CMS Updates Testing Guidance for Nursing Homes
Updated guidance issued by the Centers for Medicare and Medicaid Services (CMS) requires twice-weekly COVID-19 testing of unvaccinated staff in nursing homes this week. The guidance, QSO 20-38-NH, implements a new methodology for determining the frequency of routine testing of unvaccinated staff based on a combination of community transmission levels (CTLs) and positivity rates in the facility's county. It also provides for a new, targeted approach to outbreak investigations and associated testing.
Routine Testing
Under the new methodology, facilities should use their county level of community transmission to trigger the frequency of routine testing of unvaccinated staff. All counties in New York State are experiencing high CTLs, based on the most current Centers for Disease Control and Prevention (CDC) data. As a result, nursing homes throughout New York State are required to conduct twice-weekly testing of unvaccinated staff. Twice-weekly testing is also required in counties with "substantial" CTLs. Facilities in counties that have "moderate" CTLs are required to test once weekly, while those with "low" levels are not required to conduct routine testing.
CTLs are published by the CDC here. LeadingAge NY will post the CDC CTLs weekly, in conjunction with the publication of Intelligence, here. Community transmission is calculated based on new cases per 100,000 persons in the past seven days and the county positivity rate for nucleic acid amplification tests (e.g., PCR tests). When new cases per 100,000 are less than 10, the CTL is low; between 10 and 49.99, the CTL is moderate; between 50 and 99.99, it is substantial; and 100 or more, it is high. If the positivity rate suggests a different CTL, the higher level is selected.
Like the prior guidance, the update directs facilities to monitor their level of community transmission every other week and adjust the frequency of performing staff testing accordingly. If the level of community transmission increases to a higher level of activity, the facility should begin testing staff at the required frequency as soon as the criteria for the higher activity level are met. If the level of community transmission decreases to a lower level of activity, the facility should continue testing staff at the higher frequency level until the level of community transmission has remained at the lower activity level for at least two weeks before reducing testing frequency.
Outbreak Investigations
The updated guidance also includes a new contact tracing approach to outbreak investigations and outbreak testing. It is unclear whether this new, targeted approach has been accepted by the state Department of Health (DOH). The federal guidance related to outbreak investigations provides that facilities have the option to perform outbreak testing through either the new contact tracing approach or the continued use of the broad-based (i.e., facility-wide) approach. It also states that "[b]roader approaches might also be required if the facility is directed to do so by the jurisdiction’s public health authority, or in situations where all potential contacts are unable to be identified, are too numerous to manage, or when contact tracing fails to halt transmission (emphasis added)." Since DOH's testing guidance requires a facility-wide approach to outbreak testing, members are advised to continue to pursue a facility-wide outbreak approach until DOH issues its own update.
Testing of Staff and Residents with a High-Risk Exposure or Close Contact
The updated testing guidance includes a new section for managing staff who have a high-risk exposure or residents who have a close contact when a facility is not in outbreak status. For example, this might occur as a result of exposure from a visitor, while a resident is on a leave of absence, or during care of a resident on the COVID-19 unit. The CMS guidance refers to CDC guidance here and here. The CDC guidance on infection prevention in nursing homes provides the following advice to facilities in which a resident has close contact with an individual with COVID-19 infection:
- Unvaccinated residents who have had close contact with someone with SARS-CoV-2 infection should be placed in quarantine for 14 days after their exposure, even if viral testing is negative. Health care personnel (HCP) caring for them should use full personal protective equipment (PPE) (gowns, gloves, eye protection, and N95 or higher-level respirator).
- Fully vaccinated residents who have had close contact with someone with SARS-CoV-2 infection should wear source control and be tested as described in the testing section. Fully vaccinated residents and residents with SARS-CoV-2 infection in the last 90 days do not need to be quarantined, restricted to their room, or cared for by HCP using the full PPE recommended for the care of a resident with SARS-CoV-2 infection unless they develop symptoms of COVID-19, are diagnosed with SARS-CoV-2 infection, or the facility is directed to do so by the jurisdiction’s public health authority. Additional potential exceptions are described here.
Notably, the CDC update offers more detailed guidance on testing of HCP and residents who have had high-risk exposures or close contact with an infected individual:
Asymptomatic HCP with a higher-risk exposure and residents with close contact with someone with SARS-CoV-2 infection, regardless of vaccination status, should have a series of two viral tests for SARS-CoV-2 infection. In these situations, testing is recommended immediately (but not earlier than 2 days after the exposure) and, if negative, again 5–7 days after the exposure. Criteria for use of post-exposure prophylaxis are described elsewhere.
Additional information about management of outbreaks and new cases among residents or staff can be found in the updated CDC guidance entitled Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes.
Contact: Karen Lipson, klipson@leadingageny.org