CMS Issues COVID-19 Guidance for Nursing Facilities

The Centers for Medicare & Medicaid Services (CMS) released revised Quality, Safety & Oversight Group (QSO) standards for infection control and prevention of coronavirus disease 2019 (COVID-19) in nursing homes. This guidance, issued March 13, 2020, was a follow-up to the original guidance provided on March 4, 2020 and is effective immediately.

The revised guidance focuses on:

1. Limiting the transmission of COVID-19 for nursing homes
2. Transferring a resident with suspected or confirmed infection with COVID-19 to a hospital
3. Accepting a resident who was diagnosed with COVID-19 from a hospital
4. Addressing supply shortages

Each of these is discussed in turn below.

Nursing homes should contact their local health department if they have questions or suspect a resident has COVID-19. Nursing facilities experiencing an increased number of respiratory illnesses among patients/residents or health care personnel should immediately contact their local or state health department for further guidance.

Please note that CMS recommends nursing facilities stay continually stay up-to-date with information published by the Centers for Disease Control and Prevention (CDC), including specific CDC guidance impacting health care professionals.

1. Limiting the Transmission of COVID-19 for Nursing Homes

Nursing facilities should restrict visitation by all visitors and nonessential health care personnel, except for certain compassionate care situations, such as an end-of-life (EoL) situation. Nursing facilities are expected to notify potential visitors to defer visitation at the nursing facilities until further notice through signage, calls, letters and any other appropriate mode of communication. Health care workers and surveyors are exceptions to the restriction in this guidance; however, nursing homes should review the CDC guidance for restricting access to health care workers for additional details. Surveyors are being monitored by CMS and state survey agencies for any transmission risks.

The End of Life Situation

Decisions about visitation during an EoL situation should be made on a case-by-case basis, which involves a careful screening of the visitor, including clergy and bereavement counselors, for fever or respiratory symptoms. Those with symptoms of a respiratory infection should not enter the facility at any time, even in an EoL situation. If a visitor is permitted to visit a nursing facility due to an EoL situation, the nursing home must limit those visitors to a specific room, such as the resident’s room or another location designated by the nursing facility. Facilities should continue to disinfect rooms after each resident-visitor meeting. Nursing facilities handling EoL situations should require visitors to perform hand hygiene and use Personal Protective Equipment (PPE), such as facemasks. Please note that if a state implements actions that exceed CMS requirements, such as a ban on all visitation through a governor’s executive order, then a facility would not be out of compliance with CMS’ requirements, even in the case of an EoL situation.

Restrictions on Visitation

In lieu of visits, nursing facilities should continue to consider:

• Offering alternative means of communication for people who would otherwise visit, such as virtual communications (phone, video-communication, etc.)
• Creating/increasing listserv communication to update families, such as advising on the general prohibition against visitors
• Assigning staff as primary contact to families for inbound calls and conduct regular outbound calls to keep families up to date
• Offering a phone line with a voice recording updated at set times (e.g., daily) with the facility’s general operating status, such as when it is safe to resume visits

Other Ways to Manage Internal and External Risks

CMS added additional guidance for nursing homes to practice the following to limit the transmission of COVID-19:

• Cancel communal dining and all group activities.
• Screen all residents for fever and respiratory symptoms.
• Remind residents to practice social distancing and perform frequent hand hygiene.
• Screen all staff for fever and respiratory symptoms. Staff should be screened at the beginning of each shift. Nursing facilities must document a staff member’s shortness of breath, new or change in cough, and sore throat. If a staff member is ill, the nursing facility must ask them to put on a facemask and self-isolate at home.
• Communicate through multiple means to inform all individuals of the visitation restrictions, such as through signage, letters, emails and phone calls.
• 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 they do not place individuals in the facility at risk for COVID-19.
• Advise visitors and any individuals who entered the facility to self-monitor for signs and symptoms of respiratory infection for at least 14 days after exiting the facility. If symptoms occur, nursing facilities should advise these individuals to:
  • Self-isolate at home.
  • Contact their health care provider.
  • 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. Nursing facilities should contact their local health department if they have questions or suspect a resident has COVID-19.

2. Transferring a Resident With Suspected or Confirmed COVID-19 to a Hospital

CMS recognizes that residents infected with COVID-19 may vary in severity from lack of symptoms to mild or severe symptoms or fatality. Initially, symptoms may be mild and not require transfer to a hospital as long as the facility can follow the infection prevention and control practices recommended by CDC. Facilities without an airborne infection isolation room are not required to transfer the resident assuming: (1) the resident does not require a higher level of care, and (2) the facility can adhere to the rest of the infection prevention and control practices recommended for caring for a resident with COVID-19.

If a resident develops more severe symptoms and requires transfer to a hospital for a higher level of care, the nursing facility should communicate these symptoms to emergency medical services (EMS) and the receiving facility. Precautions should be taken in advance of the transfer, including placing a facemask on the resident during the transfer.

If the resident does not require hospitalization and the nursing facility determines the individual can be discharged home, the nursing facility must consult with state or local public health authorities. If such transfer is deemed medically and socially appropriate, then the nursing facility should place a facemask on the resident and isolate him or her in a room with the door closed.

Once again, nursing facilities should contact their local health department if they have questions or suspect a resident has COVID-19.

3. Accepting a Resident Diagnosed With COVID-19 From a Hospital

A nursing facility can accept a resident diagnosed with COVID-19 and still under transmission-based precautions for COVID-19 as long as the facility can follow CDC guidance for transmission-based precautions. CMS further states that nursing facilities should admit any individuals who they would normally admit to their facility, including individuals from hospitals where a case of COVID-19 was/is present. Also, if possible, nursing facilities should dedicate a unit/wing exclusively for any residents coming or returning from the hospital. This can serve as a step-down unit where the residents remain for 14 days with no symptoms.

4. Addressing Supply Shortages

CMS acknowledges that there is a scarcity of some supplies across the nation. Surveyors should not cite facilities for not having certain supplies (e.g., PPE such as gowns, N95 respirators, surgical masks and alcohol-based hand rubs (ABHR)) if they are having difficulty obtaining these supplies for reasons outside of their control. However, CMS expects nursing facilities to take actions to mitigate any resource shortages, optimize their current supply and show they are taking all appropriate steps to obtain the necessary supplies as soon as possible.

We will continually monitor for CMS guidance to nursing facilities and update this alert, as appropriate.

As the number of cases around the world grows, Faegre Drinker’s Coronavirus Resource Center is available to help you understand and assess the legal, regulatory and commercial implications of COVID-19.