Greetings!

This message includes:
  • summaries of two updated QSO memos on visitation guidance and COVID-19 survey activity;
  • an AHCA/NCAL template policies and procedures to implement the CMS staff vaccine mandate; and
  • a save-the-date for a November 22 webinar on how to implement medical and religious exemptions to the mandate. 

Sincerely,

April Payne, MBA, LNHA
Chief Quality & Regulatory Affairs Officer
Executive Director of VCAL
Virginia Health Care Association | Virginia Center for Assisted Living 
CMS Updates Visitation Guidance

CMS has updated its guidance for nursing home visitation in a November 12, 2021 revision to QSO-20-39-NH. Visitation is now allowed for all residents at all times, in accordance with adherence to the core principles of COVID-19 infection prevention and control to mitigate the risk of infection spread. Residents may continue to deny or withdraw consent for a visitation at any time. 

If a visitor, resident, or their representative is aware of the risks associated with visitation and the visit occurs in a manner that does not place other residents at risk (e.g., in the resident’s room), the resident must be allowed to receive visitors as he/she chooses.

Visitors who have a positive viral test for COVID-19, symptoms of COVID-19, or currently meet the criteria for quarantine should not enter the facility. Facilities should screen all who enter for these visitation exclusions.

Indoor visitation
  • ​​Must be allowed at all times and for all residents as permitted under the regulations. Facilities can no longer limit the frequency and length of visitation for residents, the number of visitors, or require advance schedule of visits. 
  • Facilities should ensure physical distancing can still be maintained during peak visitation times and avoid large gatherings where large numbers of visitors are in the same space at the same time and physical distancing cannot be maintained. 
  • If a resident’s roommate is not vaccinated or immunocompromised (regardless of vaccination status), visitation should not be conducted in the resident’s room if possible. 
  • ​If the nursing home’s county COVID-19 community level of transmission is substantial to high, all residents and visitors, regardless of vaccination status, should wear face coverings/masks and physical distance at all times.
  • In low to moderate transmission areas, the safest practice is to wear face coverings/masks and physically distance. 
  • If all visitors and the resident are fully vaccinated and the resident is not moderately or severely immunocompromised, they may choose not to a wear face covering and have physical contact. 
  • Visitors should wear face coverings/masks while around other residents or health care personnel, regardless of vaccination status. 
  • Residents on transmission-based precautions (TBP) or quarantine, while not recommended, can still receive visitors in the resident’s room. The resident should wear a well-fitting facemask (if tolerated). Visitors should be made aware of the risks of visitation, core principles of infection prevention. A facility is not required to, but may offer masks and other PPE as appropriate. ​

Indoor Visitation during Outbreak Investigation
  • ​Visitors must still be allowed into the facility, but they must be made aware of the potential risk of visiting and adhere to core principles of infection prevention. 
  • Visitation during outbreak should include wearing face coverings/masks, regardless of vaccination status, and visits should ideally occur in the resident’s room. 

Visitor Testing and Vaccination
  • ​Facilities may offer testing to visitors, if feasible, but it is not required. Facilities should educate and encourage vaccination. 
  • Facilities may ask visitors about their vaccination status, but visitors are not required to be tested or vaccinated, or show proof of such, as a condition of visitation. If a visitor declines to disclose their vaccination status, they should wear a face covering/mask at all times. 
  • Compassionate care visits are allowed at all times. 

Ombudsman Visiting
  • ​Ombudsman planning on visiting a resident who is on TBP or quarantine, or unvaccinated resident where county level transmission is substantial to high in the past seven days, should be made aware of the potential risk of visiting. The visit should take place in the resident’s room. 
  • If the ombudsman or resident requests alternative communication in lieu of an in-person visit, the facility, at minimum, must facilitate alternative resident communication with the ombudsman program. 

Communal Activities, Dining, and Resident Outings
  • ​Everyone should wear face coverings/masks regardless of the vaccination status. 
  • If a resident chooses to leave the facility, they should be reminded of infection prevention practices, including face coverings/masks, physical distancing, and hand hygiene. 
  • Upon return, screen residents for signs and symptoms of COVID-19. 
  • If possible close contact with COVID-19 outside of the nursing home, test the resident, regardless of vaccination status, and place on quarantine if the resident has not been fully vaccinated.  
  • If resident develops signs or symptoms of COVID-19 after the outing, test the resident and place on TBP regardless of vaccination status. 
  • Facilities may opt to test unvaccinated residents without signs or symptoms if they leave the nursing home frequently or for a prolonged length of time. 
  • Facilities may consider quarantining unvaccinated residents who leave facility based on assessment of risk. 

Survey Considerations
  • Facilities are not permitted to restrict access to surveyors based on vaccination status, nor ask a surveyor for proof of vaccination status as a condition of entry.
CMS Releases Changes to the COVID-19 Survey Activities and Increase NH Oversight
 
CMS has released changes to the COVID-19 survey activities and increased oversight in nursing homes in QSO-22-2-ALL. CMS is announcing steps to assist State Survey Agencies (SAs) in addressing the backlogs of complaint and recertification surveys including: 

  • ​Revising criteria for conducting Focused Infection Control (FIC) surveys;
  • Guidance for resuming recertification surveys; and
  • Temporary guidance and monitor flexibilities related to complaint investigations.

Focused Infection Control Surveys
  • ​CMS is no longer requiring a FIC survey to be conducted within three to five days of a nursing home having three or more new COVID-19 confirmed cases or one confirmed resident case in a facility that was previously COVID-19-free. 
  • Each survey agency must continue to perform annual FIC surveys of at least 20 percent of nursing homes. 
  • Prioritization of these surveys should be made to those facilities reporting new cases and low vaccination rates. 

Recertification Surveys
  • ​SAs should be able to resume recertification surveys on regular basis by establishing new intervals based on each facility’s next survey, not based on the last survey that was conducted prior to COVID-19 public health emergency. 
  • SAs should prioritize recertification surveys according to the potential risk to residents such as facilities with history of noncompliance, or allegations of noncompliance (abuse/neglect, infection control, violations of transfer or discharge requirements, insufficient staffing or competency, special focused facilities and/or SFF candidates, and other quality-of-care issues such as falls and/or pressures, etc.)
  • CMS is temporarily allowing certain mandatory survey protocol tasks to be discretionary or triggered based on concerns identified during offsite preparation activities such as complaints to be investigated during the survey, or those that raise to ombudsman, and pervious patters of citations.
  • Mandatory survey tasks eligible for temporary discretion include Resident Council Meeting, Dining Observation Task, and Medication storage.

Investigating Complaints with the Recertification Survey
  • SAs must utilize the efficiencies built into the long term care survey process software application to investigate complaints with the recertification survey. 

Complaints/Facility Reported Incidents (FRIs)
  • ​SAs to investigate the backlog of complaints/FRIs according to level of triage and would remain in effect only until States are able to clear any backlogs and resume routine operations.
  • LTC Complaints and FRIs triaged as IJ or non-IJ High are required to be investigated as soon as possible.
  • LTC Complaints and FRIs triaged as non-IJ Medium may be investigated at next scheduled standard survey if received within one year of the scheduled standard survey date or if the allegation involves staff to resident abuse, neglect, or misappropriation of resident property, regardless of the date received.
  • LTC Complaints and FRIs triaged as non-IJ Low – SAs are not required to investigate backlogged complaints/FRIs at this level and may be closed in ACTS at the next standard survey. 

Increasing Oversight in Nursing Homes
  • Surveying for nurse competency: Ensure temporary nurse aides are competent to perform skills and techniques necessary to care for residents’ needs. 
  • CMS is alerting SAs to pay attention to compliance with the requirements for nursing services regarding sufficient nursing staff with appropriate competencies and skills sets to provide nursing and related services.
  • SAs continue to focus on efforts of identifying inappropriate use of antipsychotic medications and emphasis on non-pharmacological approaches and person-centered care practices.
  • SAs are assessing other care areas of concern such as unplanned weight loss, loss of function/mobility, depression, abuse/neglect, or pressure ulcers. 
New Template Policies and Procedures Available
on CMS Staff Vaccine Mandate

The CMS interim final rule (IFR) requiring skilled nursing facilities, nursing facilities, and ICF-IIDs to establish a policy ensuring that all eligible staff be vaccinated for COVID-19 or request a medical or religious exemption outlines a two-phase policy. 
The implementation dates for this rule are as follows: 
  • Phase 1 – December 6, 2021: Staff must have received at least the first dose of a two-dose COVID-19 vaccine or a one-dose COVID-19 vaccine.
  • Phase 2 – January 4, 2022: Staff must be fully vaccinated, except staff who have been granted exemptions, or those whom COVID-19 vaccination must be temporarily delayed as recommended by the CDC due to clinical precautions and considerations. 
 
It is important that providers put a policies and procedures in place now to come into compliance with these requirements. To assist members, AHCA/NCAL has developed a template policies and procedures (P&P) that members can personalize to meet their needs. Note that this P&P document will be updated once CMS has released its interpretive guidance. 
AHCA/NCAL Webinar on Implementing Religious
and Medical Exemptions to the Vaccine Mandate
 
AHCA/NCAL will host a webinar on how to implement religious and medical exemptions to the COVID-19 mandate on November 22 at 4 pm. The webinar will be presented by Craig S. Roberts and Henry S. Shapiro, labor and employment attorneys with Jackson Lewis, P.C. Mark your calendar to save the date.

CMS’s Staff Vaccine Mandate:
Implementing Religious & Medical Exemptions 
November 22, 2021 | 4:00 pm

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