Coronavirus Update #71
New MDH Directive, Testing Options, Five Star Updates, Continuing Visitor Restrictions, and CMS Updates COVID-19 FAQs on Medicare FFS Billing  

I can’t say thank you enough for all you and your teams are doing to provide quality care to Marylanders in need, and to save lives during this stage of the COVID-19 pandemic. We continue to advocate and fight on all fronts to get you the tools and funding you need.

As you all know, skilled nursing and rehabilitation centers in Maryland provide quality long-term and post-acute care to people with multiple chronic or pre-existing health conditions. A study published Wednesday in the Journal of American Medicine ( JAMA ) reported that among people hospitalized with COVID-19 in New York, the majority had at least one chronic pre-existing condition and 21 percent of those who were treated died.

One hundred percent of residents and patients in our nursing homes have multiple pre-existing or chronic medical conditions, and many of the staff providing care may have at least one condition—that’s the battle our frontline heroes are up against for the people in their care. These facts are important.

Sadly, in our sector people with DNRs and DNIs sometimes die with and not because of COVID-19. Most importantly, let’s not lose sight of the fact that residents, patients and staff are beginning to successfully recover from COVID-19.

Nursing home and assisted living healthcare heroes are truly working hard and doing all they can to save lives.

The general themes we’ve been discussing together, communicating and advocating since February remain more critically important than ever before:

  • Focus on providing quality care.
  • Don’t let what you can’t do prevent you from what you can do in providing quality care.
  • Appreciate your team.
  • Be transparent in your communication with residents, patients, families and staff.
  • Operate DRIVEN by your infectious disease protocol.
  • Execute your observation and isolation beds.
  • Work closely with your acute-care hospital partners and home health partners.
  • Stay in contact with local health offices and the Office of Health Care Quality (OHCQ).

No one knows for sure how long we will be in this most challenging part of the surge for our sector, but based on what we are seeing, it’s a fair bet we will be navigating this part well into May. It is essential that skilled nursing and rehabilitation centers keep the bar on diligence, performance and quality HIGH during this most critical time.

Thank you for all you and your teams are doing to provide quality care and to save lives.  Continue to DO THE RIGHT THINGS.  You are the heroes, don’t forget it.

Be well,
Joe DeMattos
President & CEO
New MDH Directive and Order

On Friday night, the Maryland Department of Health issued new directive and order for nursing homes. Even before these guidelines were posted, HFAM has been working with the help of our members, partners at MHA, and hospitals to improve the guidance relative to physician and other medical professional care (section 4D). 

The Guidance includes work we’ve been doing with MHA and CRISP, and the questions we have developed collaboratively with MHA and CRISP.  The expanded questions, which were are in alignment with the direction CMS is heading, are not as the result of our collaborative work in Maryland. Our sector continues to navigate COVID-19 in a time of increasing transparency and government scrutiny.
CRISP Reporting Tool

As we shared recently, our partners at the Maryland Hospital Association (MHA) and CRISP have been working with post-acute providers and hospitals to streamline nursing home daily bed availability reporting. 

Nursing homes can input information via this link:
Testing Options

First Call Medical Center, an urgent care clinic located in Gambrills, is available to provide testing to staff and residents of long-term care centers. Skilled nursing centers and assisted living campuses may set up testing for staff and/or residents in several ways: staff can utilize the urgent care’s drive through testing, the urgent care clinic can set up at your center, or a mix of these options. Please note for staff testing, it is most efficient to send employee information ahead of the testing in order for the clinic to process tests quicker. This testing is available 7 days a week.

In addition, this urgent care clinic has adequate access to PPE and they are even offering to share PPE (including face shields and masks) with other providers. 

Please contact Dr. Ron Elfenbein to discuss the testing process and figure out which option works best for your center. Dr. Elfenbein can be reached via email at or via phone at 410-507-9698 (please leave a message if no answer). 

Diamond Medical Labs, located in Owings Mills, has the capacity to do in-residence test collection for seniors during the COVID-19 outbreak so that they do not have to go out. Contact Andy Diamond at or  443-992-2782 if there is demand at your center or if you would like additional information.

The Maryland Department of Health Laboratory - click here for more information.

On April 24, 2020, the Centers for Medicare & Medicaid Services (CMS) released a memo (QSO-20-28-NH) with updates on Nursing Home Compare (NHC), Five Star, public staffing information, and a list of frequently asked questions (FAQs). 

Inspection Domain of Five Star Quality Rating System Will NOT be Updated Due to Prioritization of Surveys

CMS will temporarily hold constant the inspection domain of Five Star to prevent an unequal impact on the rating for those facilities who receive a survey during this time. This freeze will begin with the scheduled Nursing Home Compare update on April 29, 2020. 

CMS will post the results of any health inspections conducted on or after March 4, 2020, on the landing page of Nursing Home Compare, but they will not be used to calculate a center’s Five Star inspection rating.

The Quality Measure and Staffing domains of Five Star will be updated on April 29 as they are not impacted by the CMS blanket waivers  because they rely on data from before March 1, 2020.

Release of Certain Staffing Information 

CMS will use Payroll-Based Journal staffing data to publicly report the average number of staff onsite at each nursing home each day (both nursing staff and total staff) and will also post aggregated data at a state and national level. The publicly posted information will include all staff listed in section 2.3, Table 1 of the PBJ Policy Manual

This information will be based on data submitted for the fourth quarter of 2019. CMS states this information can be used to help local, state, and federal agencies’ plan for how much personal protective equipment (PPE), testing and other resources providers may need. Providers can also use this information along with the CDC PPE burn rate calculator


The memo includes a FAQ document that addresses CMS guidance in the areas of visitation, surveys, waivers, and more. The FAQs provide information on topics including: 

  • Individuals entering and leaving the nursing center, including visits by health care personnel, visitation for compassionate care situations, and residents who want to leave the facility against medical advice;
  • Surveys and infection control self-assessment, including the ongoing suspension of standard surveys and the recommended use of the infection control focused survey protocol for self-assessment on infection control practices and preparedness;
  • Waivers of Federal requirements including those related to in-facility and inter-facility cohorting; and,
  • Additional information on resident cohorting, separation and admission.

CMS reminds providers that a negative test for COVID-19 is not a prerequisite for discharging a resident to a nursing home from the hospital; however, consistent with current guidance, admissions decisions should be made based on the resident’s clinical status and the ability of the accepting facility to meet their care needs and infection control requirements. Providers who can’t meet the needs of the residents due to PPE, staffing or other issues should not accept the person. 

CMS is allowing civil money penalty (CMP) funds to be used for purchasing devices such as tablets or web-cams as well as accessories, with a maximum of $3,000 allowed per facility to help with communications between residents and their families or friends. To apply to receive CMP funds for this purpose, contact your state agency’s CMP contact

For questions related to the Nursing Home Compare website and the Five Star Quality Rating System, please email

For questions related to the FAQs, please email .

Even as states are beginning to lift their stay at home orders, nursing homes must continue to maintain current restrictions on visitors. As a reminder, CMS released guidance on March 13 that required all nursing homes to significantly restrict visitors and nonessential personnel, as well as restrict communal activities. The guidance indicates that individuals other than essential health care staff and visits for end-of-life situations, should no longer enter nursing homes until further notice.

Even though certain states may be lifting their individual stay-at-home orders, nursing homes must continue to follow this directive from CMS until new guidance is received. For help communicating these policies, please see this sample letter to families on restricting visitors
Assisted living communities must follow any applicable state guidance. If no state guidance is issued, we recommend they follow AHCA/NCAL guidance and continue restricting the number of people entering the facility.

For all long term care communities, these restrictions remain critical safeguards to help protect against the spread of COVID-19.

On April 23, CMS updated their 41-page COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing guidance . This guidance is directed at all providers of Medicare Part A and Part B services, including SNFs.

A general billing requirements FAQ related to using the “DR” condition code and “CR” modifier on claims to indicate that the Medicare payment is conditioned on the presence of a “formal waiver” has been updated and should be reviewed by billing staff.

The SNF-specific FAQs are on pages 34-35 and have not changed since last updated on April 10. 
Did you miss HFAM's previous alerts?

Visit our website to view all previous HFAM alerts, as well as guidance
from our federal and state partners.
Thank you.

We cannot thank you enough for the dedication and diligence in doing all that you can for the residents in your communities. HFAM continues to monitor the COVID-19 pandemic with our state and national partners and will do all we can to support you during this time.