April 3, 2020
We have learned in the past week that COVID-19 can be spread through infected but asymptomatic individuals, and that spread can be done through simply talking and breathing. Because of this updated information, it is important to follow stricter guidelines in your building in order to minimize person-to-person contact. New AHCA/NCAL guidance provides some ideas on how to achieve this goal.

Your staff should wear a mask at all times.  President Trump is now requiring that all nursing home staff wear masks while at work. Several Washington state counties have directed all long term care facilities, including assisted living communities, do the same. Because of the shortage of masks, consider having health care personnel wear the medical-grade masks, and other staff wear cloth or other types of mouth/nose barriers. In order to minimize spread, facilities may also request residents wear masks whenever interacting with others, including your staff. CDC guidelines in optimizing the supply of facemasks can be found here .
WA 2-1-1 is a confidential community helpline that, starting next week, will help serve the public with questions or concerns about the COVID-19 pandemic. Should a caller inquire about a long-term care facility where his/her family member lives, the referral specialist will route the caller to the Washington State Ombuds program. The ombuds will work with the caller to address issues like how to reach the facility with questions, how to navigate communication methods with loved ones, or how to trouble-shoot placement issues for people needing long term care.

Facility administrators have likely received an information request from the regional ombuds. This information allows the ombuds to perform their duties, particularly as they are unable to visit the buildings during the COVID-19 outbreak, and to better serve families who might call the WA 2-1-1 resource line with questions.  While email requests may include different items for your follow-up and submission to them, there is a theme that includes a resident roster and resident family member contact information, including mailing addresses, and the names and contact information for the resident council leadership, if applicable. This information can be provided on a list or, if you are unable to create this list, face sheets can be provided. The ombuds will also request a good contact number for the administrator; this can be a cell number or a landline, but please provide a number where you can indeed be reached promptly to facilitate a quick response should one be necessary.

Your reply to ombuds’ request might rightly need to be delayed due to circumstances surrounding the COVID-19 issues in your building. If gathering this information proves difficult in the timeframe requested by the ombuds, please email and/or call your ombuds to discuss a feasible time this information can be sent. If you have questions or concerns, please email Vicki McNealley at the WHCA office.
Yesterday, DSHS filed emergency rules to immediately suspend TB testing requirements in assisted living facilities. The provision to ensure each staff person is screened for tuberculosis within three days of hiring is stricken. The requirement that an individual with a positive result have a chest X-ray within seven days was also repealed. Click here to review the CR-103E that suspends the testing requirement.
Earlier this week the Department announced that it was going to adjust Medicaid rates by implementing a $29 ppd rate add-on. The Department planned to back date the adjustment to February 1, 2020. We supported the Department’s efforts as a way to get as much money out to providers as quickly as possible. Back-dating claims to February 1, would have resulted in retroactive lump sum payments that are sorely needed by providers. Unfortunately, the ability to back-date to February 1 has hit a snag with CMS. DSHS is still working with CMS to confirm how far back retroactive rate change can be applied. There are concerns that DSHS may only be able to go back to March 1st.
As soon as DSHS gets final confirmation from CMS, it will make any necessary and appropriate adjustments to the rates. However, this does cause more immediate concerns of which we want you to be aware:
  • DSHS is planning to finalize mass adjustments for prior claims from March 1, 2020 forward at the $29 a day rate;
  • Depending on the final decision from CMS, DSHS may extend the mass adjustment back to February 1;
  • If the February 1 extension is not approved by CMS, the $29 adjustment will be increased by approximately an additional $8 ppd to fully utilize the additional funding from March 1 onward;
  • If CMS does not allow retroactive application back to February, DSHS will have to correct any February claims paid at the higher rate.

DSHS has explained its position here . We understand that the DSHS Rates Unit is doing its best to get to providers as much of the federal funding available as possible. We salute them in their efforts and stand by ready to help. 
It has come to WHCA’s attention that the Department of Labor and Industries Division of Occupational Safety and Health (DOSH) has begun to respond to safety related COVID-19 workplace employee complaints. A long term care community in the King County area recently received a DOSH compliance letter wherein the complainant (15 employees) alleged they were working without the necessary PPE (personal protective equipment) that would protect them from errant exposure to the virus. L&I is required by law to investigate any employee complaints they receive.  
This is a standard format letter that DOSH sends regarding a situation where there has been no serious accident or incident. They are seeking a timely response of corrective actions that have been made to mitigate the complaint. The recipient of the letter is also instructed to post the letter from DOSH in a place where all employees can see it, for a period of a minimum of three days.
Any employer that receives a letter from DOSH must pay attention to the instructions within the letter and adhere to the timeframes noted. While a compliance inspection of the property is not imminent, failure to comply with the provisions in the letter may result in a compliance inspector visit to the property.
If your building receives such a letter and you participate in WHCA’s Group Retro program, please contact Oscar Granger by email , or at (253) 237-0819 and he can help guide you through the response.
Residential Care Services (RCS) has issued a directive to their staff regarding the use of PPE. RCS staff that make site visits to facilities must always carry and use Personal Protective Equipment (PPE) while performing onsite investigation or inspection visits. ALL RCS STAFF MUST CARRY AND USE PPE AT ALL TIMES WHILE CONDUCTING ONSITE INVESTIGATIONS OR INSPECTIONS.
  • In COVID-19 positive facilities or homes, RCS staff will wear full PPE and change as needed if moving in and out of resident rooms for observations of infection control practices or care being provided to a resident. Full PPE includes face shield, N95 mask, gown, and gloves. 
  • In COVID-19 suspected facilities or homes with residents with COVID-19 symptoms only (pending test results, no confirmed positive test results), RCS staff will wear full PPE and change as needed if moving in and out of residents rooms for observation of infection control practices or care provided to a resident. 
In non-COVID-19 positive or suspected facilities or homes, RCS staff will wear at least a surgical mask or an N95 mask, and have additional PPE available for use as needed. If RCS staff are not adhering to this directive, RCS senior management has asked to be notified immediately by the facility. Please notify your local RCS office or Bett Schlemmer, Office Chief for Field Operations. RCS contact information is available here.
The US Small Business Administration (SBA) has set up loan opportunities for small businesses to support them during the COVID-19 pandemic. There are a few loan options that some long term care providers may be able to utilize. The Paycheck Protection Program is designed for employers with 500 and fewer employees, and there are exceptions for employers will more than 500 employees. The US Treasury Fact Sheet provides insight on who is eligible to apply and links to the application form.

The Paycheck Protection Program is designed to help employers continue to pay employees as well as support them with some other expenses. The loan is designed to provide 2.5 times the average monthly payroll and could ultimately be completely forgiven. We encourage you to reach out to your local lender if you are interested in applying.
Late yesterday (Thursday, April 2), the Centers for Medicare & Medicaid Services (CMS), in consultation with the Centers for Disease Control and Prevention (CDC), issued a press release and new recommendations to state and local governments, as well as nursing homes, to help mitigate the spread of COVID-19 in nursing homes.

The recommendations announced last night include:
  • Nursing homes should immediately ensure that they are complying with all CMS and CDC guidance related to infection control, particularly focusing on consistent hand washing and changing and removing of PPE based on preliminary data from infection control focused surveys. 
  • Hand Hygiene Technique
  • Focused Survey Self-Assessment Tool
  • CDC Guidance
  • Conserving PPE
  • CMS/CDC urges State and local leaders to consider the needs of long term care facilities with respect to supplies of PPE and COVID-19 tests.
  • Medicare is now covering COVID-19 testing when furnished to eligible beneficiaries by certified laboratories. These laboratories may also choose to enter facilities to conduct COVID-19 testing. 
  • Nursing homes should immediately implement symptom screening for all staff, residents, and visitors – including temperature checks.
  • An exception to this is Emergency Medical Service (EMS) workers responding to an urgent medical need. They do not have to be screened, as they are typically screened separately.
  • Facilities should limit access points and ensure that all accessible entrances have a screening station. 
  • Patients and residents who enter facilities should be screened for COVID-19 through testing, if available.
  • This new guidance can be provided to get the hospitalized patient tested before admission to the nursing home. 
  • Nursing homes should ensure all staff are using appropriate PPE when they are interacting with patients and residents, to the extent PPE is available and per CDC guidance on conservation of PPE. The recommendations provide NEW detail on steps to take including:
  • All long-term care facility personnel in the country should wear a facemask while they are in the facility.
  • Full PPE should be worn per CDC guidelines for the care of any resident with known or suspected COVID-19 per CDC guidance on conservation of PPE. 
  • To avoid transmission within nursing homes, facilities should use separate staffing teams for residents to the best of their ability, and the administration urges nursing homes to work with state and local leaders to designate separate facilities or units within a facility to separate COVID-19 negative residents from COVID-19 positive residents and individuals with unknown COVID-19 status. The recommendations provide detail on steps to take.
Last night CMS issued updates to their Frequently Asked Questions guidance to state Medicaid agencies on COVID-19. You may access the updated version of this document by clicking here. Importantly in these updates, starting on page 15, they addressed accounting for new costs NFs will experience due to COVID-19, upper payment limits for nursing home rates, as well as steps states may take if they need extra time to submit these UPL demonstrations.
The Secretary of Health has extended health profession license expiration dates for licenses up for renewal between April 1 and September 30, 2020. This extension will allow health professionals to focus on patient care and promote continued patient safety during the COVID-19 outbreak. Because renewal payment will not be required until September 30, 2020, it will also reduce the economic burden on those providers not able to work during this emergency.

Washington law allows the Secretary of Health to grant an administrative modification for the duration of any license, certification, or registration period to address unusual circumstances. Governor Inslee’s Proclamation 20-32 provides authority for the action without agency rulemaking. More information is available on the Department of Health website.
We have heard from CMS that a common theme they are finding during COVID-19 infection control focused surveys are PPE not being used correctly, including donning and doffing procedures. Surveyors are having staff demonstrate handwashing and donning and doffing of PPE.

We encourage you to review with your teams the appropriate way to apply and remove all PPE, including gloves, gowns, masks, and eye protection. Performing observations yourself can be helpful to prepare staff for surveyor observation and to quickly correct any practices needing improvement.
  • These documents can be printed and posted in your center to ensure your staff are aware of how to appropriately don PPE. 
  • These documents can be printed and posted in your center to ensure your staff are aware of how to appropriately doff PPE.  
  • The following video explains how to perform hand hygiene and donning/doffing PPE appropriately.
  • The following video shows several different types of masks and how to put them on correctly.
Some AHCA members have been asking if CMS has made any changes to the MDS coding guidance associated with item O0100M – Isolation for active infectious disease (does not include standard precautions) located in Chapter 3 of the MDS 3.0 RAI Manual v 1.17.1 October 2019. Below is an excerpt from the current coding requirements describing the four specific conditions that must be met to check the O0100M item box for the presence of isolation for active infectious disease.

Code for “single room isolation” only when all of the following conditions are met:
  1. The resident has active infection with highly transmissible or epidemiologically significant pathogens that have been acquired by physical contact or airborne or droplet transmission.
  2. Precautions are over and above standard precautions. That is, transmission-based precautions (contact, droplet, and/or airborne) must be in effect.
  3. The resident is in a room alone because of active infection and cannot have a roommate. This means that the resident must be in the room alone and not cohorted with a roommate regardless of whether the roommate has a similar active infection that requires isolation.
  4. The resident must remain in his/her room. This requires that all services be brought to the resident (e.g. rehabilitation, activities, dining, etc.).

A recent email received from CMS indicates that providers should continue to code residents for the O0100M isolation item per current MDS-RAI manual instructions. 

AHCA recognizes that many providers have applied recent CMS and CDC guidance and 1135 waivers during the COVID-19 emergency and have sometimes cohorted beneficiaries in the same isolation room when the residents have tested positive for COVID-19 or are presumed to be positive. We also recognize that with respect to payment models including PDPM, State case-mix, and Medicare Advantage, the current inability to code for isolation in situations where residents were required to be cohorted into the same room may result in a lower payment rate. CMS is aware of this concern. AHCA will share updates as they become available.
CMS has responded to member concerns that the ICD-10-CM diagnosis codes identified by the CDC as appropriate to code for COVID-19 were not compatible with the Medicare Part A SNF PPS PDPM payment model. Specifically, none of the CDC identified codes could be used to represent the Primary Reason for SNF Stay on the MDS assessment Item I0020B.

On March 31, CMS posted an updated FY 2020 PDPM ICD-10 Mappings file (.zip) which adds the ICD-10-CMS code ‘U07.1 - 2019-nCoV acute respiratory disease’ as an appropriate code to enter in the MDS I0020B Primary reason for SNF stay item field. If entered, this code will map to the PDPM ‘Pulmonary’ default clinical category used for the PT, OT, and SLP components. This new code does not impact the PDPM Nursing or NTA component classifications at present.

This new code U07.1 is ONLY in effect for assessments with target date April 1, 2020, and later. For assessments with an assessment reference date March 31, 2019, or earlier, providers will need to enter the most appropriate ICD-10 code available that is not listed as a ‘return to provider’ code in the MDS I0020B item field.

Additional files related to coding specifications necessary for software companies to implement this change are located on the MDS 3.0 Technical Information webpage. Providers do not need to review these files but should check with their MDS software vendors to confirm when these updates have been applied or you will see a ‘return to provider’ error in your MDS software.  
CMS released a COVID-19 Provider Burden Relief FAQ document that states that the Agency has suspended most Medicare Part A and Part B Fee-For-Service (FFS) medical review during the emergency period due to the COVID-19 pandemic. This includes pre-payment medical reviews conducted by Medicare Administrative Contractors (MACs) under the Targeted Probe and Educate program, and post-payment reviews conducted by the MACs, Supplemental Medical Review Contractor (SMRC) reviews and Recovery Audit Contractor (RAC). No additional documentation requests will be issued for the duration of the PHE for the COVID-19 pandemic. Targeted Probe and Educate reviews that are in process will be suspended and claims will be released and paid. Current post-payment MAC, SMRC, and RAC reviews will be suspended and released from review.

This suspension of medical review activities is for the duration of the PHE. However, CMS may conduct medical reviews during or after the PHE if there is an indication of potential fraud. Other topics in the FAQ are related to proof of delivery beneficiary signature waivers for drugs and DME, and for pausing non-emergent ambulance and home health review choice demonstrations Providers should contact their Medicare review contractor if there are questions.
With residents staying in their apartments and self-isolating, there are ways to keep them engaged and entertained while still honoring the “no group activities” mandate to minimize COVID-19 spread. AHCA/NCAL has published some ideas on keeping residents engaged. Providers are encouraged to share their creative resident activities via their website or Facebook page; these efforts can ease the minds of residents’ families and infuse a bit of fun into the staff’s stressful workday.
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.