June 2, 2020
Quick Links:
Wednesday June 3 at 10 AM:  
Virtual Spring Conference Live Webinar:
PDSA Cycles - An Essential Part of Everyday Operations
Thursday June 4 at 11 AM:
DQA webinar on COVID-19 and LTC

Meeting ID:
948 1795 1711 
Password: covid19 
By Phone:  
(312) 626-6799 
Meeting ID: 94817951711#
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COVID-19 Updates: June 2, 2020
This update includes:
  • DHS Releases CARES Payment Information
  • Punitive Measures in CMS Survey Memo
  • Gov. Evers, WHCA/WiCAL Reps Meet on LTC Funding Needs
  • June 3 Attestation Deadline Applies Only to Medicare FFS Provider Relief Payment
  • AHCA/NCAL President & CEO Mark Parkinson: COVID-19 Data Release Confirms Need for More Assistance
  • NHSN Requirements
  • AHCA Council of States Passes Dues Special Assessment to Fund Media Campaign
  • Application for Temporary Assisted Living Facility Expansion Units and Transfer Options during the COVID-19 Public Health Emergency State
  • SNF Therapy Telehealth Waivers and other Updated COVID-19 Billing FAQ Updates
  • CMS Updates Guidance on Proper Use of COVID-19 Waivers Claim Codes
  • JAMA Article on Observation Stays Issue
  • ICYMI: Bipartisan Support For Long Term Care Communities Continues To Build
As of today, there are 18,543 confirmed cases of COVID-19 in the state of Wisconsin and 595 deaths caused by the virus. Click HERE to view the latest outbreak information from the Wisconsin Department of Health Services. Click HERE to view COVID-19 projections for Wisconsin and the United States.
DHS Publishes CARES Payment Information Page
Today the Wisconsin Department of Health Services published its CARES payment information page for long-term care providers. Starting on June 5, the portal will be open for providers to apply for funding. This $100 million in funds for these payments were provided to the State under the federal Coronavirus Aid, Relief, and Economic Security (CARES) Act.

All long-term care providers all eligible for this funding – including home and community based service providers, assisted living facilities and skilled nursing facilities. The webpage provides details on what costs and losses are eligible to receive this money.

DHS has indicated the page will continue to be updated with details and FAQs. As WHCA/WiCAL reported last week, the money will be paid out in two tranches. Amounts available in the first payout, by number of beds, can be found in the article linked above. DHS personnel has said that the application will include fields for providers to fill in related to COVID-19 costs and losses they’ve incurred.

If you have any questions, please contact WHCA/WiCAL Director of Reimbursement Policy Kate Dickson.
Punitive Measures in CMS Survey Memo

CMS released  QSO-20-31-All on Monday, a memo relating to: COVID-19 Survey Activities, CARES Act Funding, Enhanced Enforcement for Infection Control deficiencies, and Quality Improvement Activities in Nursing Homes.
The memo includes new requirements of state survey agencies, with new CARES Act funding tied to completing Focused Infection Control Surveys: 
  • States that have not completed 100% of their focused infection control nursing home surveys by July 31, 2020 will be required to submit a corrective action plan to their CMS location outlining the strategy for completion of these surveys within 30 days. If, after the 30-day period, States have still not achieved surveys in 100% of their nursing homes, their CARES Act FY2021 allocation may be reduced by up to 10%. Subsequent 30-day extensions could result in an additional reductions up to 5%. These funds would then be redistributed to those States that completed 100% of their focused infection control surveys by July 31.
Note : if you are a nursing home in Wisconsin and have not had a FICS survey yet, you can likely expect one by July 31 based on the above information.
CMS in the memo also laid out a new survey plan for state survey agencies, including requiring states to perform on-site surveys of nursing facilities with previous higher instances of COVID-19 outbreaks and requiring states to perform on-site surveys (within three to five days of identification) of any nursing home with new COVID-19 suspected and confirmed cases. A full breakdown of the new survey/enforcement plan is available  here .
The memo did raise some additional questions due to inconsistencies and unclear language. For example, the memo says that states can expand survey activity ‘once a state has entered Phase 3’ of the  CMS Nursing Home Reopening Guidance , or earlier. However, that guidance has a phased approach specific to metrics at each individual nursing home, and it is unclear when an entire state would ‘enter Phase 3’.
WHCA/WiCAL has reached out to AHCA/NCAL and state survey officials about this and other questions. Along with these questions, the association has raised serious concern about the punitive nature of this new survey framework . CMS is increasing enforcement (that is, civil money penalties) for facilities with persistent infection control violations, and imposing enforcement actions on lower-level infection control deficiencies. See p. 4 of the  new memo  for a breakdown of the new penalty framework, tiered by scope/severity. WHCA/WiCAL asserts that the new punishment/CMP scheme laid out in this memo shows a disregard for the unique challenges facing nursing homes during the COVID crisis.
AHCA/NCAL President & CEO Mark Parkinson said CMS imposing additional enforcement and fines is not as helpful to improving the situation as it would be for the agency and its survey teams to work together with the nursing home sector to fight the COVID-19 battle.
“This situation will get worse if surveyors are only looking for reasons to find deficiencies and issue fines instead of identifying ways for nursing homes to make real changes and help them improve their infection control programs,” Parkinson said. “It’s time to recognize that when nursing homes receive citations, it’s a failure not just of the provider, but of CMS and the survey process as well. Citations and fines without assistance will not help us keep residents and staff safe from this virus.”

CMS said to assist SNFs in implementing infection control best practices, CMS will provide technical assistance through Quality Improvement Organizations. Shortly after receiving the above information, WHCA/WiCAL received a notice from Superior Health Quality Alliance , informing providers they will be working on a process which includes reaching out to each nursing home to complete and infection prevention and control-related assessment, determine opportunities for improvement and develop a data-driven action plan. This Quality Improvement Initiative (QII) will last for several months. Superior Quality Innovation Network will be working with the Wisconsin Department of Health Services to coordinate efforts.  
In discussion with Superior Quality Health Alliance representative Diane Dohm today, WHCA/WiCAL officials were told that SQIN already been working with many facilities on their Infection Control and Prevention activities and they will continue to be a resource in this process. Dohm is scheduled to present at the WHCA/WiCAL Quality Symposium on July 8 and will be continuing with the presentation on Current Infection Prevention and Control Challenges and Expectations in Long-Term Care Settings.
WHCA/WiCAL will be holding a Survey/Regulatory Committee meeting next week to respond the punitive approach that CMS is taking regarding the SNF survey process, and what options are available to the provider community to respond to this counter-productive approach to enforcement. 
Gov. Evers, WHCA/WiCAL Reps Meet on LTC Funding Needs
WHCA/WiCAL secured a meeting with Gov. Tony Evers Tuesday morning to emphasize the unique challenges of Wisconsin’s skilled nursing and assisted living facility providers in light of the COVID-19 pandemic. The key request that was presented to the Governor was relative to funding, and to ensure that additional CARES Act and surge funding would be earmarked for providers.
In addition to WHCA/WiCAL President & CEO John Vander Meer; Jim Stoa, WHCA/WiCAL Director of Government Relations and Regulatory Affairs; and Ramie Zelenkova, WHCA/WiCAL contract lobbyist, the following members participated in the call:
  • Steve Kuranz, WHCA Board President, and the Executive Director of Oak Ridge Care Center in Union Grove, as well as Hope Health and Rehabilitation in Lomira, two family-operated SNFs and ALFs;
  • David Mills, WHCA Board First Vice President, and CEO of North Shore Health Care, which operates 50 skilled nursing and assisted living facilities around the state of Wisconsin.
On behalf of all WHCA/WiCAL members, Vander Meer raised the concern that while many sectors of the economy are facing challenges, LTC providers are experiencing the most significant challenges in this crisis due to the potential for loss of life because of the frail older adults who SNF and ALF providers care for are the most vulnerable population when it comes to this virus. The COVID response for long-term care will be much more sustained and ongoing well beyond any “reopening” plan for the state generally, and the LTC provider community as a sector was already struggling financially. These unique challenges, in addition to the significant challenges we were facing before the crisis began and the significant vulnerability of the population LTC providers serve, translate into a more acute level of need for LTC providers.
During the call, providers thanked Gov. Evers for the regulatory relief and liability protections that Gov. Evers and his Administration have enacted during the COVID crisis, which were critically necessary in these challenging times. They also thanked Gov. Evers for the CARES Act funding that is in the process of being appropriated. However, they emphasized that while this funding is an important step in the right direction, there are numerous challenges on the horizon relative to fiscal stability of the profession due to the increased costs and loss of revenue for the profession.
Providers indicated that while t he recent injections of federal funding have been much appreciated, the need remains to ensure that LTC facilities don’t get overlooked given the challenges that we currently face, and will likely see in a fall surge in positive cases of COVID-19. Members on the call stressed the s ignificant increased costs as a result of the tremendous increase in the need for PPE in the weeks since COVID-19 was designated a pandemic , as well as increases in labor costs. Those on the call discussed the very real possibility that additional facility closures could occur without adequate funding.
Ultimately, providers were told by Gov. Evers that he was interested in hearing their ideas on the need for funding reform as they head toward the next biennial budget.
WHCA/WiCAL will be following up with Gov. Evers to call for a payment standard that connects costs to reimbursement, and to indicate that the provider community is ready to work with the Evers Administration to help be our own source of solutions to federal funding.

June 3 Attestation Deadline Applies Only to Medicare FFS Provider Relief Payment
This morning the U.S. Department of Health and Human Services clarified that the June 3 deadline for providers to submit revenue data:

  • Is only for providers who received a Tranche 1 allocation and would like to submit financial information to receive additional Tranche 1 funding. 
  • Providers would still be required to ensure that their General Distribution payment is the lesser of 2% of their provider net revenue or the sum of incurred losses for March and April.

Below is the relevant HHS webpage text:
ALERT: Providers need to take action by [TOMORROW,] June 3, 2020

Providers must submit revenue information to the  General Distribution Portal by June 3, 2020  to be considered for an additional payment from the Provider Relief Fund $20 billion General Distribution. Once providers submit their revenue information by June 3, 2020, if deemed qualified for additional payment, providers will then have 90 days from receipt of payment of the additional General Distribution funds to agree to the program Terms and Conditions.

AHCA/NCAL recognizes how challenging the lack of guidance is for members. The Association is working with HHS to secure additional information.

All other questions about the fund should be directed to HHS Hotline at (866) 569-3522. HHS reported on May 22 that the call center now has access to additional data and new HHS guidance to better answer questions.

Tranche by Tranche Questions
Tranche 1: HHS as provided the formula and allocation process in its FAQs. The data source for the award amounts was 2019 Medicare Part A Fee-For-Service (FFS) net revenue.

Tranche 2: As above, HHS has provided the formula for Tranche 2 in its  FAQs. Of note, HHS explains why a provider who received a Tranche 1 award may not have received a Tranche 2 award. The data source for Tranche 2 was 2018 Medicare Cost Report.

Tranche 3 (SNF-Only): All SNFs with Medicare-certified beds should have received an allocation on May 22. If the SNF did not receive an allocation this could be because:

  • it is a Medicaid-only or private pay only facility; or
  • errors in HHS’ data source (April 2020 CASPER Report).

If the SNF believes they should have received a Tranche 3 award or received the incorrect amount, they should contact the Hotline (above) and have the following information ready:

  • Tax Identification Number(s) (TIN)
  • CMS Certification Number(s) (CCN)
  • Dollar amount in question by building 

Also, for Tranche 3, the SNF Allocation, have the number of SNF certified beds (Medicare, Medicaid or both), the amount they received and the amount they believe they should have received.

At this point, the above information is all HHS has shared. AHCA/NCAL continues to request clarification on Change in Ownership, TINs and reporting window information.
AHCA/NCAL President & CEO Mark Parkinson: COVID-19 Data Release Confirms Need for More Assistance
After the federal government released data from skilled nursing facilities (SNFs) on the number of COVID-19 infections and deaths, and also unveiled new incentives and penalties for infection control adherence, the American Health Care Association/National Center for Assisted Living (AHCA/NCAL) said the information confirms what the industry has said since March: Residents and staff of nursing centers require top priority in the coronavirus battle.
“These numbers show what we have known for months, that COVID-19 disproportionately impacts the elderly with chronic diseases and the dedicated staff who care for them,” said Mark Parkinson, president and chief executive officer of AHCA/NCAL.
“Today’s report validates the need for the assistance that nursing homes have been calling for since the beginning of this pandemic. Especially as we continue to expand testing for residents and staff in long term care centers in June, we should anticipate the number of cases to rise as asymptomatic residents and staff will be identified. While an increase in these reported numbers may be startling, it will improve our ability to confront this threat and protect our residents.”
In a Monday press conference, Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma said the first round of SNF-provided data on COVID-19 showed some 60,000 virus infections and 26,000 related deaths among the 12,500 facilities reporting. The information will be made public online later this week and will be updated as well before the week’s close, she said. The public reporting system that Verma has touted saw some 80 percent of the nation’s nursing facilities comply with the requirement to report coronavirus infections and deaths.
By way of background, since April 19, CMS has required SNFs to inform residents, their families, and representatives of COVID-19 cases in their facilities. For the first time, nursing facilities have also been required to report COVID-19 cases and deaths directly to the Centers for Disease Control and Prevention (CDC) on an ongoing basis since May 1.
In response, Parkinson said, “We hope this public reporting system will help identify areas that are most in need of resources to fight the battle against COVID-19. We hope state and federal public health officials can use the data to help nursing homes by sending urgently needed resources.”
Verma also announced a new CMS push to get full compliance to the reporting law, a new survey activity time frame, and new incentives/penalties for states to have 100 percent of their SNFs inspected under focused surveys measuring infection control.
NHSN Requirements
On 5/6/20, CMS released QSO 20-29-NH that identified the rules for submission of COVID-19 data. The NHSN rules provided facilities with an initial two-week grace period to begin reporting cases in the NHSN system (which ended at 11:59 p.m. on May 24, 2020). 
The rule stated that "Facilities that do not begin reporting after the third week (by 11:59 pm on May 31, 2020) will receive a warning letter reminding them to begin reporting the required information to the CDC. For facilities that have not started reporting in the NHSN system by 11:59 p.m. on June 7, ending the fourth week of reporting, CMS will impose a per day (PD) CMP of $1,000 for the failure to report that week."
We are hearing from members that they are continuing to have difficulty with getting access to the NHSN site. In communication with Dr. David Gifford regarding AHCA assistance with this problem, he responded that "CMS is not going to delay issuing fines but will likely accept appeals if they have documentation of good faith efforts to register and load for the past couple of week though they have not yet said what that looks like."
Dr. Gifford asked that we collect the names and CCN number of each facility that continues with difficulty registering or uploading COVID-19 data. Please contact Pat Boyer at  pat@whcawical.org  with that information and it will be reported to Dr. Gifford for further assistance. 

Dr. Gifford did discuss this further with CMS. He indicated that CMS said they are open to appeals  if a facility has been trying and can show they were unable to submit due to delays from CDC. So the process will be to file an IDR once the citation or fine is issued. Not a good answer but the best we know now. Please contact pat at pat@whcawical.org or at (414) 690-7898.
AHCA Council of States Passes Dues Special Assessment to Fund Media Campaign
The AHCA Council of States met in a virtual session Tuesday to pass a $10 per bed special assessment in dues to fund a national media campaign.
The special assessment, which was passed unanimously by all state delegates, will be used to influence Washington, D.C. lawmakers and will also include a media plan to purchase national cable ad time to influence the public's perceptions of nursing homes.
The WHCA Board of Directors met in special session on Saturday to be briefed on the plan by Gov. Mark Parkinson, President and CEO of AHCA/NCAL. While there were concerns raised by WHCA Board members about whether the current challenging financial environment for providers was the right time to fund a dues increase, members agreed that there was a significant need for a campaign of this nature.
WiCAL members will not be assessed this dues increase, it will only be assessed on SNF members.
Details on this special assessment will be forthcoming.
Application for Temporary Assisted Living Facility Expansion Units and Transfer Options during the COVID-19 Public Health Emergency State
Please visit the following link to view DQA Memo 20-009 / Licensure/Certification Application for Temporary Assisted Living Facility Expansion Units and Transfer Options during the COVID-19 Public Health Emergency State: https://www.dhs.wisconsin.gov/dqa/memos/20-009.pdf

The purpose of this memorandum is to establish the process for assisted living facilities to temporarily cohort, transfer, and/or discharge residents within and between facilities during the COVID-19 Public Health Emergency. The temporary cohorting and transfer/discharge options discussed in this memorandum are intended to allow assisted living facilities flexibility to the extent necessary to maintain the health, safety and well-being of residents during the COVID-19 Public Health Emergency.

For questions related to assisted living licensure, please contact Judy Jordan or William Gardner.
For question related to Physical Environment or Life Safety Code, please contact  Henry Kosarzycki.

For general questions regarding this memo, please contact Alfred Johnson.

Please see the DQA Memo webpage at https://www.dhs.wisconsin.gov/dqa/memos/index.htm for more information.
SNF Therapy Telehealth Waivers and other Updated COVID-19 Billing FAQ Updates
The Centers for Medicare and Medicaid Services (CMS) provided  important updates to coverage and billing guidance impacting SNF related to COVID-19 1135 waivers. The date, each FAQ was posted or updated is listed immediately under each answer.

New FAQs that SNF providers should review are listed in the following sections:

  • Section L. Medicare Telehealth starting on page 42 which contains several clarifications mostly related to physician services;
  • Section DD. Diagnosis Coding under International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) on pages 69-70 indicate where the current resources are available; and 
  • Section FF. Outpatient Therapy Services on pages 70-71 finally clarifies that telehealth technology can be used to furnish PT, OT, and SLP services for both Medicare Part A and Part B services for facility-based providers including SNF. Specifically, it provides guidance that to identify that a Part B therapy telehealth service under the 1135 waiver was furnished for the SNF outpatient revenue centers 22X or 23X on the UB-04 (CMS-1450) claim, providers must also append a -95 modifier to the claim lines for such services. CMS also affirms that while telehealth technology can be used to furnish therapy services under Part A, such services are not separately payable due to SNF PPS consolidated billing requirements. 

AHCA/NCAL has developed  therapy telehealth waivers FAQs that address questions that SNF and AL members may have regarding applying these waivers to improve resident mobility care needs. See Q.10. for Assisted Living resident-specific guidance related to who can provide therapy telehealth in their residence.
CMS Updates Guidance on Proper Use of COVID-19 Waivers Claim Codes
On June 1, CMS issued updated guidance clarifications for using the "DR" Condition Code and "CR" modifier on Medicare fee-for-service claims for services furnished under COVID-19 Section 1135 waivers such as the SNF-specific 3-day stay and spell-of-illness waivers. The full list of waivers and flexibilities can be found here.

CMS is clarifying which waivers the usage of modifier “CR” or condition code “DR” when submitting claims to Medicare. The chart in the updated guidance identifies those blanket waivers and flexibilities for which CMS requires the use of the modifier or condition code.

Please note that CMS will not deny claims due to the presence of the “CR” modifier or “DR” condition code for services/items related to a COVID-19 waiver that are not on this list, or for services/items that are not related to a COVID-19 waiver. There may be potential claims implications, such as claims denials, for claims that do not contain the modifier or condition code as required in the chart. However, providers do not need to resubmit or adjust previously processed claims to conform to the requirements below, unless claims payment was affected.
JAMA Article on Observation Stays Issue
On May 26, 2020, the Journal of the American Medical Association (JAMA) included an article entitled, “The Continued Conundrum of Discharge to a Skilled Nursing Facility After a Medicare Observation Stay,” that notes the history of the Medicare observation stays issue along with recent COVID-19 policy developments. The authors stated their support for calling for immediate, permanent change with this issue – and that CMS should count observation stays toward the 3-day rule while simultaneously researching and subsequently replacing an arbitrary LOS with specific functional criteria for SNF care to determine eligibility. You can read the full article here.
ICYMI: Bipartisan Support For Long Term Care Communities Continues To Build
In case you missed it, the needs of long term care facilities are capturing the attention of a growing number of Members of Congress on both sides of the aisle. Democrat and Republican Members alike are calling for greater support and funding for nursing homes and assisted living communities as they continue to fight COVID-19.

Senator John Cornyn (R-TX) said in a recent interview, “It is older Americans, it is people with underlying chronic illness that are the most vulnerable, and so it makes sense to me to put the money where it’s needed most.” He’s working to make sure that the next round of funding goes to seniors.

Senator Jeanne Shaheen (D-NH) said there should have been testing early on to prevent the number of COVID-19 deaths in nursing homes. She has cosponsored a bill that would require an Inspector General investigation into the spread of COVID-19 in nursing homes.

In a Senate hearing, Senator Susan Collins (R-ME), chair of the Senate Special Committee on Aging, said testing for every nursing home resident and staff was a good idea. She also remarked recently she was “very concerned” about COVID-19 outbreaks among vulnerable seniors and delays in funding for the nation’s nursing homes, and called for additional support and resources to protect residents and employees.

Senate Minority Leader Chuck Schumer (D-NY) said nursing homes should remain on the list of beneficiaries in a phase four coronavirus relief package, adding, “Our health system is under enormous strain. We need more money to flow to hospitals, community health centers, nursing homes.”

Other Members of Congress have asked the federal government for additional support. Last month, Congresswoman Haley Stevens (D-MI) led a group of 16 Members urging U.S. Department of Health and Human Services (HHS) Secretary Alex Azar to direct a portion of CARES Act funding to long term care facilities, and another group of 87 Members, led by Congresswoman Jan Schakowsky (D-IL), sent a letter to Secretary Azar and Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma requesting that emergency funding be allocated for expanded testing.

The American Health Care Association and National Center for Assisted Living (AHCA/NCAL) released a state by state breakdown last week that shows it would cost $672 million to test every nursing home and assisted living resident and staff one time. The data underscores the urgent need for additional funding and support from federal and state governments to meet long term care facilities’ ongoing testing needs.

HHS granted $4.9 billion in much-needed funding to the country’s nursing homes, but more help is needed, especially for assisted living communities who have yet to receive any direct aid. In order to protect our most vulnerable citizens and frontline caregivers, they must be made a priority. Federal and state governments must rally around them and give them the funding and resources they need.
John Vander Meer, MPA | President & CEO | john@whcawical.org

Jim Stoa, J.D. | Director of Regulatory Affairs and Government Relations | jstoa@whcawical.org

Pat Boyer, MSM, RN, NHA | Director of Quality Advancement and Education | pat@whcawical.org

Kate Dickson, MPA | Director of Reimbursement | kate@whcawical.org

Kate Battiato, MPA | Director of Workforce Development | kbattiato@whcawical.org

Allison Cramer | Communications and Government Relations Specialist | allison@whcawical.org

Jena Jackson | Director of Development | jena@whcawical.org

Jammie Moore | Director of Administrative Services | jammie@whcawical.org

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