IHCA/INCAL Summary of CMS’s Revised Testing Guidance

The Center for Clinical Standards and Quality Survey & Certification Group released the revised guidance related to Long-Term Care (LTC) facility testing requirements on September 23, 2022.

What you need to know:

• Routine testing of asymptomatic staff is no longer recommended but may be performed at the discretion of the facility.
  • Review the facility policy for those that have a health or religious waiver to identify if your facility policy mandates more frequent testing regardless of the presence of COVID-19 symptoms.
• Recommendations for testing individuals who have recovered from COVID-19 have been updated.
• Read memorandum including 483.80 Infection Control in QSO-20-38-NH Revised 09/23/22 here.

Testing of Nursing Home Staff and Residents

• Facilities are required to test residents and staff for COVID-19 infection based on parameters and a frequency set forth by the HHS Secretary.
• The definition of “facility staff” is unchanged.
• Facilities should prioritize individuals with signs and symptoms of COVID-19 infection first, then perform testing triggered by an outbreak investigation as specified:
• Instruct facility staff, regardless of their vaccination status, to report any of the following criteria to occupational health or another point of contact designated by the facility so they can be responsibly managed:
• A positive viral test for SARS-CoV-2,
• Symptoms of COVID-19, or
• A higher-risk exposure to someone with SARS CoV-2 infection

Definitions

“Higher-risk exposure” refers to exposure of an individual’s eyes, nose, or mouth to material potentially containing SARS-CoV-2, particularly if present in the room for an aerosol-generating 3 procedure. This can occur when staff do not wear adequate personal protective equipment during care or interaction with an individual.

“Close contact” refers to someone who has been within 6 feet of a COVID-19 positive person for a cumulative total of 15 minutes or more over a 24-hour period.

Testing of Staff and Resident with COVID-19 Symptoms or Signs

• A symptomatic employee must be tested as soon as possible and restricted appropriately regardless of vaccination status.
• If COVID-19 is confirmed, staff should follow CDC guidance – follow link: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html
• Staff who do not test positive for COVID-19 but have symptoms should follow facility policies to determine when they can return to work.
• A symptomatic resident, regardless of vaccination status should be tested as soon as possible and placed on transmission-based precautions in accordance with CDC guidance. Once test results are obtained, the facility must take appropriate actions based on the results. A word of caution: COVID-19 is not the sole reason for signs and symptoms of infection and should be considered when COVID-19 testing is negative and especially when symptoms continue to manifest.

Testing of Staff with a Higher-Risk Exposure and Residents who had a Close Contact

• In General, asymptomatic HCP who have had a higher-risk exposure do not require work restriction, regardless of vaccination status, if they do not develop symptoms or test positive for SARS-CoV-2.

• Asymptomatic patients and HCPs with close contact with someone with SARS-CoV-2 infection should have a series of three viral tests for SARS-CoV-2 infection. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5.

• Due to challenges in interpreting the result, testing is not recommended for asymptomatic people who have recovered from SARS-CoV-2 infection in the prior 30 days. Testing should be considered for those who have recovered in the prior 31-90 days; however, an antigen test instead of NAAT is recommended. This is because some people may remain NAAT positive but not be infectious during this period.

Testing of Staff and Residents During an Outbreak Investigation

• An outbreak investigation is initiated when a single new case of COVID-19 occurs among residents or staff to determine if others have been exposed.
• An outbreak investigation is not triggered when a resident with known COVID-19 is admitted directly into TBP or when a resident known to have close contact with someone with COVID-19 is admitted directly into TBP and develops COVID-19 before TBP are discontinued.
• Upon identification of a new case of COVID-19 infection in staff or residents, testing should begin immediately (not before 24 hours after the exposure, if known).
• There are two options to a facility approach to outbreak testing – contact tracing approach or broad-based facility-wide testing.

Routine Testing of Staff

• Routine screening testing of asymptomatic staff is no longer recommended but may be performed at the discretion of the facility.

Resident Testing – New Admissions

• Facilities are directed to CDC’s Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic guidance under Managing admissions and Residents who leave the facility for information on testing of residents who are newly admitted or readmitted to the facility and those who leave the facility for 24 hours or longer.
  • Admissions in counties where Community Transmission levels are high should be tested upon admission (admission testing at lower levels of Community Transmission is at the discretion of the facility).
  • Testing is recommended at admission and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test.
  • They should also be advised to wear source control for the 10 days following their admission.
  • Residents who leave the facility for 24 hours or longer should be managed as an admission.

Refusal of Testing

• Facilities must have procedures in place to address staff who refuse testing. The procedures should ensure that staff who are symptomatic and refuse testing are not allowed into the building until return-to-work criteria are met.
• When outbreak testing is underway and a staff member refuses to test, the person should not enter the building until outbreak testing is completed.
• Residents may exercise their right to decline COVID-19 testing.
• Facilities must have procedures in place to address residents who refuse testing and are managed in accordance with CDC guidance for use of transmission-based precautions.

Other Considerations

• Testing is not necessary for asymptomatic people who have recovered from SARS-CoV-2 infection in the prior 30 days.
• Testing should be considered for those who have recovered in the prior 31-90 days.
  • If testing is performed, the use of an antigen test instead of a nucleic acid amplification test (NAAT) is recommended.

Please contact Lori Davenport, director of regulatory and clinical affairs at ldavenport@ihca.org with any questions.