The Indiana State Department of Health (ISDH) today reported three new presumptive positive cases of COVID-19 - READ MORE
Below are some of the latest developments from the White House, CMS and LeadingAge. Please feel free to distribute to others in your circles, and let us know if you have any follow up concerns/questions. 

- LeadingAge Indiana Staff

  • Facilities are to restrict all visitors and non-essential health care personnel, except for compassionate care situations such as end of life situations. In those cases visitation is restricted to that patient room only.  States that go further than this by banning all will not be out of compliance (just noting this, not recommending it).
  • Cancel communal dining and all group activities, internal and external
  • Actively screen all residents and staff for fever and respiratory symptoms
  • Suspension of non-emergency enforcement activities
  • Remind all of social distancing and hand hygiene
  • Screen all staff at the beginning of shift for fever and respiratory symptoms. Take temperature and document absence of shortness of breath or change in cough/sore throat. If they are ill, place them in a mask and send them home to self-isolate.
  • Communicate visitor restrictions in a variety of ways – signage, emails, letters, phone calls, recorded messages
  • Screen staff that work at multiple facilities and actively screen
  • Ombudsman are subject to same restrictions as visitor guidance (compassionate care only), though facilities may review on case by case basis
  • Advise all that enter the facility to monitory for signs and symptoms for 14 days after leaving the facility. To self-isolate at home if symptoms occur, contact their healthcare provider, immediately notify the facility of the date they were in the facility, who they were in contact with and the locations in the facility they visited. Facilities then need to screen individuals of the reported contact and take necessary actions from there.
CMS Announces New Visitor Restrictions
At 8:52 p.m. on March 13, CMS issued a revised memorandum related to visitor restrictions in nursing homes which is effective immediately.  This was alluded to earlier today in a press conference where CMS Administrator Verma shared that visitation would be restricted “to all visitors and non-essential personnel, with a few exceptions, such as end-of-life personnel.” 

Members are encouraged to review the revised memorandum and CDC added recommendations for infection control practices in nursing homes when planning to implement these changes.

New Directive on Visitors
In the new guidance, CMS directs ALL Facilities nationwide to restrict visitation of all visitors and non-essential health care personnel, except for certain compassionate care situations, such as an end-of-life situation. Facilities are expected to communicate through multiple means to inform individuals and nonessential health care personnel of the visitation restrictions, such as through signage at entrances/exits, letters, emails, phone calls, and recorded messages for receiving calls. 

End-of-Life Care Exception
In cases of compassionate/end-of-life care, CMS specifies that visitors will be limited to a specific room only and shall be required to perform hand hygiene and use Personal Protective Equipment (PPE), such as facemasks. Decisions about visitation during an end of life situation should be made on a case by case basis, which should include careful screening of the visitor (including clergy, bereavement counselors, etc.) for fever or respiratory symptoms. Those with symptoms of a respiratory infection (fever, cough, shortness of breath, or sore throat) should not be permitted to enter the facility at any time (even in end-of-life situations). Those visitors that are permitted, must wear a facemask while in the building and restrict their visit to the resident’s room or other location designated by the facility. They should also be reminded to frequently perform hand hygiene and suggest refraining from physical contact with residents and others while in the facility.

Healthcare Workers
Facilities should follow CDC guidelines for restricting access to health care workers which also applies to other health care workers, such as hospice workers, EMS personnel, or dialysis technicians, that provide care to residents. They should be permitted to come into the facility as long as they meet the CDC guidelines for health care workers. Note that the CMS revised visitation guidance seems to have been based on the new CDC guidance released which provides some additional guidance on essential health care personnel as well. 

CMS and state survey agencies are constantly evaluating their surveyors to ensure they don’t pose a transmission risk when entering a facility. For example, surveyors may have been in a facility with COVID-19 cases in the previous 14 days, but because they were wearing PPE effectively per CDC guidelines, they pose a low risk to transmission in the next facility and must be allowed to enter. However, there are circumstances under which surveyors should still not enter, such as if they have a fever. (Note from article below regarding CMS emergency action that CMS temporarily suspended non-emergency survey inspections)
Other Key Directives from CMS

  • Cancel communal dining and all group activities, such as internal and external group activities. 
  • Screen all staff at the beginning of their shift for fever and respiratory symptoms. Actively take their temperature and document absence of shortness of breath, new or change in cough, and sore throat. If they are ill, have them put on a facemask and self-isolate at home
  • Implement active screening of residents and staff for fever and respiratory symptoms. Remind residents to practice social distancing and perform frequent hand hygiene.
  • Facilities should identify staff that work at multiple facilities (e.g., agency staff, regional or corporate staff, etc.) and actively screen and restrict them appropriately to ensure they do not place individuals in the facility at risk for COVID-19.
  • Residents still have the right to access the Ombudsman program. Their access should be restricted except in compassionate care situations, however, facilities may review this on a case by case basis. If in-person access is not available due to infection control concerns, facilities need to facilitate resident communication (by phone or other format) with the Ombudsman program or any other entity listed in 42 CFR § 483.10(f)(4)(i).
  • Advise visitors, and any individuals who entered the facility (e.g., hospice staff), to monitor for signs and symptoms of respiratory infection for at least 14 days after exiting the facility. If symptoms occur, advise them to self-isolate at home, contact their healthcare provider, and immediately notify the facility of the date they were in the facility, the individuals they were in contact with, and the locations within the facility they visited. Facilities should immediately screen the individuals of reported contact, and take all necessary actions based on findings.
President Declares National Emergency; CMS Announces Emergency Actions
President Trump declared a National Emergency due to COVID-19. The declaration of a national emergency grants federal agencies powers to waive provisions of the law to free providers and others to act to address the emergency at hand. 

CMS announced that for the first time since 2009 they will issue 1135 waivers nationally to rapidly expand efforts against COVID-19. Section 1135 waivers authorize the Secretary to waive certain Medicare and Medicaid waivers. In a conference call this evening, CMS explained that the Medicare waivers will be issued nationally, while the Medicaid waivers will require state action to request. 

Examples of flexibilities available to states under section 1135 waivers include the ability to permit out-of-state providers to render services, temporarily suspend certain provider enrollment and revalidation requirements to promote access to care, allow providers to provide care in alternative settings, waive prior authorization requirements, and temporarily suspend certain pre-admission and annual screenings for nursing home residents.

  • Waiver of the 3-day Stay Requirement for Skilled Nursing Facilities- CMS is waiving the requirement at Section 1812(f) of the Social Security Act for a 3-day prior hospitalization for coverage of a skilled nursing facility (SNF) stay provides temporary emergency coverage of (SNF services without a qualifying hospital stay, for those people who need to be transferred as a result of the effect of a disaster or emergency.
  • Extension of Skilled Nursing Facility Benefits-For certain beneficiaries who recently exhausted their SNF benefits, the waiver authorizes renewed SNF coverage without first having to start a new benefit period. Second,
  • Waiver of the MDS Timeframe-CMS is waiving 42 CFR 483.20 to provides relief to SNFs on the timeframe requirements for Minimum Data Set assessments and transmission.
  • Durable Medical Equipment-Where Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS) is lost, destroyed, irreparably damaged, or otherwise rendered unusable, contractors have the flexibility to waive replacements requirements such that the face-to-face requirement, a new physician’s order, and new medical necessity documentation are not required. Suppliers must still include a narrative description on the claim explaining the reason why the equipment must be replaced and are reminded to maintain documentation indicating that the DMEPOS was lost, destroyed, irreparably damaged or otherwise rendered unusable or unavailable as a result of the emergency.
  • Home Health Agencies-Provides relief to Home Health Agencies on the timeframes related to OASIS Transmission. Allows Medicare Administrative Contractors to extend the auto-cancellation date of Requests for Anticipated Payment (RAPs) during emergencies.
  • Provider Locations-Temporarily waive requirements that out-of-state providers be licensed in the state where they are providing services when they are licensed in another state. This applies to Medicare and Medicaid.
  • Provider Locations-Temporarily waive requirements that out-of-state providers be licensed in the state where they are providing services when they are licensed in another state. This applies to Medicare and Medicaid.
  • Provider Enrollment-Establishes a toll-free hotline for non-certified Part B suppliers, physicians and nonphysician practitioners to enroll and receive temporary Medicare billing privileges and waives the application fee, criminal background checks associated with FCBS, and site visits. Also allows licensed providers to render services outside of their state of enrollment and expedites any pending or new applications from providers.
  • Medicare Appeals in Fee for Service, MA and Part D- Extension to file an appeal, waive timeliness for requests for additional information to adjudicate the appeal, processing the appeal even with incomplete Appointment of Representation forms but communicating only to the beneficiary, processing requests for appeal that don’t meet the required elements using information that is available, and utilizing all flexibilities available in the appeal process as if good cause requirements are satisfied.

In addition to the waivers, CMS announced that they will temporarily suspend non-emergency survey inspections to allow providers to focus on the most current serious health and safety threats, like infectious disease and abuse. 
CDC Issues New Guidance for Infection Control; LAI Updates Templates

The CDC added recommendations for infection control practices in nursing homes to their website. The guidance was clearly the basis for CMS’ new visitor restriction policy but also includes other useful information. The CDC states that these recommendations are specific for nursing homes, including skilled nursing facilities, but that much of this information could also be applied in assisted living facilities. This information complements, but does not replace, the general  infection prevention and control recommendations  for COVID-19.  

To support members with the new CDC guidance, LAI has updated the Emergency Preparedness Template to address the IDPH’s new reporting Protocol for Iowa LTC Providers; and the Infection Control Policy Template (with tracked changes) to include the vast number of updates from the CDC related to resident and employee screening and recommended visitor restrictions.

The CDC has developed a website for COVID-19 preparedness specific to nursing homes to include a preparedness checklist and updated guidance and information.
New Crisis Communication Tools

Understanding that your job is to care for people, LeadingAge has created some tips on working with the media in wake of COVID-19. 

They have also provided a template for a media statement in case the virus makes it onto your campus.

Below are sample letters that might make your jobs a bit easier as you navigate this uncharted territory: