March 17th COVID-19 Update

Developments around the COVID-19 outbreak are rapidly evolving, as are the guidance and requirements coming from public health authorities and government regulators. Outlined below are the latest updates for nursing homes, adult day health care (ADHC) programs, adult care facilities (ACFs), home and community-based services (HCBS) providers, and affordable housing/independent living, as well as information pertaining to recent changes in federal regulation and reimbursement.

As a reminder, LeadingAge NY has begun convening weekly webinars on Mondays with members from all service lines to address emerging questions related to COVID-19. The first of these webinars took place on Mon., March 16^th at 11 a.m.; the recording can be accessed here. Please send your questions to Ami Schnauber here, and check your email for the dial-in information, or contact Jeff Diamond here. Additionally, LeadingAge NY has just issued new COVID-19 questions and answers (Q&As) addressing issues of general concern to multiple provider types, as well as provider-specific issues. To access the Q&As, which will be updated regularly, click here.

Federal Regulatory Flexibility and Reimbursement

The March 13^th Declaration of National Emergency allows the Centers for Medicare and Medicaid Services (CMS) to waive certain federal regulatory requirements. This can take the form of blanket waivers as well as state- or provider-requested waivers authorized by section 1135 of the Social Security Act. CMS issued several blanket waivers on March 13^th, with those most relevant to members described briefly below. They are scheduled to remain in place for the duration of the emergency declaration. While the geographic scope of the blanket waivers is nationwide, members should note that they apply to situations related to the emergency (e.g., the 3-day stay requirement is waived in specific scenarios) and should be careful to ensure that they are utilizing any flexibilities appropriately and documenting the circumstances as well as possible. We are seeking further guidance and will provide more detail as soon as it becomes available.

3-Day Hospital Stay. Makes temporary emergency coverage for skilled nursing facility (SNF) services available without a qualifying 3-day hospital stay for beneficiaries who experience dislocations or are otherwise affected by the emergency, such as those who are (1) evacuated from a nursing home in the emergency area; (2) discharged from a hospital (in the emergency or receiving locations) in order to provide care to more seriously ill patients; or (3) need SNF care as a result of the emergency, regardless of whether that individual was in a hospital or nursing home prior to the emergency.
100-Day Benefit Period. Allows certain beneficiaries who have exhausted their 100 days of Medicare Part A SNF coverage to continue receiving services without the normally required break in the spell of illness.
MDS and OASIS Assessments. Provides as-of-yet unspecified flexibility regarding the timing of Minimum Data Set (MDS) and Outcome and Assessment Information Set (OASIS) assessment submissions.
Durable Medical Equipment. In situations where durable medical equipment (DME) is lost, destroyed, irreparably damaged, or otherwise rendered unusable, certain mandates governing replacement such as face-to-face requirements, new physician’s orders, and new medical necessity documentation are not required.
Authorized Medicare Providers. Waives requirements that out-of-state providers be licensed in the state where they are providing services when they are licensed in another state; allows new non-certified Part B suppliers, physicians, and non-physician practitioners to expeditiously obtain temporary Medicare billing privileges; expedites provider enrollment; and postpones revalidation actions.
Medicare Administrative Appeals. Extends filing timelines and adds flexibilities for Medicare appeals in fee-for-service (FFS), Medicare Advantage, and Part D, using all flexibilities available in the appeals process, including processing incomplete requests.

A fact sheet outlining these provisions is available here, with some additional information on the SNF benefit waiver provisions here.

General information on 1135 waivers is available here, and the dedicated CMS site is here. The purpose of 1135 waivers is to ensure that sufficient health care items and services are available to meet the needs of beneficiaries and that health care providers that provide such services in good faith can be reimbursed for them and not be subjected to sanctions for noncompliance, absent any fraud or abuse. They allow reimbursement during an emergency or disaster even if providers cannot comply with certain requirements that would under normal circumstances bar Medicare or Medicaid payment. They do not extend payment to services that are not covered by the program, nor do they allow ineligible individuals to receive services.

CMS also issued two documents addressing payment issues related to COVID-19. A Medicare Coverage and Payment fact sheet issued on March 5^th is here, and a COVID-19 Payment Frequently Asked Questions (FAQ) document from March 6^th is here.

Nursing Homes

CMS Announces New Visitor Restrictions

On March 13^th, CMS issued a revised memo on visitor and worker restrictions in nursing homes. All facilities nationwide are directed to restrict visitation of all visitors and non-essential health care personnel (HCP), except for certain compassionate care situations (e.g., an end-of-life situation). Facilities are expected to communicate through multiple means to inform individuals and non-essential HCP of the visitation restrictions, such as through signage at entrances/exits, letters, emails, phone calls, and recorded messages for receiving calls.

In cases of compassionate/end-of-life care, decisions about visitation should be made on a case-by-case basis and include careful screening of the visitor (including clergy, bereavement counselors, etc.) for fever or respiratory symptoms. Those with such symptoms should not enter the facility at any time (even in end-of-life situations). Allowed visitors must wear a facemask while in the building, restrict their visit to the resident’s room or other designated location, be reminded to frequently perform hand hygiene, and avoid physical contact with residents and others while in the facility.

Facilities must follow Centers for Disease Control and Prevention (CDC) guidelines for restricting access to health care workers (including hospice workers, emergency medical services (EMS) personnel, or dialysis technicians who care for residents). They can come into the facility if they meet the CDC guidelines for health care workers.

CMS and state survey agencies are evaluating their surveyors to ensure that they do not pose a transmission risk when entering a facility. For example, surveyors may have been in a facility with COVID-19 cases in the previous 14 days, but because they were wearing personal protective equipment (PPE) effectively per CDC guidelines, they pose a low risk to transmission in the next facility and must be allowed to enter. However, there are circumstances under which surveyors should still not enter, such as if they have a fever.

Other key directives from CMS in this memo include the following:

Cancel communal dining and all group activities, such as internal and external group activities.
Screen all staff at the beginning of their shift for fever and respiratory symptoms. Actively take their temperature and document absence of shortness of breath, new or change in cough, and sore throat. If they are ill, have them put on a facemask and self-isolate at home.
Implement active screening of residents and staff for fever and respiratory symptoms. Remind residents to practice social distancing and perform frequent hand hygiene.
Facilities should identify staff who work at multiple facilities (e.g., agency staff, regional or corporate staff, etc.) and actively screen and restrict them appropriately to ensure that they do not place individuals in the facility at risk for COVID-19.
Residents still have the right to access the Ombudsman program. Their access should be restricted except in compassionate care situations; however, facilities may review this on a case-by-case basis. If in-person access is not available due to infection control concerns, facilities must facilitate resident communication (by phone or other format) with the Ombudsman program.
Tell visitors and any individuals who entered the facility (e.g., hospice staff) to monitor for signs and symptoms of respiratory infection for at least 14 days after exiting the facility. If symptoms occur, advise them to self-isolate at home, contact their health care provider, and immediately notify the facility of the date they were in the facility, the individuals they were in contact with, and the locations within the facility they visited. Facilities should immediately screen the individuals of reported contact and take all necessary actions based on findings.

DOH Issues Memo on COVID-19 Cases in Nursing Homes and ACFs

DOH issued a March 13^th Health Advisory to nursing homes and ACFs on preventing introduction of COVID-19 into these facilities and instructions for dealing with confirmed and suspected cases of the virus. This supersedes previous DOH guidance on the subject.

To help prevent introduction of COVID-19, nursing homes and ACFs are instructed to:

Suspend all visitation except when medically necessary or for family members of residents in imminent end-of-life situations, and those providing hospice care. Visitors should wear a facemask while in the facility and only be allowed in the resident’s room. Facilities must otherwise meet social and emotional needs of residents, such as video calls. Post signage notifying the public of the suspension, and notify resident family members.
Implement health checks for all HCP and other facility staff at the beginning of each shift. This includes all personnel entering the facility, regardless of whether they are providing direct patient care. Facility staff performing health checks must wear facemasks. HCP and other facility staff with symptoms or with T ≥ 100.0 F should be sent home, and HCP and other facility staff who develop symptoms or fever while in the facility should immediately go home.
All HCP and other facility staff must wear a facemask while within six feet of residents. Extended wear of facemasks is allowed; they should be changed when soiled or wet and when HCP go on breaks. Facilities should bundle care and minimize the number of HCP and other staff who enter rooms to reduce the need for facemasks.

If there are confirmed cases of COVID-19 in a nursing home or ACF:

Notify the local health department (LDH) and DOH if not already involved.
In nursing homes, actively monitor all residents on affected units once per shift, including a symptom check, vitals, lung auscultation, and pulse oximetry.
Ensure that all residents in affected units remain in their rooms. Cancel group activities and communal dining. Offer other activities for residents in their rooms to the extent possible, such as video calls.
Residents must wear facemasks when HCP or other direct care providers enter their rooms, unless such is not tolerable.
Do not float staff between units. Cohort residents with COVID-19 with dedicated HCP and other direct care providers. Minimize the number of HCP and other direct care providers entering rooms.
In nursing homes, all residents on affected units should be placed on droplet and contact precautions, regardless of the presence of symptoms and regardless of COVID-19 status. HCP and other direct care providers should wear appropriate PPE and perform hand hygiene.
For residents who initially test negative, re-testing should be performed immediately if they develop symptoms consistent with COVID-19.

If there are suspected cases of COVID-19 in a nursing home or ACF:

Residents suspected of infection with COVID-19 should be given a facemask to wear, and the facility must immediately contact DOH. The resident must be isolated in a separate room with the door closed. Staff attending the resident if and until they are transferred should wear full PPE and maintain social distancing of at least six feet from the resident, except for brief, necessary interactions. Facilities should bundle care and minimize the number of HCP and other staff who enter rooms to reduce the need for facemasks.

Adult Day Health Care

Adult Day Health Care Programs Suspended

On March 17^th, DOH notified nursing home administrators and ADHC program directors to immediately suspend ADHC program services. The letter is linked here, and questions and answers are available here.

Adult Care Facilities

On March 11^th, DOH issued Dear Administrator Letter (DAL) #20-10 to ACFs outlining infection control and Person Under Investigation (PUI) standards and urging all ACFs to ensure that the contact information for their leadership team members in the Health Commerce System (HCS) is up to date. A Health Advisory issued on March 13^th covering both ACFs and nursing homes supersedes some of the previous guidance and prohibits all visitors except those providing medically necessary or hospice care or in imminent end-of-life situations. The Advisory, available here and summarized in the nursing home section above, lays out procedures to help prevent introduction of COVID-19 and outlines required actions that an ACF must take if a confirmed or suspected case is identified.

On March 17^th, DOH issued another advisory directing all ACFs with day care programs for non-residents to suspend operation until further notice. Click here to review the directive.

The dedicated email address for ACF COVID-19 questions is covidadultcareinfo@health.ny.gov.

Home and Community-Based Services

DOH Issues COVID-19 Guidance for Home Care and Hospice

DOH issued guidance on March 14^th for certified home health agencies (CHHAs), long term home health care programs (LTHHCPs), hospices, and licensed home care services agencies (LHCSAs). The document outlines several recommendations relating to the health and safety of home care workers and patient care.

All agencies should revisit and reinforce current infection control policies, including droplet and contact precautions with staff. All care to potential and/or confirmed patients with COVID-19 should follow guidelines in CMS guidance here.

It is strongly recommended that all agencies screen patients upon admission and referral for care with recommended questions regarding symptoms and characteristics to determine persons to be referred for evaluation. Best practices would suggest that agencies adhere to the CMS guidance above for screening potential patient admits.

The Department requires agencies to contact the LDH where the patient resides in advance of patient visits to determine if any patients are under mandatory quarantine or precautionary quarantine for possible COVID-19 infection and discuss how to ensure required patient care, particularly Level 1 patient care. Agencies must coordinate and establish points of contact with LDHs to ensure timely and accurate information in this regard. It is our experience that agencies are having difficulty connecting with LDHs. Please let us know if that is the case, and LeadingAge NY can help facilitate that connection.

Staff to agency to LDH contact should occur when a patient is suspected of COVID-19 infection. Additional state public health bureau contacts in the guidance may be utilized in addition to the LDH.

Agencies and staff must be educated regarding the patient screening process to detect and report changes in patient condition and symptoms. Staff should communicate with agencies to report back and receive guidance on next steps. Patients with respiratory distress should call 911. Agencies should report potential COVID-19 infection of patient to the LDH. The LDH is responsible for following up on the patient with respect to suspected infection. The home care agency must stay in contact with the LDH to ensure that the patient receives any care he/she may need.

Agencies must screen staff for respiratory and fever symptoms upon arriving at work and should ensure that there is a policy in place to speak with and screen staff prior to daily patient visits. Agencies must strictly enforce illness and sick leave policies. Guidance is offered regarding staff persons who have been potentially exposed to COVID-19 or to someone who is a PUI for COVID-19.

More guidance from CMS regarding home health care and COVID-19 is provided here. CDC guidance on care in the home is here.

No Blanket Closure for Social Adult Day Care Programs

At this time, the State has not issued any blanket guidance for Social Adult Day Care program closures. The State is relying on county governments to make this decision. A significant number of programs across the state have been closed following county orders, but a few remain in operation. Currently, the New York State Office for the Aging (NYSOFA) is following the Governor’s mass gathering restrictions for senior centers and congregate programs. This requires gatherings of under 500 to operate at 50 percent capacity. NYSOFA does not consider Social Adult Day Care programs to fall under this requirement. This may change in the coming days. We will keep you informed.

The New York City Department for the Aging (DFTA) has closed all senior centers and social day programs. LeadingAge NY will provide updated information as it becomes available.

NYSOFA Changes to EISEP

NYSOFA issued a policy document which temporarily suspends assessment and reassessment requirements for their Expanded In-home Services for the Elderly Program (EISEP) and home-delivered meal program. They encourage Area Agencies on Aging (AAAs) and their contractors to perform assessments when they can be done, but time requirements have been loosened. Plans of Care that are expiring may also remain in place due to this interim policy.

COVID-19 Guidance for Health Homes

This guidance allows face-to-face requirements to be waived for Health Home care management, unless medically necessary. Telephone or telehealth is acceptable in lieu of face-to-face. The document also addresses criteria for screening members prior to conducting a face-to-face visit and instructions for agency personnel who are at risk of being a PUI.

COVID-19 Guidance for 1915(c) Children’s Waiver

This weekend, DOH issued guidance to allow face-to-face requirements to be waived for HCBS provided under the 1915(c) Children’s Waiver, unless medically necessary. The guidance also addresses criteria for screening members prior to conducting a face-to-face visit and instructions for HCBS agency personnel who are at risk of being a PUI.

Housing

On March 13^th, the Department of Housing and Urban Development (HUD) published a joint letter from the Offices of Public and Indian Housing (PIH) and Multifamily Housing. The letter encourages housing providers to “be proactive and refer to official government channels of information, including your state, local, or Tribal health departments.” It also directs providers to the HUD COVID-19 site, which will be updated as necessary and recommends staying up to date on CDC’s updates and insights from medical professionals. Additionally, HUD will be updating both the Office of Multifamily Housing’s Q&A Document and the recently released PIH FAQ document as more information becomes available.

The letter goes on to review the decision to postpone inspections by the Real Estate Assessment Center (REAC) until further notice. An exception will be made where there are exigent circumstances or reason to believe that there is a threat to life or property at a location. In such a case, inspections will be conducted by HUD quality assurance inspectors. Further information regarding HUD’s decision to postpone REAC inspections may be found in both a summary of the decision and statement provided by LeadingAge National and in the previously mentioned Q&A and FAQ documents provided by HUD.

Finally, the letter goes on to state that HUD staff is working to ensure that all housing assistance payments, operations funding, and various other funding streams continue to be obligated in the event of a prolonged telework situation. The Q&A and FAQ documents address flexibilities provided to Multifamily owners and ways Multifamily owners can provide relief to residents affected by COVID-19.

Further Resources Available

HUD has established an email address where more specific programmatic questions may be sent. Multifamily Housing program questions that are not answered by the FAQs should be directed to MFCommunications@hud.gov. For PIH program questions that are not answered by the FAQs, email PIH-COVID@hud.gov. PIH and Multifamily Housing will continue to provide periodic updates to all stakeholders.

HUD Office of Multifamily Housing Deputy Assistant Secretary Lamar Seats is hosting a call on Wed., March 18^th from 2:30 to 3:30 p.m. ET. Please send questions in advance of the call to MFCommunications@hud.gov and use the following dial-in information to join: 844-867-6169, 6248475.

Finally, LeadingAge NY and LeadingAge National will continue to submit questions for HUD Multifamily Housing staff to answer in writing regarding regulatory waivers, emergency supplemental funding, quarantine protocol, technical assistance, in-unit maintenance, and support for residents to access services and supplies. Please check LeadingAge NY’s Coronavirus Resources page and LeadingAge National’s Coronavirus Information for Affordable Housing page for more, and continually updated, information.