March 25, 2020
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COVID-19 Updates: March 25, 2020

This update includes:

  • "Safer-At-Home" Order Now in Effect Through April 24th
  • COVID-19 State Legislative Request
  • DHS Submits 1135 Waiver Requests to Joint Committee on Finance
  • Action Requested: Strategic National Stockpile Order Process -- Deadline Extended! Complete by 9:00 a.m. TOMORROW, March 26th!
  • Q&A with DHS on Survey Suspension
  • CDC Releases COVID-19 Guidance for Retirement Communities and Independent Living 
  • Direct Care Workforce Funding Updates
  • Appraisals for Skilled Nursing Facilities Update
  • Updates for WCCEAL Members
  • AL Hospital Admissions Guidance
  • Possible Extension of Medicare Cost Report Due Date 
  • Template Letter to Health Plans and Accountable Care Organizations Requesting Relief
  • COVID-19 HUD Update
  • Workforce Resources for Long-Term Care Facilities
As of today, there are 585 confirmed cases of COVID-19 in the state of Wisconsin and five deaths caused by the virus. Click HERE to view the latest outbreak information from the Wisconsin Department of Health Services.
"Safer-At-Home" Order Now in Effect Through April 24th
Governor Evers has issued an order that will require people to mostly stay at home except for essential travel. Long-term care workers traveling to and from work will be exempt from the travel restrictions. Health care/long-term care operations are allowed and expected to continue.

The order took effect at 8:00 a.m. on Wednesday, March 25, and will remain in effect until 8:00 a.m. on Friday, April 24, unless canceled by a subsequent order.

The Governor’s Order does not require any kind of verification for essential travel. However, enforcement is left up to local law enforcement officers, and DHS officials indicated that the best practice in other states with similar orders has been to have simple documentation available to your workers to share with officers if they ask.

WHCA/WiCAL has drafted a template employment verification letter that facilities can provide to employees. The letter providers information related to why the individual is exempt from the Safer-at-Home Order.


Click HERE to view more information on how the "Safer-At-Home" order will affect long-term care providers.
COVID-19 State Legislative Request
John Vander Meer, President & CEO of WHCA/WiCAL, along with representatives of LeadingAge Wisconsin had a conference call earlier today with Representative John Nygren and Senator Alberta Darling, Co-Chairs of the Legislature’s Joint Committee on Finance regarding the significant increased costs associated with response to COVID-19.
 
It was clear that both Darling and Nygren understand the provider community’s significant concerns related to the provider community’s key priorities of workforce and the availability of PPE. Both legislators indicated that there are still a significant questions about how the process for consideration of the funding package will be determined.
 
WHCA/WiCAL encourages facilities located in districts with members of the Joint Finance Committee to contact their legislators.
 
Key Documents:
 
PPE: There is a critical shortage of available Personal Protective Equipment.
 
WORKFORCE: Wisconsin LTC facilities have been experiencing a workforce shortage. Wisconsin facilities have a 1 in 4 vacancy. No one really knows what a COVID-19 world with the Safer at Home Policy, unemployment benefits, lack of available PPE, lack of childcare, and the need for some people to take care of their own parents will mean for our staffing. Our associations want to communicate the fear that we hear in the dozens of calls our organizations take from providers every day. 
 
We requested that a legislative relief package in response to the COVID-19 pandemic address the needs of long-term care facilities as providers work to protect and care for Wisconsin’s frail elderly population during this public health emergency
  • $347 per patient day for Nursing Home Care
  • $301 per patient day Increase of for Assisted Living Care
DHS Submits 1135 Waiver Request to Joint Committee on Finance
DHS has submitted its 1135 waiver request draft to the state legislature's Joint Finance Committee for review. Due to statutory changes to agency requests included in 2019 Act 370, DHS must first submit this request to JFC for approval before it is able to send the official request in to CMS.



When the President declares a disaster or emergency under the Stafford Act or National Emergencies Act and the HHS Secretary declares a public health emergency under Section 319 of the Public Health Service Act, the Secretary is authorized to take certain actions in addition to regular authorities. Thus, in times of national public health emergencies like the COVID-19 pandemic, CMS through HHS can grant waivers from regulations that may impede care during these emergencies.

DHS's proposed waiver request letter includes several provisions related to long-term care. Click here to see the full draft request. Of particular note:

  • § 12.5 requests allowing a nurse aide to serve for longer than 4 months without being enrolled in an approved training and competency evaluation program.
  • § 12.4 requests a waiver or training requirements for feeding assistants.
  • § 12.3 requests an end to the CNA training lockout.
  • § 12.1 requests that all clinical nurse aide training hours be allowed via online simulation.
  • § 11 in general requests temporary authority to:
  • Waive the 30/60/90 day schedule requirements for physician visits, with more options for telehealth;
  • Suspend the 120 day limitation on CNAs who have not been able to take a certification test;
  • Allow for physician extenders;
  • Waive certain documentation requirements;
  • Waive bedhold requirements;
  • Waive in-service education requirements;
  • Suspend pharmacist visits for record review;
  • Waive/lessen requirements for training of feeding assistants;
  • Waive fire extinguisher maintenance reviews.

WHCA/WiCAL is in support of this draft proposal and has indicated our support to the co-chairs of the Joint Finance Committee.
Action Requested: Strategic National Stockpile Order Process
RESPONSE DUE BY 9:00 A.M. TOMORROW, THURSDAY, MARCH 25th!

The State Emergency Operations Center has notified Wisconsin Department of Health Services that a limited supply of personal protective equipment (PPE) from the Strategic National Stockpile (SNS) is available for distribution.

These supplies include N95 respirators, surgical masks, face shields, hoods, gowns, coveralls, and gloves.

The following groups are eligible to receive PPE resources from the SNS supply:
  • Long term care
  • Hospitals
  • In-home personal care agencies
  • Emergency Medical Services (EMS)

Facilities/agencies that submit requests must meet all of the following criteria:
  • Facility/agency supply is depleted or will be in one week,
  • Shortage or depletion is impacting ability to ensure patient care and/or worker safety,
  • Facility/agency has exhausted attempts to secure PPE from other sources, and
  • Facility/agency has consistently implemented CDC strategies to optimize use of N95 respirators.

Additionally, in order to be eligible, hospitals must complete the COVID-19 Essential Elements of Information daily in EMResource.

DHS will use a Scarce Resource Decision Tree to determine to which agencies PPE will be allocated.

Please use this link to order PPE from the SNS: 

THIS ORDER NEEDS TO BE COMPLETED BY 9:00 A.M. TOMORROW, MARCH 26th

PLEASE NOTE: These items are past their manufacturer-designated shelf life. They may not be used in surgical settings. FDA has provided an emergency use authorization that allows these resources to be used for this purpose. Due to scarcity of resources, you will not receive your full order.
Q&A with DHS on Survey Suspension
Earlier this week, CMS released  guidance 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.

WHCA/WiCAL contacted Ann Angell, the Director of the Department of Health Services' Bureau of Nursing Home Resident Care, for clarification on the suspension of survey activity. Her answers are below in pink.

We have had questions from both our members and the DON council about this CMS memo related to the COVID-10 Focused Survey for Nursing Homes Thank you for asking these questions. 

Am I correct in understanding that the survey should be used as a self-assessment by facilities but will also be used by surveyors?  Yes that is also my understanding, we did not receive any other assessment piece of paper. 

Could you share how frequently these surveys will be happening? The frequency depends on if we get an IJ complaint…if this happens then we go to the facility and we are also directed to go through the Focused Survey for Nursing Homes. The second scenario would be if CMS directed us to do a Focused Survey for Nursing Homes. (Per the memo it states that would be a collaborative request from the CDC and ASPR.) 

Are they random? From what I read it states Federal Surveyors will perform targeted ICS of facilities in those areas most [in] need of additional oversight as ID’s through collaboration with the CDC and ASPR. What that [seems] to mean to me is that where there are huge issues (deaths, positives or not-in-control spreading). So I believe they are not essentially random but where necessity is.

Will they occur after COVID-19 is confirmed in a facility? I do [not] know the answer to that question. I am thinking they are doing it so that facilities are ready not after the fact, but not sure.

What should facilities expect? They should expect limited surveyor interactions, they will be filling out the Focused form and asking questions about that. The surveyor may verify some of the info and talk to the Infection preventionist. Whatever the outcome will be discussed with the RFOD and then routed to [Ann Angell].

Also, I think some concern is if surveyors will be flexible regarding shortages of PPE and other guidance that seems to be updated on a daily basis. We are all working off the same page as you. We know PPE is a problem but our expectation [is that if] that a facility has tried to obtain the needed equipment, surveyors are not citing the facility's ability to obtain PPE

I truly feel that most facilities are doing everything they can to accommodate the guidelines, however, staff shortages and PPE shortages make the situation very difficult. I also truly believe that is the case and we are doing everything to make these visits that we are required to do to be as short as can be and nonintrusive as possible. 

An additional question has arisen regarding families doing personal laundry of residents. Some [facilities are] banning and some are allowing. What is your guidance on this issue?  I’ll let DP answer that for sure but how are these facilities allowing this to occur? Just pick up and drop off since they cannot visit? I am thinking that this is non-essential and with the stay home ban I think this would fall under not necessary since the facility can do the laundry.
CDC Releases COVID-19 Guidance for Retirement Communities and Independent Living 
The Centers for Disease Control and Prevention (CDC) released guidance for retirement and independent living communities, including assisted living communities that do not provide medical services.

AHCA/NCAL has learned that the CDC will be releasing guidance for assisted living communities in the coming days. Until that guidance is published, we strongly recommend that members follow AHCA/NCAL’s previously issued recommendations on visitors, communal dining and events. 

The CDC guidance for retirement communities and independent living is similar to AHCA/NCAL’s guidance in that they suggest canceling all public or non-essential group activities and events, cleaning and disinfecting all areas, screening visitors when appropriate and possible and posting information related to COVID-19.

In recognizing the home-like environment of these residences, the guidance also highlights asking residents to self-monitor , asking residents to ensure they have needed medications, etc. The guidance also recommends that providers work with the local department of health if a positive case of COVID-19 were to be found in the building. It is key to note that the guidance covers retirement communities, assisted living communities that are a less medical model, and CCRCs. Again, we recommend that members utilize AHCA/NCAL’s more robust guidance as well. 

For additional questions, please email COVID19@ahca.org and visit www.ahcancal.org/coronavirus for more information and resources. 
Direct Care Workforce Funding Updates
DHS has received approval from CMS to move forward with the first Direct Care Workforce payment for the 2019-21 state budget funding. See below for additional details from Ben Nerad, Director of the Bureau of Rate Setting:

First Payment
This first, CMS-approved payment of the 2019-21 Direct Care Workforce funding totals $21.4 million and will be distributed based on July 1 – September 30, 2019 utilization. The Department is directing MCOs to start making payments by April 10, and complete all payments by April 24. Between now and April 10th, we are working as quickly as possible with the MCOs to validate providers and payment amounts to ensure the dollars get to the correct, eligible providers. We recognize the need to get this money to providers as quickly as possible especially with the challenges providers face due to COVID-19, and so we are operating under a faster MCO payment timeframe compared to prior payments.

Remaining 2019-21 Payments
While we are still waiting on CMS approval for the remaining DCW payments, we held a phone call with CMS staff yesterday to push for additional flexibilities and expedited payment timeframes given the current COVID-19 crisis. CMS staff suggested that they were open to some flexibilities for these payments, and so we are working with them now to submit a request through their approval process as quickly as possible. I am hopeful we will have more to share with you on these additional payments very soon, hopefully no later than as the first payments are getting out to providers in early April. The Department is also reviewing additional flexibilities that can be provided for the survey process moving forward, and will be communicating more on that soon.

CY 2018 Recoupments and Redistribution Payments
Due to the emerging COVID-19 situation, the Department is waiving provider recoupments for the calendar year 2018 direct care workforce payments. The Department has directed MCOs not to recoup direct care workforce payments from providers that did not complete the Direct Care Workforce Attestation and Survey. Separately, the Department will be redistributing the remaining 2018 Direct Care Workforce funds not yet paid to providers out to eligible 2018 Quarter 4 providers in April. These remaining funds, approximately $2 million, are those that the MCOs were not able to distribute because a given provider was ultimately deemed not eligible or did not participate in the program.
Appraisals for Skilled Nursing Facilities Update
The Division of Medicaid Services has decided that SNFs who are due for an appraisal this year will be completed over the phone. If the appraiser has already visited the facility, the appraisal will be completed using that information. For the remaining homes, the appraiser would review the Auditor Special Instructions to see if there are drastic changes to the facilities, or if there are new shared areas to be measured. Then, the appraiser will plan to setup phone calls to interview each facilities’ administrator and building engineer, to discuss the same topics normally looked for on the actual site visit. Based on that interview and building plans, the appraisal can be completed. If there are outstanding questions, photos may be required.

WHCA will plan to offer a webinar covering best practices for nursing home appraisals so members can be better prepared.
Updates for PEAL/WCCEAL Members
The WCCEAL Advisory Committee met virtually on Tuesday, March 24, 2020. Pat Boyer was involved in this call. Multiple issues were discussed. The following are the highlights:
  • COVID-19 and WCCEAL: All associations focusing on COVID-19. Request for extension of deadlines were made by both Leading Age and WiCAL. It looks like surveys deadline will be extended and open enrollment pushed back. Any additional changes will be discussed by WCCEAL and notices sent to Advisory Committee members. We will update you when received. 
  • Update regarding the MCO assisted living incentive: An MCO will receive an incentive payment for each member residing in an ALC that meets one of the following criteria:
  • Incentive 1 Criteria—The ALC:
  • Qualifies for an Abbreviated DQA Survey.
  • Is compliant with the Home and Community-Based Services settings rule.
  • Incentive 2 Criteria—The ALC:
  • Qualifies for an Abbreviated DQA Survey.
  • Is compliant with the Home and Community-Based Services settings rule.
  • Is a member of the Wisconsin Coalition for Collaborative Excellence in Assisted Living (WCCEAL) in good standing?
  • Has a rate of less than three falls with injury per 1,000 occupied bed between January 1, 2019 and December 31, 2019 (CY 2019), as documented by WCCEAL.
  • A fall with injury means a fall that results in an injury requiring medical treatment.
  • DQA is reviewing data collected to verify. Expected 2nd quarter info to MCOs
  • 2020 WCCEAL Assisted Living Quality Summit
  • A summit is scheduled for the Advisory Council but may be delayed or held virtually depending on COVID-19 status
  • National participants are involved – Many states are looking at Wisconsin’s WCCEAL program as a way to track quality in Assisted Living. We are in the forefront of this project so be proud that we are being looked at as a great example.
  • Workforce initiative
  • Review updated website: https://wcceal.chsra.wisc.edu/member-list.php
  • 3/23/2020 - Email sent to 4,661 WisCaregivers who signed up for training but did not get into the program prior to it ending. The message stated:
Opportunity
If you are interested in working for an assisted living community (ALC), many will hire you and pay for your training. Please visit:  http://wcceal.wisc.edu/ 
  • Click on the WCCEAL Member List map in the middle of the page
  • If you click on the “Table” tab, you can see all the ALCs that have employment opportunities listed with contact information in the last column. You can filter by employment opportunity, the county that you live in or by the type of facility you’d like to work in.
  • Or on the” map” tab you can zoom in to where you live and click on an assisted living community to find their contact and employment information
  • Then simply contact the ALC and let them know you are interested in employment

Good luck on your journey to a healthcare career.
It is important that you list your employment openings on the WCCEAL system, and your facility name will then show up with an icon and directions to call you.

We will keep you up to date on any more specifics regarding deadlines. If you have questions, please contact Pat Boyer at pat@whcawical.org
AL Hospital Admissions Guidance
AHCA/NCAL has updated their interim guidance regarding accepting hospital discharges during COVID-19 pandemic to include assisted living communities. It is important to note that the decision-making and guidance will likely change as the prevalence of COVID-19 varies in communities and hospital surge increases in the community.
Possible Extension of Medicare Cost Report Due Date 
With the considerable burden posed by COVID-19, SNFs have been exploring as many possible ways to reduce administrative burden and free up staff. A key question has been whether CMS would extend cost report due dates. Today, at least one Local Administrative Contractor (MAC) posted information indicating CMS has the authority to extend cost reporting due dates (42 CFR § 413.24 (f) (2) (ii)).  
Specifically, the MAC noted that CMS will delay the filing deadline of Fiscal Year End (FYE) December 31, 2019 cost reports due at the end of May due to the COVID-19 outbreak. 
 
The filing deadline for the following cost reports are now June 30, 2020: 
  • FYE October 31, 2019 due by March 31, 2020 
  • FYE November 30, 2019 due by April 30, 2020 

The filing deadline for FYE December 31, 2019 is now July 31, 2020. 
Suggested Action Steps: 
  1. Check your MAC Provider Information webpage for similar information; or 
  2. If none is posted, contact your MAC and ask about the dates, above. MAC often do not follow the same procedures and post differing information.  

Email COVID19@ahca.org for additional questions, or visit ahcancal.org/coronavirus for more information.
Template Letter to Health Plans and Accountable Care Organizations Requesting Relief 
As AHCA previously reported, health plans have announced, and CMS is allowing Medicare Advantage plans flexibilities  to offer, relief to patients and providers specific to COVID-19-related services. However, due to the extraordinary efforts SNF providers are taking to care for all residents, AHCA is providing a template letter to ask Managed Care Organizations (MCOs) for further relief from administrative burdens including all prior authorizations, all pre- and post-payment reviews, excessive documentation requests, and payment delays. 

Similarly, AHCA is providing a template letter to use with Accountable Care Organizations (ACOs) to request a reduction in documentation requests, loosening of utilization management strategies and effective communication and partnership on COVID-19 patients. To use the letters, download the document(s) and include the MCO’s or ACO’s name and SNF’s contact information where indicated, and send the letter to the provider or contract representative at the MCO or ACO. 
COVID-19 HUD Update
The Office of Healthcare Programs for the Federal Housing Administration has put together a questions and answers document  for external stakeholders around COVID-19. This document addresses questions such as whether the U.S. Department of Housing and Urban Development’s (HUD’s) Office of Healthcare Programs is cancelling or postponing inspections or other site visits in the event of a confirmed COVID-19 case at a HUD-insured facility and what steps Owners and Operators should take to protect residents, staff, and the community. HUD knows long term care providers are looking for supplemental Q&As, and they are working on it daily.  
Workforce Resources for Long-Term Care Providers
  1. Get the word out to JobCenterofWisconsin@dwd.wisconsin.gov that you have open positions available.
  2. Check out our website https://wisconsin.carefortheaging.org/ and see if you can use it to promote your efforts
  3. Use our Jobs Center: https://www.whcawical.org/careers/post-a-job/
  4. Reach out to your local Workforce Development Board: https://dwd.wisconsin.gov/dislocatedworker/wda/wda-map.htm
WHCA/WiCAL Staff
As a reminder, WHCA/WiCAL's staff team is ready to serve your facility. We are committed to providing members with the services you need to succeed in your mission to provide high-quality care to Wisconsin's most vulnerable residents.
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

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

WHCA/WiCAL | 608.257.0125 | info@whcawical.org | www.whcawical.org