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November 25, 2020

More Purple Counties. The latest version of the Ohio Public Health Advisory System map, released today, shows that the state now has four purple counties, as Lake, Lorain, and Montgomery joined Franklin County, a holdover from last week. Only nine counties remain orange; the rest are red. The state again tallied over 10,000 new COVID-19 cases, with many other test results untabulated. The 156 recorded COVID-19 deaths blew away the previous single-day record of 98. The 417 new hospitalizations and 44 new intensive care unit (ICU) admissions eclipsed the three-week trend. A total of 4,541 COVID-19 patients are hospitalized currently, with 1,077 in the ICU and 615 on ventilators. Today also saw the release of new state long-term care case and mortality data that show the impact of many facility outbreaks. A total of 6,005 new cases were reported in the past week, a jump of more than 1,000 from last week, with 3,439 cases among residents. Mortality also spiked, with 185 reported deaths compared to 89 last week.

NHSN Training Repeated. As we reported in yesterday's COVID-19 Update, the National Healthcare Safety Network (NHSN) will repeat their "Office Hours: Review November Changes to LTCF COVID-19 Module Pathways: Resident Impact and Facility Capacity and Staff and Personnel Impact" webinar
next week. The webinars will be offered on Monday, November 30, and Thursday, December 3. The Monday webinar will be from 12:30 to 1:15 p.m., but in a change from the previous announcement, the Thursday session moved to 1:30 to 2:15 p.m. NHSN notes that the webinars are the same, so users should plan to attend only one. Here is the registration link for both sessions - you can choose which one you wish to attend.

DODD Adult Day Services. Today, the Department of Developmental Disabilities (DODD) released an announcement regarding adult day and vocational habilitation services beginning January 1, 2021. As anticipated, the announcement indicates these services will be paid at the acuity B rates for those individuals within acuity groups A and B and at the acuity C rate for those who are assigned to acuity C group. Also as anticipated, missing from the announcement is any adjustment to the Department of Health order limiting day services to groups of 10 or less. The announcement states:

Given the higher rate of COVID-19 transmission and the likelihood of complications for people with developmental disabilities, DODD is asking teams to work closely with people with developmental disabilities and their families to determine the safest way to deliver adult day or employment services. Through the person-centered team process, the team should consider, at any time in the process, alternative ADS, VH, or ICF Day Program options, including virtual or in-home services, as facility-based services may not be the wish of every person or the desire of every team. 

In addition, OHCA learned of at least one county (Trumbull) where the local health department issued a public health advisory that specifically advises in-person adult day programs for people with developmental disabilities to close for the duration of the advisory. While providers of adult day services for people with developmental disabilities may want to begin preparing for similar advisories from other counties, OHCA reminds members that public health advisories are different than public health orders and are not mandatory.

Anthem Commercial Suspends Prior Authorization Requirements for SNF Admissions. Today, Anthem of Ohio issued a notice suspending authorization requirements for SNF admissions for Anthem commercial health plans. The same notification does not appear on the Medicare Advantage notice page. The notice states:

Prior authorization requirements are suspended for patient transfers from acute IP hospitals to skilled nursing facilities effective November 23 through December 31, 2020. These adjustments apply for our fully-insured and self-funded employer and individual plan members receiving care from in-network providers. While prior authorization is not required, we continue to require notification of the admission via the usual channels and clinical records on day two of admission to aid in our members’ care coordination and management. Anthem reserves the right to audit patient transfers.

State Expands Friendly Caller Program to Facility Residents. For some time, Ohio's Area Agencies on Aging (AAAs) have offered a friendly caller program to reach out to shut-in seniors. Yesterday, the Department of Medicaid (ODM) announced that they are working with the AAAs and the Medicaid managed care organizations to provide a similar program for residents of SNFs and assisted living communities. With the recent proliferation of red counties and facility outbreaks, family visits have been curtailed severely, so this initiative could benefit some residents. According to the ODM release:

ODM and managed care volunteer participants trained by AAAs on “friendly caller” techniques provide companionship and support through scheduled, informal conversations. Residents interested in the initiative are linked through the AAAs with trained callers to share their thoughts, feelings, and memories, or converse on any topics of interest during twice-weekly, 30-minute phone chats. Additionally, callers trained on the UCLA Loneliness Scale the leading scientific measure in evaluating loneliness include three questions from the assessment tool to identify residents who may need additional interventions.

ODM has not explained to us how individuals will be selected for the program or what facility staff need to do to facilitate this potentially beneficial interaction.

Left-Over Questions from Tuesday's SNF Member Call. As usual, there were a few questions in the chat box at the end of our 90-minute SNF member call. The following is a selection of them.

Q. With the BD machine - are people still taking pictures of the results, or are we allowed to document the result since we are just documenting the result of the BINAX cards?

A. A member responded, "we are not taking pictures of the BD. We are using a documented sheet with lot number, etc." In our view, this approach is an appropriate way of recording BD Veritor test results because the machine does not produce an adequate report to document this testing, as also is the case with BinaxNOW tests.

Q. Has there been any pushback to ODH on the length of some of these surveys? We have surveys going over 2 weeks, where the surveyors are starting surveys in multiple buildings without finishing other surveys. This is obviously extending the survey cycles. This was never their prior practice and I would think we could challenge ODH on this practice now.

A. Yes, OHCA has questioned the length of the surveys. ODH's response was that CMS requires them to investigate all complaints lodged during the period when ODH was not doing surveys and to conduct Focused Infection Control surveys according to CMS direction. This has resulted in long surveys. We are in the process of raising with ODH some of the other excesses such as open cycles and surveyors conducting multiple surveys simultaneously.

Q. What is the reporting requirement to families for ALFs that are attached to NFs? Do the same rules for NFs still apply (notify by 5 PM the following day)?

A. No, that requirement is prescribed by CMS and applies only to SNFs. It does not apply to assisted living. Under the state family notification order, only the first positive case must be reported to families and residents, but we recommend reporting all cases for purposes of transparency and maintaining trust.

Resident Quarantine in Case of Outbreak. Also on the SNF call, we discussed quarantining residents when there is an outbreak in the facility. Here is a provision from a Centers for Disease Control and Prevention (CDC) guideline that addresses this topic relative to COVID-19-positive staff:

  • Determine which residents received direct care from and which HCP had unprotected exposure to HCP who worked with symptoms consistent with COVID-19 or in the 48 hours prior to symptom onset.
  • Residents who were cared for by these HCP should be restricted to their room and be cared for using all recommended COVID-19 PPE until results of HCP COVID-19 testing are known. If the HCP is diagnosed with COVID-19, residents should be cared for using all recommended COVID-19 PPE until 14 days after last exposure and prioritized for testing if they develop symptoms.
  • Exposed HCP should be assessed for risk and need for work exclusion.
  • If testing is available, asymptomatic residents and HCP who were exposed to HCP with COVID-19 should be considered for testing .... If testing identifies infections among additional HCP, further evaluation for infections among residents and HCP exposed to those individuals should be performed as described above.
Likewise, the same CDC guideline recommends actions when there is a positive resident:
  • Maintain all interventions while assessing for new clinical cases (symptomatic residents):
  • Maintain Transmission-Based Precautions for all residents on the unit at least until there are no additional clinical cases for 14 days after implementation of all recommended interventions.
  • If testing is available, asymptomatic residents and HCP who were exposed to the resident with COVID-19 (e.g., on the same unit) should be considered for testing
  • The incubation period for COVID-19 can be up to 14 days and the identification of a new case within a week to 10 days of starting the interventions does not necessarily represent a failure of the interventions implemented to control transmission.