DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop C2-21-16 Baltimore, Maryland 21244-1850 Center for Clinical Standards and Quality/Quality, Safety & Oversight Group Ref: QSO-20-30-NH DATE: May 18, 2020 TO: State Officials FROM: Director Quality, Safety & Oversight Group SUBJECT: Nursing Home Reopening Recommendations for State and Local Officials • • Memorandum Summary CMS is committed to taking critical steps to ensure America’s nursing homes are prepared to respond to the Coronavirus Disease 2019 (COVID-19) Public Health Emergency (PHE). Recommendations for State and Local Officials: CMS is providing recommendations to help determine the level of mitigation needed to prevent the transmission of COVID19 in nursing homes. The recommendations cover the following items: o Criteria for relaxing certain restrictions and mitigating the risk of resurgence: Factors to inform decisions for relaxing nursing home restrictions through a phased approach. o Visitation and Service Considerations: Considerations allowing visitation and services in each phase. o Restoration of Survey Activities: Recommendations for restarting certain surveys in each phase. Background Nursing homes have been severely impacted by COVID-19, with outbreaks causing high rates of infection, morbidity, and mortality. The vulnerable nature of the nursing home population combined with the inherent risks of congregate living in a healthcare setting, requires aggressive efforts to limit COVID-19 exposure and to prevent the spread of COVID-19 within nursing homes. Recommendations for States This memorandum provides recommendations for State and local officials to help them determine the level of mitigation needed for their communities’ Medicare/Medicaid certified long term care facilities (hereinafter, ‘nursing homes”) to prevent the transmission of COVID-19. We encourage State leaders to collaborate with the state survey agency, and State and local health departments to decide how these and other criteria or actions should be implemented in their state. Examples of how a State may choose to implement these recommendations include: Page 1 of 10 • • • A State requiring all facilities to go through each phase at the same time (i.e., waiting until all facilities have met entrance criteria for a given phase). A State allowing facilities in a certain region (e.g., counties) within a state to enter each phase at the same time. A State permitting individual nursing homes to move through the phases based on each nursing home’s status for meeting the criteria for entering a phase. Given the critical importance in limiting COVID-19 exposure in nursing homes, decisions on relaxing restrictions should be made with careful review of a number of facility-level, community, and State factors/orders, and in collaboration with State and/or local health officials and nursing homes. Because the pandemic is affecting communities in different ways, State and local leaders should regularly monitor the factors for reopening and adjust their plans accordingly. Factors that should inform decisions about relaxing restrictions in nursing homes include: • 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 onset 1 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: o 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; o 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); o Written screening protocols for all staff (each shift), each resident (daily), and all persons entering the facility, such as vendors, volunteers, and visitors; o 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 1 A “new, nursing home onset” refers to COVID-19 cases that originated in the nursing home, and not cases where the nursing home admitted individuals from a hospital with a known COVID-19 positive status, or unknown COVID-19 status but became COVID-19 positive within 14 days after admission. In other words, if the number of COVID-19 cases increases because a facility is admitting residents from the hospital AND they are practicing effective Transmission-Based Precautions to prevent the transmission of COVID-19 to other residents, that facility may still advance through the phases of reopening. However, if a resident contracts COVID-19 within the nursing home without a prior hospitalization within the last 14 days, this facility should go back to the highest level of mitigation, and start the phases over. Page 2 of 10 • • • (e.g., within 48 hours). Antibody test results should not be used to diagnose someone with an active SARS-CoV-2 infection. o 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. Contact: For questions or concerns regarding this memo, please contact DNH_TriageTeam@cms.hhs.gov. Effective Date: Immediately. This policy should be communicated with all survey and certification staff, their managers and the State/Branch training coordinators immediately. /s/ David R. Wright Attachments: Recommended Nursing Home Phased Re-opening for States cc: Survey & Operations Group (SOG) Management Page 3 of 10 Attachment 1 – Recommended Nursing Home Phased Reopening for States The reopening phases below cross-walk to the phases of the plan for Opening Up America Again, and includes efforts to maintain rigorous infection prevention and control, as well as resident social engagements and quality of life. Note: The Opening Up America Guidance for communities includes visitation guidance for “senior care facilities.” The term “senior care facilities” refers to a broader set of facilities that may be utilized by seniors, and is not specific to Medicare/Medicare certified long term care facilities (i.e., nursing homes), whereas, this guidance is specific to nursing homes. Due to the elevated risk COVID-19 poses to nursing home residents, we recommend additional criteria for advancing through phases of reopening nursing homes than is recommended in the broader Administration’s Opening Up America Again framework. For example: • Nursing homes should not advance through any phases of reopening or relax any restrictions until all residents and staff have received a base-line test, and the appropriate actions are taken based on the results; • States should survey those nursing homes that experienced a significant COVID-19 outbreak prior to reopening to ensure the facility is adequately preventing transmission of COVID=19; and • Nursing homes should remain in the current state of highest mitigation while the community is in Phase 1 of Opening Up America Again (in other words, a nursing home’s reopening should lag behind the general community’s reopening by 14 days). For additional criteria, please see the Appendix. Status Current state: Significant Mitigation and Phase 1 of Opening Up America Again Criteria for Implementation • Most facilities are in a posture that can be described as their highest level of vigilance, regardless of transmission within their communities. Visitation and Service Considerations • • • • Visitation generally prohibited, except for compassionate care situations. In those limited situations, visitors. are screened and additional precautions are taken, including social distancing, and hand hygiene (e.g., use alcohol-based hand rub upon entry). All visitors must wear a cloth face covering or facemask for the duration of their visit. Restricted entry of non-essential healthcare personnel. Communal dining limited (for COVID-19 negative or asymptomatic residents only), but residents may eat in the same room with social distancing (limited number of people at tables and spaced by at least 6 feet). Non-medically necessary trips outside the building should be avoided. • • • • Surveys that will be performed at each phase Investigation of complaints alleging there is an immediate serious threat to the resident’s health and safety (known as Immediate Jeopardy) Revisit surveys to confirm the facility has removed any Immediate Jeopardy findings Focused infection control surveys Initial survey to certify that the provider has met the required conditions to participate in the Medicare Program (initial certification surveys) Page 4 of 10 Status Criteria for Implementation Visitation and Service Considerations • • • • • • • • Restrict group activities, but some activities may be conducted (for COVID-19 negative or asymptomatic residents only) with social distancing, hand hygiene, and use of a cloth face covering or facemask. For medically necessary trips away from of the facility: o The resident must wear a cloth face covering or facemask; and o The facility must share the resident’s COVID-19 status with the transportation service and entity with whom the resident has the appointment. 100% screening of all persons entering the facility and all staff at the beginning of each shift: o Temperature checks o Ensure all outside persons entering building have cloth face covering or facemask. o Questionnaire about symptoms and potential exposure o Observation of any signs or symptoms 100% screening for all residents: o Temperature checks o Questions about and observation for other signs or symptoms of COVID-19 (at least daily) Universal source control for everyone in the facility. Residents and visitors entering for compassionate care wear cloth face covering or facemask. All staff wear appropriate PPE when they are interacting with residents, to the extent PPE is available and consistent with CDC guidance on optimization of PPE. Staff wear cloth face covering if facemask is not indicated. All staff are tested weekly. All residents are tested upon identification of an individual with symptoms consistent with COVID-19 or if staff have tested positive for COVID-19. Weekly testing continues until all residents test negative. Dedicated space in facility for cohorting and managing care for residents with COVID-19; plan to • Surveys that will be performed at each phase Any State-based priorities (e.g., localized “hot spots,” “strike” teams, etc.) Page 5 of 10 Status Phase 2 of Reopening nursing homes and Opening Up America Again Criteria for Implementation • • • • • • Case status in community has met the criteria for entry into phase 2 (no rebound in cases after 14 days in phase 1). There have been no new, nursing home onset COVID cases in the nursing home for 14 days. The nursing home is not experiencing staff shortages. The nursing home has adequate supplies of personal protective equipment and essential cleaning and disinfection supplies to care for residents. The nursing home has adequate access to testing for COVID-19. Referral hospital(s) have bed capacity on wards and intensive care units. Visitation and Service Considerations • • • • • • • manage new/readmissions with an unknown COVID19 status and residents who develop symptoms. Visitation generally prohibited, except for compassionate care situations. In those limited situations, visitors are screened and additional precautions are taken, including social distancing, and hand hygiene (e.g., use alcohol-based hand rub upon entry). All visitors must wear a cloth face covering or facemask for the duration of their visit. Allow entry of limited numbers of non-essential healthcare personnel/contractors as determined necessary by the facility, with screening and additional precautions including social distancing, hand hygiene, and cloth face covering or facemask. Communal dining limited (for COVID-19 negative or asymptomatic residents only), but residents may eat in the same room with social distancing (limited number of people at tables and spaced by at least 6 feet). Group activities, including outings, limited (for asymptomatic or COVID-19 negative residents only) with no more than 10 people and social distancing among residents, appropriate hand hygiene, and use of a cloth face covering or facemask. For medically necessary trips outside of the facility: o The resident must wear a cloth face covering or facemask; and o The facility must share the resident’s COVID-19 status with the transportation service and entity with whom the resident has the appointment. 100% screening of all persons entering the facility and all staff at the beginning of each shift: o Temperature checks o Ensure all outside persons entering building have cloth face covering or facemask. o Questionnaire about symptoms and potential exposure o Observation of any signs or symptoms 100% screening (at least daily) for all residents Surveys that will be performed at each phase • • • • • • Investigation of complaints alleging either Immediate Jeopardy or actual harm to residents Revisit surveys to confirm the facility has removed any Immediate Jeopardy findings Focused infection control surveys Initial certification surveys State-based priorities (e.g., localized “hot spots,” “strike” teams, etc.) See Appendix for recommendations for prioritizing facilities to be surveyed Page 6 of 10 Status Criteria for Implementation Visitation and Service Considerations Temperature checks Questions about and observation for other signs or symptoms of COVID-19 Universal source control for everyone in the facility. Residents and visitors entering for compassionate care wear cloth face covering or facemask. All staff wear all appropriate PPE when indicated. Staff wear cloth face covering if facemask is not indicated, such as administrative staff. Test all staff weekly. Test all residents upon identification of an individual with symptoms consistent with COVID-19, or if staff have tested positive for COVID-19. Weekly testing continues until all residents test negative. Dedicated space in facility for cohorting and managing care for residents with COVID-19; plan to manage new/readmissions with an unknown COVID19 status and residents who develop symptoms. Visitation allowed with screening and additional precautions including ensuring social distancing and hand hygiene (e.g., use alcohol-based hand rub upon entry). All visitors must wear a cloth face covering or facemask for the duration of their visit. Allow entry of non-essential healthcare personnel/contractors as determined necessary by the facility, with screening and additional precautions including social distancing, hand hygiene, and cloth face covering or facemask. Communal dining limited (for COVID-19 negative or asymptomatic residents only), but residents may eat in the same room with social distancing (limited number of people at tables and spaced by at least 6 feet). Group activities, including outings, allowed (for asymptomatic or COVID-19 negative residents only) with no more than the number of people where social distancing among residents can be maintained, appropriate hand hygiene, and use of a cloth face covering or facemask. Surveys that will be performed at each phase o o • • • • Phase 3 of Reopening nursing homes and Opening Up America Again • • • • • Community case status meets criteria for entry to phase 3 (no rebound in cases during phase 2). There have been no new, nursing home onset COVID cases in the nursing home for 28 days (through phases 1 and 2). The nursing home is not experiencing staff shortages. The nursing home has adequate supplies of personal protective equipment and essential cleaning and disinfection. supplies to care for residents. The nursing home has adequate access to testing for COVID-19. • • • • • • • • • • Normal Survey operations All complaint and revisit surveys required to identify and resolve any non-compliance with health and safety requirements Standard (recertification) surveys and revisits Focused infection control surveys State-based priorities (e.g., localized “hot spots,” “strike” teams, etc. See Appendix for recommendations for prioritizing facilities to be surveyed Page 7 of 10 Status Criteria for Implementation • Referral hospital(s) have bed capacity on wards and intensive care units. Visitation and Service Considerations • • • • • • • • Surveys that will be performed at each phase Allow entry of volunteers, with screening and additional precautions including social distancing, hand hygiene, and cloth face covering or facemask. For medically necessary trips outside of the facility: o The resident must wear a mask; and o The facility must share the resident’s COVID-19 status with the transportation service and entity with whom the resident has the appointment. 100% screening of all persons entering the facility and all staff at the beginning of each shift: o Temperature checks. o Ensure all outside persons entering building have cloth face covering or facemask. o Questionnaire about symptoms and potential exposure o Observation of any signs or symptoms 100% screening (at least daily) for all residents o Temperature checks o Questions about and observation for other signs or symptoms of COVID-19 Universal source control for everyone in the facility. Residents and visitors wear cloth face covering or facemask. All staff wear all appropriate PPE when indicated. Staff wear cloth face covering if facemask is not indicated, such as administrative staff. Test all staff weekly. Test all residents upon identification of an individual with symptoms consistent with COVID-19, or if staff have tested positive for COVID-19. Weekly testing continues until all residents test negative. Dedicated space in facility for cohorting and managing care for residents with COVID-19; plan to manage new/readmissions with an unknown COVID-19 status and residents who develop symptoms. Page 8 of 10 APPENDIX Additional Recommendations • Reminder: When a community enters phase 1 of Opening Up America Again, nursing homes remain at their highest level of vigilance and mitigation (e.g., visitation restricted except in compassionate care situations). Nursing homes do not begin to de-escalate or relax restrictions until their surrounding community satisfies gating criteria and enters phase 2 of Opening Up America Again. • A nursing home should spend a minimum of 14 days in a given phase, with no new nursing home onset of COVID-19 cases, prior to advancing to the next phase. • A nursing home may be in different phases than its surrounding community based on the status of COVID-19 inside the facility, and the availability of key elements including, but not limited to PPE 2, testing, and staffing. For example, if a facility identifies a new, nursing home onset COVID-19 case in the facility while in any phase, that facility goes back to the highest level of mitigation, and starts over (even if the community is in phase 3). • States may choose to have a longer waiting period (e.g., 28 days) before relaxing restrictions for facilities that have had a significant outbreak of COVID-19 cases, facilities with a history of noncompliance with infection control requirements, facilities with issues maintaining adequate staffing levels, or any other situations the state believes may warrant additional oversight or duration before being permitted to relax restrictions. State Survey Prioritization (Starting in Phase 2 of the above chart) 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 2 Facilities should review the Centers for Disease Control and Prevention’s guidance on COVID-19 for healthcare professionals. Page 9 of 10 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.) For example, a facility whose last standard survey was 24 months ago and was cited for abuse at a “G” level of noncompliance, would be surveyed earlier (i.e., prioritized higher) than a facility whose last standard survey was 23 months ago and had lower level deficiencies. We recognize that there are many different scenarios or combinations of timing of surveys and types of noncompliance that will exist. We defer to States for final decisions on scheduling surveys consistent with CMS survey prioritization guidelines. Page 10 of 10