As part of President Trump’s Guidelines for Opening Up America Again, the Centers for Medicare and Medicaid Services (CMS) announced new nursing home reopening recommendations for state and local officials. These recommendations detail criteria for relaxing certain restrictions and mitigating the risk of resurgence, visitation and service considerations, and restoration of survey activities.
The guidance encourages state leaders to collaborate with the state survey agency and state and local health departments to decide how these criteria or actions should be implemented in their state and provides examples of how a State may choose to implement the recommendations, which includes options of states to require that all facilities go through each phase at the same time, allowing facilities in a certain region within the state to enter each phase at the same time, or permitting individual facilities to move through each phase based on their status for meeting the criteria for each phase.
Given the critical importance in limiting COVID-19 exposure in nursing homes, CMS recommends that decisions on relaxing restrictions be made with careful review of the following facility-level, community, and state factors:
- Case status in the community: State-based criteria to determine the level of community transmission and guides progression from one phase to another. For example, a decline in the number of new cases, hospitalizations, or deaths (with exceptions for temporary outliers).
- Case status in the nursing home(s): Absence of any new nursing home onset of COVID-19 cases (resident or staff), such as a resident acquiring COVID-19 in the nursing home.
- Adequate staffing: No staffing shortages and the facility is not under a contingency staffing plan.
- Access to adequate testing: The facility should have a testing plan in place based on contingencies informed by the Centers for Disease Control and Prevention (CDC). At minimum, the plan should consider the following components:
- The capacity for all nursing home residents to receive a single baseline COVID-19 test. Similarly, the capacity for all residents to be tested upon identification of an individual with symptoms consistent with COVID-19, or if a staff member tests positive for COVID-19. Capacity for continuance of weekly re-testing of all nursing home residents until all residents test negative;
- The capacity for all nursing home staff (including volunteers and vendors who are in the facility on a weekly basis) to receive a single baseline COVID-19 test, with re-testing of all staff continuing every week (note: State and local leaders may adjust the requirement for weekly testing of staff based on data about the circulation of the virus in their community);
- Written screening protocols for all staff (each shift), each resident (daily), and all persons entering the facility, including vendors, volunteers, and visitors;
- An arrangement with laboratories to process tests. The test used should be able to detect SARS-Cov-2 virus (e.g., polymerase chain reaction (PCR)) with greater than 95% sensitivity, greater than 90% specificity, with results obtained rapidly (e.g., within 48 hours). Antibody test results should not be used to diagnose someone with active SARS-Cov-2 infection.
- A procedure for addressing residents or staff that decline or are unable to be tested (e.g., symptomatic resident refusing testing in a facility with positive COVID-19 cases should be treated as positive).
- Universal source control: Residents and visitors wear a cloth face covering or facemask. If a visitor is unable or unwilling to maintain these precautions (such as young children), consider restricting their ability to enter the facility. All visitors should remain social distancing and perform hand washing or sanitizing upon entry to the facility.
- Access to adequate Personal Protective Equipment (PPE) for staff: Contingency capacity strategy is allowable, such as CDC’s guidance at Strategies to Optimize the Supply of PPE and Equipment. All staff wears all appropriate PE when indicated. Staff wears cloth face covering if facemask is not indicated, such as administrative staff.
- Local hospital capacity: Ability for the local hospital to accept transfers from nursing homes.
- According to CMS, state and local leaders are urged to regularly monitor the factors for reopening and can adjust their plans accordingly, depending on local data about the circulation of the virus in their community.
The guidance includes an attachment that outlines the three phases for reopening that cross-walks to the phases of the plan for Opening Up America Again. The recommendations stress that nursing homes should not advance through any phases of reopening or relax any restrictions until all residents and staff have received a base-line COVID-19 test, and appropriate actions are taken based on the test results and that states should survey those nursing homes who experienced a significant COVID-19 outbreak prior to reopening to ensure the facility is adequately preventing transmission of COVID-19. Nursing homes should spend a minimum of 14 days in each given phase, with no new cases of COVID-19 before advancing to the next phase. In prioritizing when to begin resuming standard recertification surveys, the guidance recommends that priority is given to facilities who had a significant number of COVID-19 positive cases, special focus facilities, and special focus facility candidates, and then facilities that are overdue (>15 months since last standard) with a history of harm level citations related to abuse or neglect, infection control, violations of transfer or discharge requirements, insufficient staffing or competency, or other quality of care issues.