COVID-19 MARCH 23, 2020

CMS Announces Prioritization of SNF Surveys

Today (March 23), CMS released guidance prioritizing and suspending most federal and state survey agency (SSA) surveys, and delaying revisit surveys, for the next three weeks beginning on March 20, 2020, for all nursing homes. For non-IJ related onsite surveys that are currently in process, survey teams are instructed to end the survey and exit the facility.

State and federal surveyors should not enter the building, for any type of survey, if they are unable to meet the Personal Protective Equipment (PPE) expectations outlined by the latest CDC guidance. They may instead obtain necessary information remotely, to the extent possible.

Federal and state surveyors will conduct targeted infection control surveys of providers identified together with the Centers for Disease Control and Prevention (CDC) and the HHS Assistant Secretary for Preparedness and Response (ASPR). They will use this survey tool to review infection prevention and control practices. Surveyors will review for:

• Overall effectiveness of the Infection Prevention and Control Program (IPCP) including policies and procedures
• Standard and Transmission-Based Precautions (with the understanding that certain essential supplies are scarce, and facilities should not be penalized for not having certain supplies if they are unable to obtain them)
• Quality of resident care practices, including those with COVID-19 (laboratory-positive case), if applicable
• Surveillance plan
• Visitor entry and facility screening practices
• Education, monitoring and screening practices of staff
• Facility policies and procedures to address staffing issues during emergencies, such as transmission of COVID-19

Please access the full summary of the memo here.

Stay at Home Order Issued By Governor Holcomb

On March 23, 2020 Governor Eric Holcomb issued a Stay at Home order that will go into effect at 11:59pm on March 24, 2020 and remain in effect until 11:59pm on April 6, 2020.  Persons may leave their homes for Essential Activities and Essential Travel, and to participate in Essential Business and Operations.

Key elements:

• Healthcare and Public Health Operations are Essential Activities.  Healthcare workers and operations are permitted to travel for work.
• Individuals may travel for health and safety reasons.  This includes seeking emergency services, obtaining medicine and medical supplies, visiting a health care professional.
• Individuals may travel to obtain necessary supplies and services.  This includes obtaining groceries and food or other consumer goods necessary to maintain safety, sanitation, or essential operation of homes and residences.  Applies to individuals obtaining these items for themselves, family or persons who are unable or should not leave their home.
• Individuals may engage in outdoor activities.  Social distancing of at least 6 feet is required for all outdoor activities.   Public parks and open recreation areas are open, but public access playgrounds will be closed.
• Individuals may travel to take care of others.  This includes family, friends, and pets, including transport of those persons and pet for permitted activities.
• Elderly and vulnerable are urged to stay in their residences except to seek medical care.
• Essential Travel Defined.  In addition for Healthcare and Public Health Operations and other Essential Activities above, Essential Travel includes:
  • Travel to care for the elderly, minors, dependents, persons with disabilities, and other vulnerable persons.
  • Travel to and from educational institutions to received materials for distance learning and meals, or other related services.
  • Travel in order to return to a place of resident from outside of the state.
  • Travel required by law enforcement or court order, including children pursuant to a custody agreement.
  • Travel required for non-residents to return to their place of residence outside of Indiana.

IHCA/INCAL has developed this Essential Healthcare Personnel form for you to place your facility logo on and provide to each of your staff members so that they can have this with them while they travel for work. Please contact Zach Cattell at zcattell@ihca.org with questions or request for assistance.

Letter from ISDH’s Dr. Box on masks, PPE and testing

State Health Commissioner Kristina Box, M.D. issued additional guidance on March 23, 2020 and recommended all direct care providers in skilled nursing facilities wear a mask while in facility. Specifically, the guidance states:

• Only essential providers should come in direct contact with patients
• Those essential providers should wear a surgical mask for the duration of their shifts. Masks should be conserved and only a single mask should be worn by staff each shift.
• Limit patient access to only those proving direct medical care (e.g., Nurses, QNA, QMAs, Hospice, EMS)
• Those staff who do not provide direct care (e.g., housekeeping, meal delivery, maintenance) should not, if possible enter patients’ rooms.
• Cohort confirmed or presumed COVID-19 positive patients.
• Cohort, if possible, direct care providers caring for confirmed or presumed COVID-19 patients into one area of the building

Conserving PPE: If supplies of PPE are limited, the ISDH recommends that each employee that provides direct care to patients wear a mask for the duration of their shift. This may require wearing a single mask each day. Should supplies become critically low, this may mean wearing a single mask on multiple days.

EMResource: ISDH will be adding all the statewide skilled nursing facilities to their EMResource database. Once added, each facility will provide a daily upload of their current PPE stores.

Widespread Testing:

• ISDH reports that their testing capacity is still low to conduct widespread community surveillance, therefore their focus of testing will be on vulnerable populations, such those in skilled nursing facilities, and those who provide for them.
• ISDH has developed teams that can go to facilities with residents, and providers, who are suspected to have COVID-19 and do testing. These strikeforce teams, will also have with them nurse surveyors.

ISDH Issues Regulatory Waivers for Nursing Home and Residential Care Facility Operations

The ISDH issued the following waivers for nursing home and residential care facility operations.

Comprehensive Care Facility Regulatory Waivers

• Living Arrangements under 410 IAC 16.2-3.1-10 are waived so to facility resident movement when needed.
• Thirty (30) day notice of transfer and discharge under 410 IAC 16.2-3.1-12(a)(7) is waived and modified to require notice to be made as soon as practicable before the resident is transferred or discharged.
• CNA employment prior to completion of training and testing is expanded to eight (8) months rather than four (4) months.
• CNA required completion of classroom instruction from date of employment is expanded to two hundred forty (240) days rather than one hundred twenty (120) days.
• Physician scheduled visits are waived to facilitate telemedicine and other means of physician contact and oversight (410 IAC 16.2-3.1-22(d)).
• The following activities are waived (410 IAC 16.2-3.1-33(b)(1)-(7) and (9)):
  • Group social activities.
  • Indoor and outdoor activities, which may include daily walks.
  • Activities away from the facility.
  • Spiritual programs and attendance at houses of worship.
  • Opportunity for resident involvement in planning and implementation of the activities program.
  • Creative activities, such as the following:
    1. Arts.
    2. Crafts.
    3. Music.
    4. Drama.
    5. Educational programs.
  • Exercise activities.
  • Promotion of facility/community interaction.
• Dining Assistants training is waived and is waived and modified as follows (410 IAC 16.2-3.1-53).  Read the waiver letter for details on the required training and documentation standards (page 2, item 7).

Residential Care Facility Regulatory Waivers

• Thirty (30) day notice of transfer and discharge under 410 IAC 16.2-5-1.2(r)(7) is waived and modified to require notice to be made as soon as practicable before the resident is transferred or discharged.
• Preparation of medication doses for residents on a weekly basis using a pill planner or similar device is permitted through waiver of 410 IAC 16.2-5-4(e).

IHCA/INCAL expects the ISDH to also waive dining assistant training requirements for Residential Care Facilities in a similar manner to the comprehensive care facility waiver.

Third Emergency Order for Residential Care Facility Waivers of March 23, 2020

• Dining Assistants training is waived and is waived and modified as follows (410 IAC 16.2-5-13).  Please read the waiver letter for details on the required training and documentation standards (page 1, item 1).
• Facility provided and/or coordinated scheduled transportation to community based activities waived.

Personal Care Attendant Order for Residential Care Facilities of March 23, 2020

• Includes Residential Care Facilities in the recently announced Personal Care Attendant (Waiver Aide) program.  The order includes the program description.

Third Emergency Order for Comprehensive Care Facility Waivers of March 23, 2020

• Waives the requirement that a pre-employment physical examination of employees be completed 1-mohth prior to employment (410 IAC 16.2-3.1-14(t)).

IHCA/INCAL continues to work with ISDH on additional waivers during the COVID-19 pandemic.   Please contact Lori Davenport, ldavenport@ihca.org, or Zach Cattell, zcattell@ihca.org, with questions.