On March 9, 2020, the Quality, Safety & Oversight Group at the Centers for Medicare & Medicaid Services (“CMS”) issued a memorandum entitled “Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (“COVID-19”) in nursing homes (REVISED)” (“QSO Memo”) that announced recommendations for skilled nursing facilities (“SNFs”) regarding restricting visitors, addressing monitoring staff health, transfers to hospitals and accepting a resident diagnosed with COVID-19.

Prompt Detection, Triage and Isolation

The QSO Memo directs that SNFs should contact their local health department if they have questions or suspect a resident of a SNF has COVID-19. CMS identifies prompt detection, triage and isolation of potentially infectious residents as essential actions to prevent unnecessary exposures among residents, health care personnel and visitors at the SNF. The QSO Memo directs that SNFs must frequently monitor for residents, staff and visitors for potential symptoms of respiratory infection as needed throughout the day. CMS also encourages SNFs to take advantage of CDC resources that have been made available by the CDC and CMS to train and prepare staff to improve infection control and prevention practices.

Visitor Restrictions

The QSO Memo instructs that SNFs should actively screen and restrict visitation by individuals who meet the following criteria:

  • International travel within the last 14 days to countries with sustained community transmission (See the CDC’s list of affected countries);
  • Signs or symptoms of a respiratory infection, such as a fever, cough and sore throat;
  • In the past 14 days has had contact with someone with a confirmed COVID-19 diagnosis, under investigation for COVID-19 or have a respiratory illness; or
  • Reside in a SNF or other community where community-based spreading of COVID-19 is occurring.

For those individuals that do not meet the above criteria, SNFs can allow entry but may require visitors to use personal protective equipment.

The QSO Memo offers eight recommendations regarding restricting visitors to prevent the spread of COVID-19:

  1. Limiting visitors if the SNF is in a county affected by COVID-19 and discouraging visitors if the SNF is in a county that has not been affected by COVID-19.
  2. SNF should increase visible signage at entrances/exist, offer temperature checks, increase availability to hand sanitizer and offer personal protective equipment for individuals entering the SNF.
  3. SNFs should ask visitors if they took any recent trips (within the last 14 days) on cruise ships or participated in other settings where crowds are confined to a common location.
  4. When SNF allows visitors, the SNF should instruct visitors to limit their movement within the SNF to the resident’s room.
  5. SNFs should review and revise how they interact with volunteers, vendors and receiving supplies, agency staff, EMS personnel and equipment, transportation providers and practitioners, and take necessary actions to prevent any potential transmission.
  6. Offer alternative means of communication for people who would otherwise visit, such as virtual communications (phone, video-communication, etc.).
  7. When visitation is necessary or allowable, SNFs should make efforts to allow for safe visitation for residents and loved ones, including suggesting limited physical contact with residents and others while in the SNF.
  8. Advise visitors who have had contact with a COVID-19 resident prior to admission to monitor for signs and symptoms of respiratory infection for at least 14 days after last known exposure and if ill to self-isolate at home and contact their health care provider.

The QSO Memo reminds SNFs that 42 CFR §483.10(f)(4) and Appendix PP of the State Operations Manual provide that a SNF may need to restrict or limit visitation rights for reasonable clinical and safety reasons to prevent community-associated infection or communicable disease transmission to the resident. CMS also reminds SNFs that visitors with signs and symptoms of a transmissible infection should defer visitation until he or she is no longer potentially infectious.

Staff

The QSO Memo instructs that SNFs should screen staff for the following:

  • International travel within the last 14 days to countries with sustained community transmission (See the CDC’s list of affected countries);
  • Signs or symptoms of a respiratory infection, such as a fever, cough and sore throat;
  • In the past 14 days has had contact with someone with a confirmed COVID-19 diagnosis, under investigation for COVID-19 or have a respiratory illness; or
  • Reside in a SNF or other community where community-based spreading of COVID-19 is occurring.

CMS directs that:

  • Health care providers who have signs and symptoms of a respiratory infection should not report to work.
  • Any staff that develops signs and symptoms of a respiratory infection while on-the-job, should:
    • Immediately stop work, put on a facemask and self-isolate at home;
    • Inform the SNF’s infection preventionist and include information on individuals, equipment and locations the person came in contact with; and
    • Contact and follow the local health department recommendations for next steps (e.g., testing, locations for treatment, etc.).

The QSO directs SNFs to the CDC guidance for exposures that might warrant restricting staff from reporting to work.

Transfers of Infected Residents to Hospital

The QSO Memo calls for SNFs to contact their local health department if the SNF suspects it has a resident with the COVID-19 infection.

During any initial mild symptom period, CMS provides that the SNFs may keep the resident at the facility rather than transfer the resident to a hospital as long as the SNF can follow the infection prevention and control practices recommended by CDC. SNFs that do not have an airborne infection isolation room are not required to transfer the resident assuming:

  • Resident does not require a higher level of care; and
  • SNF can adhere to the rest of the infection prevention and control practices recommended for caring for a resident with COVID-19.

If a resident develops more severe symptoms and requires transfer to a hospital for a higher level of care, the SNF is required to take certain steps. Prior to transfer, emergency medical services and the receiving provider should be alerted to the resident’s diagnosis, and precautions to be taken including placing a facemask on the resident during transfer. If the resident does not require hospitalization the resident can be discharged home, after consultation with state or local public health authorities, if deemed medically appropriate. Pending transfer or discharge, the SNF shall place a facemask on the resident and isolate the resident in a room with the door closed.

Accepting a Resident Diagnosed with COVID-19 from a Hospital

The QSO Memo provides that a SNF can accept an individual diagnosed with COVID-19 from a hospital and still under transmission-based precautions for COVID-19 provided that the SNF follows CDC guidance for transmission-based precautions. If the SNF cannot follow CDC guidance for transmission-based precautions, the SNF must wait until these precautions are discontinued.

The QSO Memo states that SNFs should admit any individuals that they would normally admit to the SNF, including individuals from hospitals where a case of COVID-19 was/is present. CMS directs that, if possible, the SNF should dedicate a unit/wing exclusively for any residents coming or returning from such hospitals.

Citations for Lack of Supplies

The QSO Memo directs that state and federal surveyors should not cite SNFs for not having certain supplies, including personal protective equipment, respirators and surgical masks if the SNF is experiencing difficulty in obtaining these supplies for reasons outside of their control. CMS expects a SNF to take action to mitigate any resource shortages and show it is taking all appropriate steps to obtain the necessary supplies as soon as possible. If a surveyor believes a facility should be cited for not having or providing the necessary supplies, the state agency should contact the CMS Branch Office.

Additional Recommended Actions

The QSO Memo recommends that:

  • SNFs review CDC guidance for Infection Prevention and Control Recommendations for Patients with Confirmed Coronavirus Disease 2019.
  • Increase the availability and accessibility of alcohol-based hand sanitizer, hand-hygiene practices, tissues, no-touch receptacles for disposal and facemasks at SNF entrances, waiting rooms, resident check-ins, etc. Ensure alcohol-based hand sanitizer is accessible in all resident-care areas including inside and outside resident rooms.
  • Add signs promoting infection prevention, such as hand hygiene and cough etiquette.
  • Properly clean, disinfect and limit the sharing of medical equipment between residents and areas of the SNF.
  • Provide additional work supplies to avoid sharing (e.g., pens, pads, etc.) and disinfect workplace areas (e.g., nurse’s stations, phones, internal radios, etc.).

Next Actions: Policy and Practice Reviews Needed

  • SNFs should carefully review and revise their visitor, admissions and discharge/transfer policies and practices to incorporate these recommendations.
  • SNFs should communicate these policies and procedures to residents, staff, vendors and families.
  • With the heightened scrutiny of the infection control measures, SNFs may see surveyors cite deficiencies at a higher scope and severity for not following proper infection control techniques.