COVID-19 UPDATE #16
April 1, 2020
NEW GUIDANCE ON HOSPITAL TRANSFERS
AHCA/NCAL has revised its guidance for long term care facilities on accepting admissions from and transferring patients to hospitals during COVID-19 (previously released March 20). The revisions are based on new evidence from the CDC published in its March 27 Morbidity and Mortality Weekly Report (MMWR), which found that 57% of elderly who tested positive for COVID-19 did not have symptoms but shed virus at levels that likely made them infectious to others.

Based on this new CDC data, unless a person is tested for COVID-19 and negative before admitting them to your building, you should assume the person has COVID-19 regardless of their having or not having symptoms.

AHCA/NCAL strongly urge long term care facilities to begin creating separate wings, units, or floors now by moving current residents, in order to handle admissions from the hospital and keeping current residents separate, if possible.

 As more data becomes available, this guidance may continue to change. Some state or federal officials may issue state-specific guidance that supersedes this guidance. Read more .
CDC REPORTS ON INFECTIOUS ASYMPTOMATIC PATIENTS
A new article from the CDC reports on testing of all the residents in a Seattle, Washington facility. The article reports that of all the residents who tested positive for COVID-19, 57% of them were asymptomatic at the time of a positive test. Most later went on to develop symptoms about seven days later. When tested positive, the residents were shedding virus at levels that probably made them infectious to others despite not having any symptoms. This led the CDC to recommend against using a symptoms-based approach to prioritize testing for COVID-19 since over half of elderly nursing home residents without symptoms are likely positive and infectious to others.
 
The CDC is not sure if the same finding is true in younger and healthier individuals, but there is some evidence to suggest younger adults will be infectious before developing symptoms. This dilemma is highlighted in a New York Times article, Infected but Feeling Fine: the Unwitting Coronavirus Spreaders , published March 31, 2020, that reports that as many as 25% of people infected with the virus may not show symptoms. This new data about people infected but symptom free could lead the CDC to recommended broadened use of masks. 

To date, all CDC guidance is predicated on the traditional symptom-based approach to preventing and controlling spread of respiratory viruses. This finding raises serious questions about that approach. This led to the change in AHCA’s guidance on accepting admissions from the hospital without testing. It supports:
  1. Testing of hospital discharges regardless of symptoms before being admitted to a SNF or assume they are all COIVD positive;
  2. Implementing strategies “to prevent spread once COVID is in your building” before you find it in your building;
  3. More testing of asymptomatic staff to detect virus; and
  4. Our call to VP Pence’s task force to make asymptomatic residents and staff a top priority of testing.

While the CDC report on asymptomatic residents, and associated AHCA guidance on resident admissions are focused on skilled nursing facilities, the issues and resources may be applicable to assisted living facilities as well.
SURGE PLANNING CONTINUES WITH FEDERAL AND STATE WAIVER ACTIONS
Yesterday, CMS issued several blanket waivers impacting long term care providers. Click here for the AHCA synopsis of those waivers. The goal for these waivers is to permit rapid-response to the on-going pandemic, and to allow providers to create COVID-19-specific care options. Despite the fact that CMS issued these waivers, states have additional discretion about adopting standards.

As federal waivers are granted, the state of Washington then acts to waive related state laws and regulations through  proclamations by Washington Governor Jay Inslee. Click here for the latest list of waived state laws and regulations. We are reviewing yesterday’s CMS blanket waivers and will update you regarding status of those waivers in Washington (some have already been granted). If you have specific questions about any of the CMS blanket waivers and status in Washington, please email Lauri St. Ours.
WHCA PURSUES APPROVAL OF AHCA ONLINE TRAINING FOR NURSE AIDES - STAY TUNED
Yesterday, AHCA released details about a free online 8-hour training program for temporary nursing assistants. The 8-hour program is not yet approved in Washington, where there is currently a state requirement for 16 hours of training. We have reached out to the Nursing Care Quality Assurance Commission about how we can seek approval for this program, and will update you on the status of this request. In the meantime, if you have questions about current training standards for nursing home staff including nursing assistants registered or certified nursing assistants, please email Lauri St. Ours.
AHCA ACCELERATED AND ADVANCE PAYMENTS FAQs
The AHCA Medicare Accelerated and Advance Payment FAQs was developed to supplement the recent CMS Fact Sheet related to this topic. These FAQs are based on preliminary feedback from CMS to member submitted questions. The Agency will be releasing its own version in the coming days, incorporating additional questions posed by members.

The accelerated and advance payment provisions permit providers to submit a request to their MAC on a simple form to obtain accelerated payments for Medicare Part A and Part B services for up to three months of historical billing. Providers will still be able to submit and be paid for claims during this period. After 120 days for receipt of the payment, providers will have a flexible process to repay during the subsequent 90 days. This AHCA FAQ document contains additional details regarding the process and MAC contact information and links.
PROVIDERS APPEAL TO INSLEE FOR PRIORITY PPE FOR HCBS SETTINGS
On March 27, a coalition of home and community-based services providers sent a letter to Governor Jay Inslee requesting that all community-based long term care providers, regardless of the setting for their care, be a priority for scarce personal protective equipment (PPE), noting that every member of the community-based long term care workforce should have PPE to protect them and people who depend on them for daily needs.
 
We believe that PPE should be a top tier priority for those caring for clients with confirmed cases of COVID-19, and they should be in tier 3 along with nursing homes if they do not have confirmed cases. In this time of crisis and uncertainty, we anticipate Washington State’s need for long term services and supports in all settings will only grow as our need to clear space in hospitals grows and COVID-19 survivors need assistance during recovery. To keep hospital beds available for new cases, we need to assure Washington’s complete long term care system can safely receive patients. We will keep you apprised of these efforts.
RCS SURVEYORS/LICENSORS REQUESTING REMOTE ACCESS TO EHR
Following member inquiry, WHCA reached out to RCS regarding the recent request by more than one RCS surveyor/licensor requesting remote access to electronic health records (EHR). RCS management stated that in an effort to reduce the amount of time in buildings and the amount of time RCS staff have to spend out on the floor while in the facility, they are trying to see if they can complete some of the Infection Control Tool/checklist while offsite or while in a conference room. Some facilities have the capability to allow RCS access to data through EHR platforms.

The decision to allow access is up each facility . If the facility prefers not to allow access, RCS staff may still request some data be emailed or faxed through a secure process in order for them to complete part of their review outside of the facility, thus limiting time in the facility.
REVISED SCREENING CHECKLIST FOR VISITORS AND STAFF
AHCA/NCAL has updated the screening checklist for visitors and staff based on the latest guidance from CMS and CDC. Revisions include changes to Section 3B to reflect when a staff person has worked in facilities or locations with recognized COVID-19 cases, and the staff person has worked with a person with confirmed COVID-19. They should be required to wear PPE including masks, gloves, gown before any contact with residents.
Section 4 was also expanded to include CDC guidance for health care provider use of PPE when there are cases of COVID-19 present or not in the facility, as well is in the community. Please replace the prior version of this checklist with this revised version.
WASHINGTON YMCAs HELPING HEALTHCARE WORKERS WITH CHILDCARE
Local YMCAs are rallying around healthcare workers and doing all they can to help them secure safe daycare. Click here for a list of YMCA Association offices representing the 48 YMCA branches statewide. The information includes the counties they serve and their Early Learning and School-age care programs - pre-coronavirus pandemic.

Many of our YMCAs are providing EMR Childcare services. As a starting place, please find information on Snohomish County’s EMR childcare services here. In King County, childcare teams and early learning staff are on the front lines providing needed support for about 250 families of first responders and essential workers. In fact, their efforts to provide low-costs/no-costs services made national news this past weekend.

YMCA branches are available for this important work and they have capacity for more. If you know someone who can benefit from Child Care Break Camp programs or Early Learning programs, click here for branch locations and here for early learning sites. Anyone seeking more information can text “Ykids” to 55678.
WHCA FREQUENTLY ASKED QUESTIONS RESOURCE UPDATED
WHCA created a Frequently Asked Questions document for assisted living and skilled nursing providers. We published the first iteration of the documents on March 20. We have updated these documents with the latest information and additional questions and answers that have come up since the first documents were posted. WHCA will continually make updates to the FAQs and notify members when new versions are posted. Click on the links to review FAQ AL v2 and FAQ SNF v2 .
DEPARTMENT OF HEALTH TO HOST WEBINAR THURSDAY, APRIL 2 | 11 AM
Join leaders and experts from the Department of Health each Thursday at 11 AM to receive an update on current COVID-19 impacts and resources for long term care. They review FAQs they are receiving, and they make themselves available to answer questions. Visit the WHCA COVID-19 resources page for Q&A information from previous calls. The webinar is free and open to all. Click here to join the meeting.
ADDITIONAL RESOURCES
WHCA continues to post resources and information as it becomes available on our website . If you have questions or need additional information, please call the WHCA office at (800) 562-6170.