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March 13, 2020

Recent CMS Guidance for Infection Control in COVID-19 Outbreak

This Bulletin is brought to you by AHLA’s Post-Acute and Long Term Services Practice Group.
  • March 13, 2020
  • Peggy Kozal , Gordon Rees Scully Mansukhani LLP
  • Tessa Carberry , Gordon Rees Scully Mansukhani LLP
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In the last week, the Centers for Medicare & Medicaid Services (CMS) has taken action in addressing the spread of Coronavirus (COVID-19) within nursing home and hospice settings. On March 4, 2020, CMS announced a temporary shift in focus for State Survey Agencies and Accrediting Organizations to prioritize infection control. Additionally, on March 9, 2020, CMS issued revised guidance to providers expanding on how facilities should monitor and restrict visitors. This recent guidance also includes recommendations in response to frequently raised questions, such as: (1) how facilities should screen facility staff; (2) when nursing homes should consider transferring a resident with suspected or confirmed infection to a hospital; and (3) when a nursing home should accept a resident who was diagnosed with COVID-19 from a hospital.

Suspension of Survey Activity

CMS is suspending certain non-emergency state survey inspections to allow inspectors to focus on serious health and safety threats like infectious diseases and abuse. CMS has limited survey activity to the following prioritized order:

  1. Immediate jeopardy complaints and allegations of abuse and neglect.
  2. Complaints alleging infection control concerns, including COVID-19 or other respiratory illnesses.
  3. Statutorily required recertification surveys (Nursing Home, Home Health, Hospice, and ICF/IID facilities).
  4. Re-visits necessary to resolve current enforcement actions.
  5. Initial certifications.
  6. Surveys of facilities that have a history of infection control deficiencies at the immediate jeopardy level in the last three years.
  7. Surveys of facilities that have a history of infection control deficiencies at lower levels than immediate jeopardy.

While the memorandum was directed at inspectors, CMS has committed to supplementing in real-time its memorandum with frequently asked questions for health care facilities.

CMS highlights the importance of triaging presumptive and confirmed cases of COVID-19. An attachment with detailed protocols identifies the steps surveyors will follow when coordinating and investigating facilities with actual or suspected COVID-19 cases.

Revised Guidance Focused on Infection Control Measures

Due to the rapidly changing nature of the outbreak, CMS encourages providers to stay informed with CMS and Centers for Disease Control and Prevention (CDC) updates, as well as those from local public health departments. CMS continues to emphasize a focus on infection control procedures which should already be in place at facilities. Additionally, CMS provides detailed steps and expanded recommendations for certain operational concerns. 

1. Expanded recommendations for limiting visitors:

While public health facilities generally are required by regulations to accept visitors, there are certain exceptions when it comes to the health and safety of patients. CMS has stated facilities should actively screen and restrict visitors who: (1) show symptoms of respiratory infection; (2) have had contact with someone who either has a confirmed or suspected case of COVID-19 or respiratory illness in the last 14 days; (3) traveled internationally within the past 14 days to countries with sustained community transmission; or (4) reside where there is community-based spread of COVID-19.

CMS has categorized restrictions regarding visitors and individuals into three levels: (1) restricting; (2) limiting; and (3) discouraging, based on a number of factors including the location of the facility. Other suggestions include asking about travel generally or attendance at large gatherings, designating certain individuals to care for persons under investigation or confirmed cases, limiting movement of visitors within the facility, and offering other means of communication to visitors and residents including virtual communication.

2.    Monitoring and restricting facility staff:

CMS advises that the same screening for visitors should be performed for facility staff. CMS additionally cites to CDC guidance indicating when asymptomatic health care personnel may warrant a restricted reporting to work.

3.    Transferring a resident with suspected or confirmed infection to a hospital:

For those residents who demonstrate mild symptomology, a hospital transfer may not be required as long as infection prevention and control practices can be effectively followed. If a resident develops more severe symptoms, a hospital transfer may be necessary. Discharges to home may occur if deemed medically and socially appropriate.

4.    Acceptance of a resident diagnosed with COVID-19 from a hospital:

According to the guidance, nursing homes should admit individuals that they would normally admit to their facility, including those transferring from a hospital where COVID-19 was or is present. However, these nursing homes must be able to follow CDC guidance for Transmission-Based Precautions. Also, if possible, a unit or wing should be dedicated for residents coming or returning from the hospital, which serves as a step-down unit for 14 days.

5.    Citations for not having appropriate supplies:

Given the shortage of personal protective equipment (PPE), CMS recommends monitoring the CDC website and coordinating with other suppliers, coalitions, or state and local authorities on the availability of PPE. CMS has advised state and federal surveyors to refrain from citing facilities for not having certain supplies if obtaining such PPE is outside of the facility's control.

MS urges stakeholders to continually monitor federal, state and local resources that are being updated on a continual basis.

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