September 18, 2020
On Thursday, September 17, 2020, CMS issued revised guidance regarding visitation in nursing homes during the COVID-19 emergency. The revised guidance is effective immediately. WHCA met with RCS and CMS this morning for additional guidance because portions of the CMS guidance are not consistent with Washington State’s Safe Plan/ Phased Reopening Requirements. RCS and CMS agreed that providers and regulators need additional time to digest the implications of CMS’s revision. Accordingly, because portions of Washington’s phased reopening/visitation plan are more stringent than CMS’s revisions, Washington SNF providers will continue to follow Washington’s phased reopening/visitation plan until RCS is able to provide further guidance. We expect that the additional guidance will be issued sometime next week. Once we receive additional guidance from RCS, providers will then be expected to comply with the revised CMS guidance. WHCA has another meeting scheduled with RCS on the revised visitation guidance next Tuesday afternoon. As we receive additional clarification from RCS, we will provide it to you through our COVID-19 Updates.

The CMS guidance provides a degree of flexibility and states that visitation can be conducted through a variety of means in various locations. Regardless of where and how the visits are conducted, core COVID-19 infection control protocols must be maintained at all times. These "core protocols" are described in detail in the guidance. Visitation should be person-centered, consider the resident’s physical, mental, and psychological well-being, and support their quality of life. A reasonable degree of privacy should be accorded and the use of physical barriers to curb transmission (like plexiglass dividers or curtains) should be considered. Visitors who are unable to adhere to the core principles of COIVID-19 infection prevention should not be permitted to visit or should be asked to leave.

Outdoor visits are preferred, and should be facilitated. But CMS acknowledges that weather, air quality, a resident’s condition, and the facility’s outbreak status can all impact the ability to conduct outdoor visits. When conducting outdoor visits, facilities should have a process to limit the number and size of visits occurring simultaneously and limit the number of individuals visiting at any one time.

Guidelines for indoor visits include:
  • There has been no new onset of COVID-19 cases in the last 14 days and the facility is not currently conducting outbreak testing (note: this is currently inconsistent with Washington Safe Start Guidance of 28 days);
  • Visitors should be able to adhere to the core infection control principles and staff should provide monitoring for those who may have difficulty adhering to core principles, such as children;
  • Facilities should limit the number of visitors per resident at one time and limit the total number of visitors in the facility at one time (based on the size of the building and physical space). Facilities should consider scheduling visits for a specified length of time to help ensure all residents are able to receive visitors; and,
  • Facilities should limit movement in the facility. For example, visitors should not walk around different halls of the facility. Rather, they should go directly to the resident’s room or designated visitation area. Visits for residents who share a room should not be conducted in the resident’s room. 

Facilities will use the COVID-19 county positivity rate found on the COVID-19 Nursing Home Data site as additional information to determine how to facilitate visitation. Facilities in counties with low and medium positivity rates should allow visitation with adherence to infection control protocols and facility policies. Facilities in counties with high positivity rates should limit visitation to compassionate care situations. Attention should also be paid to additional factors like rates of “COVID-19-Like Illness" visits to emergency departments and the positivity rates in other counties. Note that county positivity rates do not need to be considered for outdoor visits.

The CMS memo does note that visitation can still be restricted due to high COVID-19 county positivity rates, a resident’s COVID-19 status, visitor symptoms, lack of adherence to proper infection control practice, and other factors. However, facilities may not restrict visitation without a reasonable clinical or safety cause. If a facility has had no COVID-19 cases in the last 14 days and its county positivity rate is low or medium, a nursing facility must facilitate an in-person visitation consistent with the regulations. Failure to facilitate visitation could result in citations and/or enforcement actions. Residents who are on transmission-based precautions for COVID-19 should only receive visits that are virtual, through windows, or in-person only for compassionate care situations.

In addition to the requirements listed above, the CMS-issued revised guidance also provides updated requirements for a number of other issues. Over the course of the next few days we will be providing you additional information and analysis of the following issue found in the revised guidance:
  • Compassionate Care Visits
  • Visitor Testing
  • Ombudsman Access
  • Entry by Disability Rights Groups and Protection and Advocacy Programs
  • Entry of Health Care Workers and other Service providers
  • Communal Activities
  • Communal Dining
  • Survey Considerations
  • Use of additional CMP Funds to Aid in Visitation

We encourage all impacted providers to carefully review the CMS-issued revised guidance. As additional information is made available, we will continue to keep you informed. If you have questions please email Robin Dale or Elena Madrid.
The Department has informed us the COVID Medicaid rate add-ons for assisted living and skilled nursing have been authorized to continue through the end of the year. These fourth quarter add-ons will be $7.50 PPD for skilled nursing facilities and $4.79 PPD for assisted living facilities. These add-ons should be reflected in the October 1, 2020, rate. Currently, we have received no information as to whether the add-ons will continue after the first of the year. 
On Monday, be sure to check positivity rates and test as required in skilled nursing.
Monday, September 21, is the third Monday of the month. While positivity rates may be updated before Monday, in an exercise of caution, WHCA is urging providers to check county positivity rates on Monday and ensure you are testing according to the frequency outlined in the Routine Testing table. As outlined in CMS QSO 20-38, skilled nursing facilities are required to test all staff at the frequency prescribed in the Routine Testing table (below) based on the county positivity rate reported in the past week. Facilities should monitor their county positivity rate every other week (e.g., first and third Monday of every month) and adjust the frequency of performing staff testing according to the Routine Testing table.
  • If the county positivity rate increases to a higher level of activity, the facility should begin testing staff at the frequency shown in the table above as soon as the criteria for the higher activity are met.
  • If the county positivity rate decreases to a lower level of activity, the facility should continue testing staff at the higher frequency level until the county positivity rate has remained at the lower activity level for at least two weeks before reducing testing frequency.

The guidance above represents the minimum testing expected. Facilities may consider other factors, such as the positivity rate in an adjacent (i.e., neighboring) county to test at a frequency that is higher than required. For example, if a facility in a county with a low positivity rate has many staff that live in a county with a medium positivity rate, the facility should consider testing based on the higher positivity rate (in the scenario described, weekly staff testing would be indicated). If you have questions or would like additional information, please email Elena Madrid or call her at (800) 562-6170, extension 105.
The Department of Health and Human Services (HHS) released additional information on how $2 billion in incentive payments will be distributed to nursing homes under the CARES Act. Here is a summary of those details.
Starting last week, we heard concerning reports of differences between the antigen tests and PCR confirmation test results (e.g., potential false positives) from the antigen testing machines HHS has sent to nursing homes. To better understand what is going on across the country, AHCA and LeadingAge collaborated on a survey to understand the use of BD Veritor and Quidel Sofia-2 Antigen Point of Care analyzers in member communities. Read more.
On Friday, September 11, the US Department of Labor (DOL) issued an update to the temporary rule they issued in April regarding coronavirus leave. This update changes the definition of health care workers. Employees defined as health care workers are not required to have paid sick leave and extended family and medical leave under the Act. Other employees of providers are required to have paid sick leave and expanded family and medical leave. Read more
To allow healthcare professionals the ability to focus on patient care during the COVID-19 outbreak, the Secretary of Health extended expiration dates for licenses up for renewal between April 1, 2020, and September 30, 2020. All late fees were waived during this period.

What does this mean for you?
If you took advantage of this extension, you will not be able to renew online and you must submit your renewal fee by mail.

What is the deadline to submit?
To avoid late fees and expired status, you must postmark your renewal fee no later than September 30, 2020. If your renewal fee is postmarked after September 30, 2020, your license will go into expired status and you will need to pay a late fee. Your license will remain in expired status until all applicable fees are received and processed. Please allow 10 business days for your renewal to be processed.

Attention Nurses who need to renew license by September 30!
If you chose to delay your payment for your license, your license will be effective through September 30. In order to be actively licensed by October 1, you must send the check for your renewal NO LATER THAN TUESDAY, SEPTEMBER 22, to the address below.

You cannot pay or renew your license on line after your birthday–you must send a check. RN renewal is $120. LPN renewal is $85. ARNP renewal fee is $125. Make your check payable to Department of Health.

Mail applicable renewal fees to:
Department of Health
PO Box 1099
Olympia, WA 98507-1099
Frontline Impact Project matches healthcare workers and first responders with donated non-PPE resources, including snacks, meals, beverages, and personal care items. Created by The KIND Foundation, the project has become a primary way for the business community to support the heroes keeping America’s communities healthy. Assisted living and skilled nursing facilities are eligible to receive donations. Read more.
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.