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CMS Issues Nursing Home Reopening Recommendations

On May 18th, the Centers for Medicare and Medicaid Services (CMS) issued letter QSO-20-30-NH outlining recommendations for the reopening of nursing homes. The letter addresses criteria for relaxing restrictions, visitation and services considerations, and restoration of survey activities. Implementation criteria in all three phases are provided. The following criteria are to be considered in relaxing restrictions:

  • 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 onset1 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 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.
    • 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.

Letter QSO-20-30-NH also provides guidance on the resumption and prioritization of survey activities as follows:

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:
    1. Abuse or neglect
    2. Infection control, including lack of notifying families and their representatives of COVID-19 information (per new requirements at 42 CFR 483.80(g)(3))
    3. Violations of transfer or discharge requirements
    4. Insufficient staffing or competency
    5. 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:
    1. Facilities that have had a significant number of COVID-19 positive cases
    2. Special Focus Facilities
    3. Special Focus Facility candidates
    4. 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.)

Contact: Elliott Frost, efrost@leadingageny.org, 518-441-8761