May 12th COVID-19 Update

Over the past several days, public health authorities and government regulators have issued new COVID-19-related guidance and requirements for providers of long-term/post-acute care (LTPAC) and senior services. These and other updates are summarized below.

As a reminder, LeadingAge NY continues to convene weekly webinars on Mondays at 11 a.m. to address emerging questions on COVID-19. A recording of our most recent webinar, held on May 11^th, is available here. If you have questions for next week’s update, please send them to Ami Schnauber, and be sure to check your email for the access information, or contact Jeff Diamond.

In addition, LeadingAge NY continues to encourage members to review our questions and answers (Q&As) on operational and regulatory issues related to COVID-19. The Q&As contain information on numerous cross-sector issues, as well as issues specific to nursing homes, adult care facilities (ACFs)/assisted living, adult day health care (ADHC), home and community-based services (HCBS), and affordable housing/independent living. To access the Q&As, click here.

Cross-Sector Updates

LeadingAge NY Updates Resource Providing Nursing Home-Specific and General COVID-19 Guidance by Subject Area

LeadingAge NY has issued an updated compendium of federal and state COVID-19 guidance specific to nursing homes or of a general nature, arrayed by topic in reverse chronological order. It encompasses guidance from the Centers for Disease Control and Prevention (CDC), the Centers for Medicare and Medicaid Services (CMS), New York State Executive Orders (EO), and the New York State Department of Health (DOH). The compendium will be updated further as additional guidance is made available by these agencies.

Provider Relief Fund Attestation

Providers who receive payment from the Provider Relief Fund established by the federal Coronavirus Aid, Relief, and Economic Security Act (CARES Act) are required to sign an attestation confirming receipt of the funds, agree to the terms and conditions, and provide some additional information. The originally announced requirement that this be done within 30 days of receipt of funds has been extended to 45 days. That makes the deadline May 24^th for those receiving funding on the first day it was distributed (i.e., April 10^th). Please note that the Department of Health and Human Services (HHS) has posted two attestation documents and continues to have two “portals” open: one for the initial $30 billion distribution, the other for the second $20 billion distribution. The second portal requires providers to submit tax forms, as well as information on COVID-19-related costs and lost revenue. Providers seeking reimbursement for providing care to uninsured COVID-19 patients and residents should review the materials available here.

We understand that HHS is also working on another distribution of provider relief funding that is expected to target nursing homes, although timing is uncertain. As time and staff availability allow, we strongly urge all members to establish and maintain robust systems to track and document all expenses and lost revenue related to the pandemic while monitoring submission deadlines related to any funding opportunities you may be pursuing.

CMS Publishes Provider-Specific Fact Sheets on 1135 Waivers

CMS has made available multiple fact sheets summarizing changes made through regulatory actions in response to COVID-19. A fact sheet specific to skilled nursing facilities (SNFs) can be accessed here, and a full list of emergency declaration blanket waivers for health care providers implemented to date is here.

Additional fact sheets include the following:

Clinicians:

Physicians and Other Practitioners

Hospitals and Facilities:

Service Providers:

Other CMS Programs:

Members may view more resources on CMS waivers and flexibilities on the CMS website.

CMS and DOH Calls

LeadingAge NY reminds members that both CMS and DOH continue to hold scheduled calls and webinars to update providers about COVID-19-related issues. CMS staff hold “office hours” calls on Tuesdays and Thursdays from 5 to 6 p.m. The next call is on Thurs., May 14^th at 5 p.m. (dial-in: 833-614-0820; access passcode: 5688374). While there are many informational topics discussed, members should be aware that these “office hours” calls cover a wide range of COVID-19 topics and are aimed at multiple provider types, including hospitals.

CMS also holds regular calls for specific provider types, including nursing homes and home care/hospice. The next dedicated nursing home call is scheduled for Wed., May 13^th from 4:30 to 5 p.m. (dial-in: 833-614-0820; access passcode: 2675207), while the most recent home care/hospice call was held on May 12^th. Recordings and transcripts of most calls are available after several days here. The weekly DOH health care provider webinar can be accessed here, which is also the site where on-demand viewing of prior webinars is available. None of these events require advance registration, although prompt or early arrival are recommended due to high participant volume.

Red Cross Offers COVID-19 Family Support

The American Red Cross across the regions of New York State has developed a Virtual Family Assistance Center to support individuals and families who have lost loved ones as a result of COVID-19. The program will link crisis counselors with families to provide emotional and spiritual support, as well as targeted short-term casework to assist with navigating through the challenging processes they might be faced with as a result of the loss. For more information on the Virtual Family Assistance Center, click here.

Nursing Home and ACF Updates

Click here for information on certain nursing home requirements waived under EOs that are now back in effect and here for analysis of the State's directives requiring nursing homes and ACFs to test staff twice weekly and certify compliance.

CMS Letter Addresses Family Notification, CDC Reporting, and Survey Tool

On May 6, 2020, CMS issued letter QSO-20-29 outlining a number of key requirements for nursing homes.

Family Notification:

Notify all residents and family members and representatives of all residents each time either of the following occurs:
- If any resident or staff member tests positive for COVID-19, or if any resident suffers a COVID-19-related death; and
- If there is a cluster of three or more residents and/or staff with new onset of respiratory symptoms (see the CDC guidance on respiratory symptoms) within 72 hours of each other.
Provide these notifications by 5 p.m. the next calendar day following a single confirmed COVID-19 infection, respiratory symptom cluster, or COVID-19-related death or within 24 hours of such event, whichever comes first.
Provide cumulative updates of these events at least weekly, or by 5 p.m. the day following the occurrence of a confirmed COVID-19 infection or new-onset respiratory cluster.
Include information on mitigating actions implemented to prevent or reduce the risk of transmission, including if normal operations of the facility will be altered.

Reporting to the CDC:

In addition to the resident/family notification requirement, CMS guidance requires all nursing homes (for ACFs, the CDC reporting is not required, but is at the option of the provider) to report information to the CDC. LeadingAge NY had previously issued guidance on the National Healthcare Safety Network (NHSN) at the CDC with an overview of the reporting module and instructions on how to register in the network.

The areas covered in the reporting to the NHSN are as follows:

(i) Suspected and confirmed COVID-19 infections among residents and staff, including residents previously treated for COVID-19;
(ii) Total deaths and COVID-19 deaths among residents and staff;
(iii) Personal protective equipment (PPE) and hand hygiene supplies in the facility;
(iv) Ventilator capacity and supplies in the facility;
(v) Resident beds and census;
(vi) Access to COVID-19 testing while the resident is in the facility;
(vii) Staffing shortages; and
(viii) Other information specified by the Secretary.

These CDC reporting requirements are in addition to, and do not take the place of, the required daily DOH reporting through the Integrated Health Alerting and Notification System (IHANS).

Due to a high volume of nursing homes seeking to register in the NHSN, delays have been encountered by many nursing homes. Therefore, additional time beyond the original May 8, 2020 date to submit the data has been granted.

CMS is asking facilities to submit their first set of case data to the CDC by Sun., May 17^th, but is granting an initial two-week grace period (which ends on May 24^th) for this to occur.

Infection Control-Focused Survey:

Included in the CMS letter is a revised Infection Control Survey Tool that includes the requirements for family notification and CDC reporting. Currently, CMS has suspended routine survey and revisit activities and is focusing almost exclusively on survey of nursing homes for compliance with the requirements issued on COVID-19. Among the areas that the tool reviews are the use of PPEs, staffing, education, screening activities, and infection control surveillance. Members should utilize the Infection Control Survey Tool to evaluate their current infection control practices to ensure that they are in full compliance. LeadingAge NY would expect surveillance activities to be linked to data submission.

Also included in the CMS letter are several Frequently Asked Questions (FAQs) that discuss the requirements for notifying families, as well as the CDC reporting requirement.

HCBS Updates

New CMS Codes for Ordering and Certifying Home Health by Non-Physician Providers

The federal CARES Act recently authorized nurse practitioners, certified clinical nurse specialists, and physician assistants to certify beneficiaries for eligibility under the Medicare home health benefit and oversee their plan of care. This provision is a permanent change to law and will continue after the COVID-19 State of Emergency.

CMS has announced that these practitioners may utilize existing billing codes for claims with dates of services on or after March 1, 2020. They will revise the descriptors at a later date to include references to the non-physician practitioner roles. The billing codes are as follows:

G0179: Physician re-certification for Medicare-covered home health services under a home health plan of care (patient not present), including contacts with home health agency and review of reports of patient status required by physicians to affirm the initial implementation of the plan of care.
G0180: Physician certification for Medicare-covered home health services under a home health plan of care (patient not present), including contacts with home health agency and review of reports of patient status required by physicians to affirm the initial implementation of the plan of care.
G0181: Physician supervision of a patient receiving Medicare-covered services provided by a participating home health agency (patient not present) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans.

LeadingAge NY expects DOH to issue guidance recognizing this change in federal law soon.

DOH Warns of COVID-19 and Pediatric Multi-System Inflammatory Syndrome

On May 5^th, DOH issued a Health Advisory regarding pediatric multi-system inflammatory syndrome disease potentially associated with COVID-19. As of that date, 64 suspected pediatric clinical cases compatible with multi-system inflammatory syndrome associated with COVID-19 have been reported in children in New York State hospitals, including New York City.

The Advisory requires that hospitals immediately report cases of pediatric multi-system inflammatory syndrome potentially associated with COVID-19 in patients who are under 21 years of age to DOH through the HERDS application on the Health Commerce System (HCS) and perform a diagnostic and serological test to detect the presence of SARS-COV-2, the virus that causes COVID-19, or corresponding antibodies in the patient.

The syndrome, according to the Advisory, has features which overlap with Kawasaki disease and toxic shock syndrome. Inflammatory markers may be elevated, and fever and abdominal symptoms may be prominent. Rash also may be present. Myocarditis and other cardiovascular changes may be seen. Additionally, some patients have developed cardiogenic or vasogenic shock and required intensive care. This inflammatory syndrome may occur days to weeks after acute COVID-19 illness.

The syndrome may include:

A child presenting with persistent fever, inflammation (e.g., neutrophilia, elevated C-reactive protein, and lymphopenia) and evidence of single or multi-organ dysfunction (shock, cardiac, respiratory, renal, gastrointestinal, or neurological disorder). This may include children meeting full or partial criteria for Kawasaki disease.
Exclusion of any other microbial cause, including bacterial sepsis, staphylococcal, or streptococcal shock syndromes, and infections associated with myocarditis such as enterovirus. Clinicians should not delay seeking expert advice while waiting for results of these investigations. Early recognition by pediatricians and prompt referral to an in-patient specialist, including to critical care, is essential.

For questions about HERDS, providers can send an email to hospinfo@health.ny.gov. For other questions, providers can contact their LHD or the DOH Bureau of Communicable Disease Control (BCDC) at 518-473-4439 during business hours or 1-866-881-2809 during evenings, weekends, and holidays.

COVID-19 Telehealth Resources

On May 5^th, the DOH Office of Health Insurance Programs (OHIP) hosted a webinar to review the Department’s Comprehensive Guidance Regarding Use of Telehealth including Telephonic Services During the COVID-19 State of Emergency. The webinar was intended to provide an overview of the guidance and cover FAQs. The PowerPoint slides from the webinar are available here, and a recording can be accessed here.

Members are also encouraged to take advantage of Adirondack Health Institute's (AHI) COVID-19 Telehealth Resources, as well as the educational resources of the Telehealth Learning Collaborative. On May 18^th from 2 to 3 p.m., the Collaborative will host a webinar on telehealth issues featuring David Chess, MD, chief medical officer of Tapestry TeleHealth PLLC, and Dr. Christina Antoine, MBA, MHSA, RRT, of Northwell Health. Dr. Antoine will lead the discussion on Northwell Health’s integrated after-hours program, and Dr. Chess will discuss his work and platform for comprehensive SNF care via telehealth. The Collaborative will also have updates from several State agencies and an update on COVID-19 telehealth regulatory changes. Registration for the webinar is available here; the event number is 645581078, and the password is telehealth1.

DOH Conducting Limited Home Care Surveys Related to Infection Control Policies

DOH has been conducting focused off-site surveys related to COVID-19 infection control policies and procedures. Licensed home care services agencies (LHCSAs) and certified home health agencies (CHHAs) in the Metropolitan Area Regional Office (MARO) area are being surveyed, and members are now reporting that upstate agencies are undergoing surveys as well.

DOH is carrying out the surveys by email, asking agencies to provide requested materials within four hours. DOH staff then contact agencies by telephone to work with them to submit the requested documents within the established time frame.

The purpose of the survey is to assess agency response to Department guidance regarding screening of personnel and patients, as well as staff education in the use of PPE.

The information requested includes:

A copy of current updated policy and procedures with implementation of DOH COVID-19 guidance, including the following:
1. Policy for daily screening of staff
2. Policy/protocol for staff returning to work following COVID-19 exposure or infection
3. Policy/protocol for screening patients for COVID-19 symptoms prior to accepting new admissions and referrals
Records for infection control training conducted in the past 45 days to include staff trained in the content of that training
Staffing plan for COVID-19-positive or suspected patients (PUI)
A copy of the care plan for two COVID-19-positive patients you are currently caring for

Most, if not all, member agencies have had a fair experience with this process. Moving forward, please let LeadingAge NY know if the survey changes or includes additional requested material so that we can inform members.

CHHA and Hospice HERDS Surveys Modified

This week, the DOH Division of Home and Community Based Services announced modifications to the CHHA and HERDS daily surveys. The modifications will align the CHHA and Hospice survey PPE questions with those of nursing homes and ACFs. There will be additional lines requested, including whether an order has been placed and the expected amount of PPE, as well as the calculated days of each type of PPE remaining. Modifying the surveys will allow the data to be integrated with the nursing home and ACF data for the purpose of preparing PPE shipments.

DOH will also be requesting contact information for the individual who completes the survey, as well as a person who is reachable 24/7.

DOH Validating Home Care PPE and Staffing Data

DOH is reaching out to LHCSAs by telephone to validate survey data regarding staffing. They are particularly interested in the number of aides employed at the end of January, as well as the total number of home care aide hours in January, compared with more recent numbers. DOH will be calling LHCSAs to verify reported data for a specific day of the month. The data will not be changed retrospectively, as this is an effort to confirm that the agencies understand what is being asked and how to report. They will monitor changes in the numbers going forward for those LHCSAs that could not confirm their data.

DOH staff will also be calling agencies to verify the status of PPE in their agencies.

Affordable Housing/Independent Living Updates

Governor Issues New EO Extending Moratorium on COVID-19-Related Evictions, Allowing Security Deposits to Be Applied Toward Rent

On May 7^th, Governor Cuomo issued EO 202.28. Notably, the order extends the moratorium on evictions for nonpayment of rent through Aug. 20, 2020 and allows for a landlord and tenant to agree to apply a security deposit and any accrued interest of such deposit toward the payment of rent where any remaining balance of rent due is not required to be waived. This must be a mutual consenting agreement between the landlord and the tenant. Landlords are required to provide this relief at the request of (1) tenants or licensees who are eligible for unemployment benefits under state or federal law; or (2) tenants or licensees who are otherwise experiencing a COVID-19-related financial hardship.

The security deposit amount applied toward payment of rent must be replenished at a rate of no less than 1/12 per month over a one-year period. The repayment period will begin 90 days after the date of entering into the agreement, or a tenant may elect to retain insurance to provide relief to the landlord in lieu of monthly replenishment of the security deposit.

LeadingAge National Seeks Answers About Paycheck Protection Program Eligibility for Housing Providers

On May 1^st, LeadingAge National sent a letter to Treasury Secretary Steven Mnuchin and Small Business Administration (SBA) Administrator Jovita Carranza seeking clarification on the eligibility of not-for-profit affordable senior housing providers for funds under the Paycheck Protection Program (PPP). To view the letter, click here.