July 7th COVID-19 Update

New updates pertaining to the COVID-19 emergency continue to be announced by both the state and federal government on a regular basis. The latest developments for providers of long-term/post-acute care (LTPAC) and senior services are outlined 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 July 6^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.

Cross-Sector Updates

FAQs Issued and New States Added to Travel Advisory

This week, the Department of Health (DOH) posted a Frequently Asked Questions (FAQs) document regarding the recent Executive Order (EO) requiring all individuals traveling from states with “significant community-wide spread” of COVID-19 to quarantine for a 14-day period from the time of last contact within the identified state. The FAQs discuss the exemption from quarantine requirements for essential workers who meet certain conditions. Additionally, three states were added to the list on July 7^th. Click here for more information.

DOH Issues Revised Guidance on Return to Work After COVID-19 Exposure or Infection

On July 3^rd, DOH issued revised guidelines regarding returning to work after a COVID-19 exposure or infection. The Health Advisory is directed to “all healthcare settings, except nursing homes” and explicitly includes adult care facilities (ACFs) and home care providers. Click here for more information.

EOs Extended

On July 6^th, Governor Cuomo issued EO 202.48 extending several previous suspensions and modifications to law during the COVID-19 emergency. Several of these relate to long term care. The order continues suspensions and modifications made by EOs 202 through 202.14, as continued and contained in later EOs 202.27, 202.28, and 202.38, for 30 days through Aug. 5, 2020, except for several specifically mentioned provisions which do not relate to long term care.

For a list of provisions extended per EO 202.48, click here. Please note that this document is not an exhaustive list and relates only to provisions originally expiring July 6^th. Feel free to contact LeadingAge NY if you have questions regarding the status of a specific provision which may not be listed.

Paycheck Protection Program Extended; Important Reminder on Affiliation Rules

The Paycheck Protection Program (PPP), a forgivable loan program administered through the Small Business Administration (SBA), had expired on June 30^th with about $130 billion in unused funding. Good news! Congress passed legislation last week, which was signed into law by the President on July 4^th, extending the PPP application deadline to Aug. 8^th.

The PPP incentivizes small businesses, including not-for-profits (NFPs), to keep their workers on the payroll. It allows qualifying small businesses to borrow up to 250 percent of their average monthly payroll costs, up to $10 million. NFP organizations with less than 500 total workers, including any of their affiliated entities, are eligible. Loans are unsecured, and payments are deferred for six months. Forgiveness is based on the employer maintaining or quickly rehiring employees and maintaining salary levels. The maturity of the unforgiven portion of loans issued after June 5^th is five years, and all loans have a very competitive interest rate of 1 percent.

LeadingAge NY member organizations that have multiple business lines/corporate entities need to review and understand the SBA’s rules governing NFP affiliations to comply with the 500-employee threshold. The SBA uses four tests for the PPP to determine whether a business has affiliated businesses/entities that must be considered when determining the total number of employees. Businesses and entities are affiliates of each other when one controls or has the power to control the other, or a third party/parties controls or has the power to control both. It does not matter whether control is exercised, so long as the power to control exists. Affiliation is established for PPP purposes if any of the following four tests applies:

1. Affiliation based on ownership. A business is an affiliate of an individual or entity that owns or has the power to control more than 50 percent of the business's voting equity. For this purpose, the SBA will deem a Board of Directors or chief executive officer (CEO) to be in control of the business.
2. Affiliation arising under stock options, convertible securities, and agreements to merge. This test would most typically not apply to LeadingAge NY members.
3. Affiliation based on management. This arises when the CEO of the applicant also controls the management of one or more other businesses. Affiliation also arises when an individual, business, or entity that controls the Board of Directors or management of one business also controls the Board of Directors or management of one or more other businesses., as well as when a business or entity controls the management of the applicant business through a management agreement.
4. Affiliation based on identity of interest. This arises when there is an identity of interest between close family relatives with identical or substantially identical business or economic interests. This test would most typically not apply to LeadingAge NY members.

For more information on the PPP, consult with the SBA’s PPP webpage, the LeadingAge NY COVID-19 Financial Assistance Opportunities for NFP Providers guide, and a presentation on the PPP from LeadingAge NY associate member The Bonadio Group given at our June 12^th Chief Financial Officers (CFO) Council meeting.

Main Street Lending Program Open for Business

The Federal Reserve Bank of Boston announced on July 6^th that the Main Street Lending Program is now operational, ready to purchase participations in eligible loans submitted to the program by registered lenders. The Main Street Lending Program is aimed at small- and mid-sized businesses and will provide multiple types of five-year loans with two-year payment deferrals.

The Federal Reserve recently solicited comments on two proposed lending programs for NFP organizations but has not yet finalized these programs. The proposed underwriting criteria for these NFP programs were relatively restrictive, so we are hoping that they will be modified.

While we await further word on NFP eligibility, the Federal Reserve Bank of Boston webpage provides updated information on the program, as does the LeadingAge NY COVID-19 Financial Assistance Opportunities for NFP Providers guide.

Reminder on Applying for Medicaid Distribution Under Provider Relief Program

LeadingAge NY reminds members that the Department of Health and Human Services (HHS) will be distributing $15 billion of Provider Relief Funding under the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) to Medicaid and Children’s Health Insurance Program (CHIP) providers. Each qualifying provider that successfully applies will receive a grant of at least 2 percent of its reported gross revenue from patient care. Applications are due July 20^th, and the HHS portal for applying is active.

This $15 billion installment of Provider Relief Funding is targeted at existing Medicaid providers that did not receive Provider Relief Funding from the previous $50 billion General Distribution. HHS indicates that assisted living facilities, home and community-based services (HCBS) providers, nursing facilities, clinics, and hospices can apply if they meet a series of requirements, including the following: (1) the applicant cannot have received payment from the $50 billion General Distribution, which is determined based on the tax identification number (TIN) of the applicant’s operator; and (2) the applicant must have directly billed Medicaid for health care-related services during the period Jan. 1, 2018 to Dec. 31, 2019.

Unlike the General Distribution, this installment of Provider Relief Funding requires interested organizations to apply to receive funding. HHS information on CARES Act Provider Relief Funding is available here. HHS has updated its Provider Relief Fund FAQ to include questions and answers detailing eligibility, application requirements, and calculation of payments for the targeted Medicaid/CHIP distribution. The newly updated HHS Provider Relief Fund website also includes instructions on how to apply, which should be reviewed carefully prior to applying. Providers can only apply once, and the instructions outline the information that providers must collect in advance to be prepared to submit their application through the HHS portal.

Nursing Home Updates

DOH Report Attributes COVID-19 Spread in Nursing Homes to Asymptomatic Staff

DOH released a report on July 6^th that concludes that COVID-19 was more likely to have been introduced into nursing homes by asymptomatic employees than by infected patients admitted from hospitals. Entitled "Factors Associated with Nursing Home Infections and Fatalities in New York State During the COVID-19 Global Health Crisis," the report disputes the claim that the Department’s March 25^th directive prohibiting nursing homes from denying admission solely on the basis of COVID-19 infection was to blame for the transmission of the virus in facilities.

Specifically, the DOH analysis found:

• The timing of staff infections correlates with the timing of peak nursing home resident mortality across the state;
• Nursing home employee infections were related to the most impacted regions in the state;
• Peak nursing home admissions occurred a week after peak nursing home mortality, therefore illustrating that nursing home admissions from hospitals were not a driver of nursing home infections or fatalities;
• Most patients admitted to nursing homes from hospitals were no longer contagious when admitted and therefore were not a source of infection; and
• Nursing home quality was not a factor in nursing home fatalities.

The report found that nearly 7,000 nursing home workers infected with COVID-19 were working in facilities in the month of March, and roughly 20,000 were COVID-19-positive by the end of April. Interestingly, independent testing done by BioReference in May showed that 29 percent of nursing home employees surveyed had COVID-19 antibodies. Eighty percent of all infected nursing home staff were from the most impacted areas of the state: New York City (48 percent), Long Island (17 percent), and the Mid-Hudson Valley (15 percent).

DOH compared the timing of peak staff infections with peak resident mortality and concluded that, given the timing of the respective peaks and the average time from symptom presentation to death, it is likely that employees who were infected in March unknowingly transmitted the virus to residents who died during the peak mortality period in early April. The report explained that early in the COVID-19 pandemic, public health experts believed that asymptomatic people did not spread the disease, and under Centers for Disease Control and Prevention (CDC) guidance, asymptomatic positive or presumed positive employees were allowed to continue to work. Later in the crisis, experts were forced to reverse their position as evidence grew that asymptomatic people could transmit the disease.

To rebut the claim that the State’s March 25^th nursing home admission directive led to the spread of infections in facilities, the Department conducted a survey of nursing home admissions. According to the survey, most of the nursing homes that admitted COVID-19-positive patients already had COVID-19-positive residents in their facilities. In addition, the data showed that approximately 6,326 COVID-19-positive residents were admitted to facilities between March 25, 2020 and May 8, 2020. The peak date that COVID-19-positive residents entered nursing homes was April 14, 2020, a week after peak mortality in New York’s nursing homes on April 8, 2020. Based on these data, the Department concluded that admissions did not drive fatalities; if they had, the order of the peak fatalities and peak admissions would have been reversed.

In an effort to further defend the March 25^th admission order, the report points to the creation of alternative care sites in New York City, Buffalo, and Syracuse and maintains that nursing homes did not have to accept COVID-19-positive patients if they did not believe that they could provide adequate care for them. According to the report, DOH and the Attorney General’s Office are conducting an investigation to determine if nursing homes violated the law by accepting residents whom they could not properly serve.

Notably, the report found that nursing home quality did not play a role in mortality rates. Facilities with higher Centers for Medicare and Medicaid Services (CMS) 5-Star quality ratings had higher mortality rates than those with lower quality ratings (12 percent mortality rate in 5-star, versus 7 percent in the lowest rated). DOH explained that the geographic location of the nursing home and its corresponding rate of community infection had a greater connection to mortality than its performance on quality measures. In addition, the analysis found a relationship between a higher median resident age and an increase in the mortality rate downstate, but not in the rest of the state.

The report notes the comparatively low fatality rate among New York’s nursing home residents. Connecticut had 86 nursing home/long term care resident deaths for every 100,000 people; New Jersey 75 for every 100,000; Massachusetts 74 for every 100,000; and Pennsylvania 35 for every 100,000, while New York had 33 for every 100,000.

HCBS Updates

Free Home Care and Hospice Training for COVID-19 Testing

As announced by DOH, training to test for COVID-19 is available at no charge to home care and hospice clinicians whose clients may need testing. Under a grant from the Mother Cabrini Health Foundation, the Home Care Association of New York State (HCA), Iroquois Healthcare Alliance (IHA), and clinical faculty at the Mohawk Valley Health System are delivering web-based training for home health registered nurses (RNs) and other personnel on COVID-19 testing procedures that can be conducted at home. This complimentary training is open to all home care personnel in New York State whose scope of practice permits testing (i.e., nurses and respiratory therapists). LeadingAge NY encourages members to take advantage of this opportunity.

Information on the testing program and details as to how to participate are available here.

VNSNY CHOICE Resources for New York’s Aging Population 

VNSNY CHOICE is launching a series of online classes and workshops to stay connected with and support New York’s aging population during the COVID-19 emergency. In partnership with local community centers, senior advocacy groups, and health and wellness experts, they are announcing the following programs:

• VNSNY CHOICE Virtual Exercise Series (to be held Tuesdays and Thursdays)
• “Scammers Follow the Headlines: What to Know, What to Beware,” a workshop to be presented by the Attorney General’s Office on Wed., July 15^th (two one-hour sessions – English at 10 a.m., Spanish at 2 p.m.)

More information is available in the flyers linked above.