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Review of DOH and CMS Cohorting Guidance

On Jan. 4, 2022, the Department of Health (DOH) issued a Dear Administrator Letter (DAL) relating, in part, to cohorting of nursing home residents with COVID-19. LeadingAge NY has recently been receiving numerous questions from members regarding cohorting and provides the below review of the guidance.

The DAL states the following:

The purpose of this letter is to provide Nursing Homes with recommendations to follow during COVID-19 outbreaks, adding to the tools already available to decrease the risk of COVID-19 transmission in nursing homes.

. . .

Upon identification of a COVID-19 outbreak (residents and/or staff) nursing homes should implement the following:

  • Immediately contact the nursing home medical director regarding the new COVID-19 outbreak who should communicate an expectation with attending physicians, nurse practitioners and physician extenders that onsite resident rounds should be conducted on a daily basis.
  • Examine your 60-day PPE inventory and burn rate. Replenish all types of PPE to support ongoing health and safety for residents and staff. If PPE is stored at an offsite location, you are expected to request the necessary PPE prior to any shortage. Be specific when communicating PPE needs to include specific sizes (gloves, gowns), models (N95 masks) and types (disposable gowns), etc.
  • Continue to assess the need for and strongly encourage vaccination and booster shots to all eligible residents, staff and visitors. An outbreak in a facility does not prohibit ongoing vaccination for those individuals not infected with COVID-19.
  • Screen all visitors and vendors, including ombudsman and inspectors, prior to entering the nursing home. Maintain a record of this screening in the event contact tracing is needed.
  • Enhance communication with residents, families, visitors and staff regarding the outbreak. Encourage both visitors and staff to stay home if sick.
  • Assess each (both COVID and Non-COVID) resident’s oxygen saturation using a pulse oximeter every 4 (four) hours. This will assist with the early detection of resident change in condition to allow for informed clinical and medical decisions to be made expeditiously. This is extremely important with our frail elderly who often have multiple comorbid conditions. 
  • Exercise vigilant deep cleaning and surface cleaning throughout the day.
  • Strongly emphasize the need for visitor testing or vaccination when vaccination status is unknown.
  • Increase frequency of resident and staff testing to expeditiously identify new COVID-19 cases in accordance with CMS and CDC guidance outlined in DAL NH 21-23 Updated Nursing Home Testing Requirements issued on October 27, 2021.
  • Designate different staff members on all shifts to audit staff compliance with the appropriate donning and doffing of PPE and social distancing during breaks and meal-time.
  • Monitor breakrooms and common areas to ensure appropriate social distancing.
  • Conduct, at a minimum, daily team meetings to support staff and communicate strong infection prevention and control strategies.
  • Maintain ongoing communication with the State and Local Health Departments on the status of the COVID-19 outbreak and contact tracing activities.
  • Complete the daily Nursing Home HERDS survey by 1:00 PM daily.

The below excerpts from DOH's Aug. 6, 2021 Frequently Asked Questions (FAQs) on cohorting will also address some of the questions we have been receiving:

1. If a facility has only one or a few residents with COVID-19, does an entire unit need to be cleared and devoted exclusively to the care of residents with COVID-19?

Answer: No. When there are only one or a few residents with COVID-19 in a facility, they may be cohorted on part of a unit, such as at the end of a hallway. The area for residents with COVID-19 should be demarcated as a reminder for other residents and healthcare personnel. Other residents should be prevented from entering the cohort area.

2. If a facility has only one or a few residents with COVID-19, do separate staff need to be devoted exclusively to those residents?

Answer: Yes, if possible. The goal of separate staffing teams is to minimize the number of staff who care for both residents with COVID-19 and residents without COVID-19.

3. Please define positive, negative, and unknown as they apply to forming resident cohorts.

Outbreak testing is to be completed on both vaccinated and unvaccinated residents and staff. As such, resident cohorting should be based on SARS-CoV-2 diagnostic testing results where a single test defines a resident’s status at a single point in time. Three resident cohorts (positive, negative, and unknown) are defined as follows:

Positive cohort

The positive cohort should only house residents with a confirmed COVID-19 infection who have tested positive for SARS-CoV-2 by a diagnostic test (e.g., a rapid antigen, rapid molecular test, or a lab based molecular test).

  • Residents who have a confirmed COVID-19 infection should be placed in the positive cohort regardless of vaccination status.
  • Residents in the positive cohort should be cared for using transmission-based precautions.

Negative cohort

The negative cohort should house residents who have tested negative for SARS-CoV-2 by a diagnostic test, (e.g., a rapid antigen, rapid molecular test, or a lab based molecular test), excluding residents who test negative before meeting the criteria to discontinue COVID-19 transmission-based precautions (who should remain in the positive cohort until they meet criteria to discontinue precautions).

The negative cohort should house residents who have met criteria to discontinue COVID-19 transmission-based precautions after recovery from COVID-19. A resident should remain on the negative cohort until testing identifies a need to move them, or until the resident refuses indicated testing (at which time they should move to the unknown cohort).

Unknown cohort

The unknown cohort should only house residents who have not been tested (e.g., the resident refused testing).

Residents (who have not tested positive) should be moved to the unknown cohort whenever the resident is not tested during any round of serial outbreak testing as required by CMS.

Guidance from the Centers for Disease Control and Prevention (CDC), which aligns well with the DOH guidance, is also available here.

Members are encouraged to reach out to Amy Nelson with any questions.

Contact: Amy Nelson, anelson@leadingageny.org, 518-867-8383 ext. 146