Director of the Division of Nursing Homes, CMS, Office of Quality Safety and Oversight, Evan Shulman joined the LeadingAge call on September 21, 2020. Evan noted that CMS is deeply concerned of course about the deaths of so many older adults, but also about the challenges of the separation from loved ones. CMS has released several sets of guidance since the start of the pandemic. This most recent guidance supersedes previous guidance.

He reviewed some of the highlights of the new guidance:

  • It incorporates the core principles of infection prevention, including screening, hand hygiene, masks, PPE, disinfection, distancing, etc.
  • CMS sees no reason to restrict outdoor visitation except for conditions that would make it impossible such as weather or the specifics of the location.
  • While indoor visitation and still be restricted under certain circumstances, CMS believes that with what has been learned over the past months, indoor visitation should occur and, in some cases must occur.
  • If there are no new staff or resident nursing home onset cases for the past 14 days, indoor visitation should be conducted following the new guidance.
  • Visitors should adhere to infection control practices and facilities can restrict the number of visitors, schedule visits and restrict movement within the facilities.

He also indicated that CMS will soon be ready to establish ways in which CMP funds can be used to facilitate visitation such as purchasing tents, hanging plexiglass, and so forth.

Then Ruth Katz asked Mr. Shulman questions LeadingAge has been receiving:

RK- When there is a different between state and federal guidance, which takes precedence?

ES- State laws cannot conflict with federal requirements and guidance, but CMS recognizes that this is very new guidance. They will work with states to see how their policies can be consistent with CMS guidance.

RK: In light of increased testing and false positive results, what should people do with respect to cohorting residents, etc.?

ES: The number of false positives seems to be consistent with the test specificity. The CDC website describes when to do a confirmatory test and one should make decisions in light of the specifics of the person – symptomatic/ asymptomatic and so forth. If there is a positive result when there have been no cases in the post 14 days and this would trigger an outbreak, a facility could get a confirmatory test (if turnaround is within 48 hours) and wait to report the positive result until the confirmatory test results are in.

RK: We understand that CMS allows for the use of other credible data sources when using county positivity rates for staff testing. What is a considered a credible source and how should this be documented?

ES: A facility can use a county or state-based source-but it needs to be an official source – for example a state health department regularly updated website. The source, date the rate was pulled and what the rate is should be carefully documented. You should not flip back and forth between official sources – be consistent in which data you are using. The Intent is not to test more or less but to identify cases to contain spread.

RK: How should contractors be handled?

ES: If they are providing services to residents they fall under the testing requirements. There are several options:

  • Record documentation of their employer’s testing but this must be consistent with frequency of the facility’s testing rate
  • For those who don’t come in every week – test them the next time they come in (same for employees who are off on vacation)

Questions from attendees included:

Q: If you have an outbreak can you still have outdoor visits?

ES: Yes, but facilities have discretion (depends on how many residents/ staff are positive cases)

Q: It is difficult to get a turnaround time from outside labs under 48 hours – then what?

ES: CMS says do your best and contact as many labs are in a reasonable area – document, document.

Q: If facility can provide indoor visitation while testing staff

ES: Testing must occur as prescribed and visitation can occur while conducting regular staff testing, but only if the rate of testing is once a week or less often.

Q: If allow indoor visits are allowed do residents have to quarantine for 14 days if they go to the doctor or other healthcare provider?

ES: That depends on where they go – check CDC guidance

Mr. Shulman concluded by thanking LeadingAge members for their important and difficult work. The interview will be available on the LeadingAge website within a few days.