COVID-19 UPDATE #23
April 21, 2020
CMS ANNOUNCES NEW REQUIREMENTS COMING FOR REPORTING CONFIRMED CASES
At a White House briefing, Administrator Seema Verma announced that the Centers for Medicare and Medicaid Services (CMS) will be requiring skilled nursing care centers to report confirmed cases of COVID-19 to residents and families. Skilled nursing centers will also be required to report confirmed cases directly to the Centers for Disease Control and Prevention (CDC). Details on how to do this will be forthcoming later this week from CMS.

This announcement is similar to AHCA/NCAL guidance released last weekend on reporting confirmed cases to stakeholders and to the state survey agency if providers were not already doing so. While this announcement from CMS applies only to nursing homes, assisted living communities and facilities that serve ID/DD populations should continue to follow AHCA/NCAL guidance on notifications.
CMS REQUIRES RESIDENT AND RESIDENT REPRESENTATIVE REPORTING REGARDING COVID-19 FOR SKILLED NURSING FACILITIES
In addition to requiring reporting to CDC, in rulemaking that is pending, CMS will be requiring that skilled nursing facilities notify their residents and their representatives to keep them informed of the conditions regarding COVID-19 inside the facility. This is separate from the reporting required to CDC in that this information will be shared by each SNF directly with residents and their representatives.

At a minimum, once these requirements are in place, skilled nursing facilities must inform residents and their representatives within 12 hours of the occurrence of a single confirmed infection of COVID-19 , or three or more residents or staff with new-onset of respiratory symptoms that occur within 72 hours .

Also, updates to residents and their representatives must be provided weekly, or each subsequent time a confirmed infection of COVID-19 is identified and/or whenever three or more residents or staff with new-onset of respiratory symptoms occurs within 72 hours. Facilities will need to also include information on mitigating actions implemented to prevent or reduce the risk of transmission, including if normal operations in the facility will be altered. This information must be reported in accordance with existing privacy regulations and statute.

In CMS rulemaking that will follow this memorandum , CMS states a facility’s failure to report resident or staff incidences of communicable disease or infection, including confirmed COVID-19 cases (or persons under investigation for COVID-19), or provide timely notification to residents and their representatives of these incidences, as required, could result in an enforcement action against the facility by CMS. AHCA/NCAL has created guidance on keeping families up-to-date that you may find helpful.
NASOPHARYNGEAL SWABBING INSTRUCTIONS
DSHS and/or the local health jurisdiction will likely be contacting assisted living facilities to learn of their preparation and response systems for COVID-19. Part of this assessment will include questioning regarding whether or not the facility has a person qualified to conduct COVID-19 testing in-house. This will facilitate resident and/or staff testing if facilities are asked to conduct testing. Nurses should watch this video to learn how to conduct nasopharyngeal swab testing, should the need arise.
NEBULIZING GUIDANCE
AHCA/NCAL has developed new guidance that outlines when and what to do with COVID-19 residents with severe respiratory symptoms who need nebulizer treatments. CDC considers nebulizer treatments to be an aerosol generating procedure. This may increase risk of infection due to aerosols generated by the procedure or due to increased contact between health care providers and patients. Facilities should review the guidance and consider whether they can care for a resident who requires nebulizer treatment.
DSHS/RCS REQUEST FOR ONGOING COVID-19 STATUS UPDATES FOR ASSISTED LIVING AND SKILLED NURSING FACILITIES
The Aging and Long-Term Support Administration (ALTSA) has developed an on-line tool for providers to update COVID-19 information. DSHS/RCS is asking each facility to visit the website twice weekly—on Monday and Thursday by midnight—to update the COVID-19 status of residents, staff numbers, census, and COVID-19 test kit training needs. Instructions for using this tool are available here . More information can be found in the Dear Administrator letter dated April 20, 2020. According to RCS Director, Candace Goehring , if you have questions, please contact your local field manager
QUARANTINE VERSUS ISOLATION: WHAT'S THE DIFFERENCE?
The terms “quarantine” and “isolation” are oftentimes used interchangeably. In the case of COVID-19 and other infectious illnesses, however, these words are unique and bear differences in an effort to minimize spreading COVID-19.

QUARANTINE involves separation of a person or group of people, who are reasonably believed to have been exposed to COVID-19 but not yet symptomatic, from others who have not been exposed, to prevent the possible spread. In a quarantine, people are not sick yet, but may have been exposed.

Long term care facilities in Washington have been quarantining residents since early March. This quarantine was implemented due to the significant risks to the older populations, particularly due to their likelihood of comorbidities that lend to their risks of contracting COVID-19. In the current circumstances, it is assumed that all residents in an assisted living facility, whether they be assisted living or independent living, are considered exposed.

Quarantine parameters currently include limiting visitors, monitoring of symptoms for residents, staff, and the few visitors allowed, cancelling group activities, cancelling communal dining, limiting resident access to common areas, and discouraging leaving the facility. Facilities may also ask residents to wear masks, if possible, on the rare occasion they leave their apartments/rooms. All assisted living facilities should have active quarantine efforts in effect for all residents.

ISOLATION is an additional layer to quarantine and is imposed once a resident begins showing symptoms of COVID-19 or tests positive for it. Isolation involves physically separating sick residents from healthy. Isolation may include one or more of the following:
  • Dedicating a group of rooms, a hallway, unit, wing, or floor for symptomatic residents only;
  • Separate rooms for sick residents;
  • Cohorting residents who have similar symptoms or positive test results; and
  • Transferring sick residents to a dedicated COVID-19 building.

Staff caring for these individuals should not also work with healthy residents and should wear full personal protective equipment (PPE) when caring for sick residents.  In order to preserve PPE, impose a “universal worker” role where one health care professional provides multiple services while in the resident’s apartment (medication delivery, activities of daily living, meal delivery, linen changes, tidying up, etc.). Dedicated equipment should remain within the confines of the isolation area and not be used for healthy residents. Finally, residents in isolation should not leave their rooms.
DEPARTMENT OF HEALTH TO HOST STAKEHOLDER Q&A ON APRIL 23
On Thursday, April 23, the Department of Health will host a webinar at 11:00 a.m. The purpose of the webinar is to update long term care providers on the actions they have taken in response to COVID-19 and to answer questions. If you wish to join the webinar, advanced registration is required. 
LANE POWELL WILL HOST WEBINAR REGARDING CARES ACT THIS THURSDAY
On Thursday, April 23, at 2:00 p.m. PST, Lane Powell will host a webinar titled, The CARES Act and Other Financial Relief Programs for Senior Living and Care Providers. You are invited to join the webinar to learn more about the CARES Act and how it impacts senior living and care providers. Register here .
WASHINGTON SOCIETY FOR POST-ACUTE AND LONG TERM CARE MEDICINE AND COMAGINE TO HOST WEBINAR
You are invited to join a webinar to be hosted by the WA-PALTC and CoMagine titled, The SNF COVID-19 Unit—First Experiences: What have we learned? The webinar will be held on Wednesday, April 22, 2020, at 6 PM PST. Dr. Arif Nazir, CMS Signature Healthcare and Immediate Past President AMDA, Dr. Swati Gaur, Chair of Infection Control Committee AMDA, and Dr. Sabine Von Preyss-Freidman, WA-PALTC President will co-present. Register in advance.
CMS COVID-19 STAKEHOLDER ENGAGEMENT CALLS FOR WEEK OF APRIL 20
CMS hosts varied recurring stakeholder engagement sessions to share information related to the agency’s response to COVID-19. These sessions are open to healthcare providers and are intended to provide updates, share best practices among peers, and offer attendees an opportunity to ask questions of CMS and other subject matter experts. Below is a list of upcoming calls. All calls are recorded, and recordings are posted here .

Conference lines are limited, so it is highly recommended that you join via audio webcast on any device.

Tuesday, April 21 | 12:30 PM | Home Health and Hospice
Dial (833-614-0820 | Passcode 9895252 | Audio Webcast Link

Tuesday, April 21 | 2:00 PM | CMS COVID-19 Office Hours Calls
Dial (833) 614-0820 | Passcode 3963515 | Audio Webcast Link

Wednesday, April 22 | 1:30 PM | Nursing Homes
Dial (833) 614-0820 | Passcode 2672118 | Audio Webcast Link

Wednesday, April 22 | 2:30 PM | Dialysis Organizations
Dial (833) 614-0820 | Passcode 1796168 | Audio Webcast Link

Thursday, April 23 | 12:00 PM | Nurses
Dial (833) 614-0820 | Passcode 6004019 | Audio Webcast Link

Thursday, April 23 | 2:00 PM | CMS COVID-19 Office Hours Calls
Dial (833) 614-0820 | Passcode 5899488 | Audio Webcast Link

Friday, April 24 | 9:30 PM | Lessons from the Front Lines
Dial (877-251-0301 | Passcode 5096006 | Audio Webcast Link
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.