that was implemented in March and remains in effect through the duration of the national emergency or until further notice.

CMS stated that because standard health inspections are currently suspended, star rating data would be skewed and not provide an accurate picture of nursing home quality. CMS noted that while timeframes for payroll-based journal (PBJ) and Minimum Data Set (MDS) submissions are currently waived under an 1135 federal blanket waiver, the Staffing and Quality Measures domains will not be frozen at this time, as the data used to calculate these domains was collected prior to the onset of the COVID-19 pandemic. CMS states that they are prepared to make adjustments to these domains in the future if needed.

LeadingAge supports these measures by CMS but notes that some issues have not been addressed. For example, recall that the Quality Measures domain thresholds are scheduled to be recalibrated with April’s update. CMS has not announced suspension of this recalibration. Presumably, the Quality Measures thresholds will recalibrate this week, potentially causing a drop in domain and overall star ratings for nursing homes. Additionally, the Consumer Alert Icon, implemented in October 2019, remains in effect at this time. Knowing that in some cases, a standard survey is required to remove the icon, nursing homes may potentially carry the icon longer than they should.

Release of PBJ Data

CMS has publicly released PBJ staffing data through a link in QSO-20-28-NH. Noting the above-mentioned waiver of timeframe requirements for PBJ data submissions, the data that was released was from Q4 2019 reporting. CMS stated that this data can be used by state agencies to determine allocations of personal protective equipment (PPE) and testing within the state. It is unclear why this data was released publicly, as opposed to being shared directly with state agencies. It is also unclear if PBJ data will be released going forward, given the inaccuracy that may occur due to submission waivers.

Admissions from Hospitals

CMS clarified that a negative COVID-19 test is not required for admission to a nursing home. CMS recommends following CDC guidance for the discontinuation of transmission-based precautions, and while CDC states a negative test is preferred for determining when to discontinue transmission-based precautions for individuals discharging from a hospital to a nursing home, CMS clarifies that a test-based strategy is not required in making this determination. When admitting from the hospital, nursing homes should consider the following:

  • When transmission-based precautions remain in place, the individual should transfer to a nursing home that has adequate space, staff, and PPE to implement these precautions.
  • When transmission-based precautions have been discontinued but symptoms persist, the individual should be admitted to a single room, restricted to the room, and where a facemask during care.
  • When transmission-based precautions have been discontinued and no symptoms are present, no additional restrictions are needed. Recall previous guidance by CMS, however, that states that all residents should be covering their mouths and noses when staff are in their rooms. Though CMS has not been clear, one should assume that this requirement remains in effect.
  • For individuals who were in the hospital for a reason not related to COVID-19, these individuals should be admitted to a private room and placed on transmission-based precautions for a period of 14 days to monitor for the development of COVID-19 symptoms. This information is consistent with previous CMS guidance related to the admissions of individuals for whom COVID-19 status is unknown.

Staying Connected

While visitor restrictions continue in nursing homes across the country, CMS reminded nursing homes that there are a number of ways in which residents can be assisted to stay connected with family and friends. CMS recommends updating facility websites and social media, assisting residents with virtual visits, hosting regular “Virtual Office Hours” where resident representatives can call in to hear updates or ask questions, and the use of listservs, voice recordings, email updates, and updates by traditional mail services. LeadingAge notes that these strategies may also be employed in meeting upcoming requirements for notification of COVID-19 facility status and mitigation strategies to residents and resident representatives.

To support efforts to keep residents connected, CMS has authorized the use of Civil Money Penalty (CMP) funds. Nursing homes can apply for CMP funds through their state CMP contact and while CMS cautions judicious use of these limited funds, funds can be used to purchase communication devices such as tablets or webcams for connecting residents with family and friends during this time of visitor restriction. Nursing homes are limited to purchasing 1 device per 7-10 residents with a maximum allocation of up to $3,000 per facility. LeadingAge is pleased to note that these devices can also be utilized for residents’ telehealth visits with practitioners.

Visiting Healthcare Workers and Essential Personnel

Over the weeks since tightening visitor restrictions and protocols, nursing homes have been left with a number of questions about who comes in and who stays out. In effort to address these questions, CMS reminded nursing homes that all visitors and staff must be screened for symptoms and must wear appropriate PPE. CMS stated that the emphasis should be on resident safety, continuing only critical services with only the personnel who are essential to provide those services. In making these decisions, CMS recommends considering the following:

  1. What are the resident’s needs?
  2. What services are necessary to meet those needs?
  3. Who are the individuals who can meet those needs?

Nursing homes will, no doubt, find this framework useful. LeadingAge cautions, however, that this framework should not result in restrictions of critical and necessary services. Nursing homes should carefully evaluate the resident’s needs, incorporating needs identified in the resident’s individual care plan, and work with visiting healthcare workers to ensure that these services are provided in the safest way possible. Safe service provision includes both COVID-19 precautions as well as scope of practice and specialty considerations. Providers such as hospice and palliative care workers, lab and radiology technicians, and dialysis technicians all provide a specialized type of care and nursing homes should coordinate with these and other healthcare workers to ensure that the residents have access to needed services.

Off-Site Appointments

CMS recommends cancelling or postponing non-essential appointments. Residents who go out for appointments should wear masks and both transportation providers and receiving providers must be notified of the resident’s COVID-19 status. Residents should be screened for the development of symptoms upon return for a period of 14 days; CMS states that screening in a designated location (see below, “Cohorting”) is preferred.

Cohorting

CMS offered further clarification around resident cohorting. Nursing homes should designate separate space, such as wings or units, for residents diagnosed with COVID-19. Additionally, CMS recommends developing a plan for other considerations. Nursing homes should attempt to cohort according to the following:

  • Residents with suspected or confirmed COVID-19 diagnoses.
  • Residents who are newly admitted, recently readmitted or returning, or whose COVID-19 status is otherwise unknown.
  • Residents who are showing signs/symptoms of COVID-19 but have not yet received a COVID-19 diagnosis.

Recall that 1135 federal blanket waivers allow for transfer, discharge, and relocation of residents to meet these recommendations. Nursing homes can transfer residents to other certified facilities designated as COVID-19 care units, to special alternative care locations that were not previously certified as a nursing home and have been approved by the state, and to FEMA sites in accordance with Order of Governmental Authority. Nursing homes have also been granted authority through an 1135 federal blanket waiver to utilize space within the facility not previously designated as resident care space. In doing so, any licensure-related questions, such as adding beds beyond licensed capacity, should be referred to the state licensure authority.

Communal Dining

The question on communal dining received most often at LeadingAge has been “What constitutes communal dining?” CMS did not directly answer this question, but offered some suggestions. Nursing homes are not required to restrict all residents to their rooms for dining. Dining rooms may be utilized, provided that nursing homes are able to maintain social distancing and other infection control practices. Residents with signs or symptoms of COVID-19 or a confirmed diagnosis should be restricted from the dining room.

What This Means for Members

As noted above, many questions remain. LeadingAge has routinely requested more information from CMS regarding federal waivers including MDS submissions, PBJ submissions, 3-day qualifying stay, and the interplay of COVID-19 needs and skilled care. LeadingAge will continue advocacy efforts with CMS and Congress to give nursing homes the support they need and deserve as they continue to provide safe, quality care to residents during this national pandemic.