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October 22, 2020

ODA Publishes SNF Testing Details. On a new "Nursing Facilities COVID-19 Testing Program" web page, the Department of Aging (ODA) published materials on the revised SNF testing program that takes effect Monday, October 26. In addition to items carried over from the Health Department's (ODH's) testing page and Tuesday's memo announcing the program changes, ODA posted a detailed set of slides that provide the new testing guidelines.

As previously reported, the heart of the changes is a uniform, weekly testing frequency for all counties except those designated as red by the Centers for Medicare and Medicaid Services (CMS), along with availability of state support for all required tests, which will be a combination of BinaxNOW cards and polymerase chain reaction (PCR) tests. For BinaxNOW, state support means the cards are free. For PCR, state support means the state arranges for and delivers the tests, plus requires laboratories to bill third-party payers, with state reimbursement for self-insured providers. Another change effective this coming Monday is elimination of the Survey Monkey to report SNF testing results. 

ODA also posted a survey for SNFs to opt in or opt out of state support for testing that offers four options: full state support, two kinds of partial state support, and no state support. The deadline for the survey now is November 6 (a change from this afternoon), and the opt-in/out decision will apply to the testing period beginning November 23. The choice to opt in or out is locked in for 30 days. For more information on the meaning of the four options, see the slide deck. For the first month under the new system, all SNFs will receive a supply of BinaxNOW and polymerase chain reaction (PCR) test kits, enough to cover their routine testing plus any possible outbreak testing needs. Please reach out to OHCA with any questions about the new structure.

HHS Makes Reporting POC Test Data to NHSN Mandatory for SNFs. In a revision to their June 4, 2020, COVID-19 laboratory test reporting memo, the Department of Health and Human Services (HHS) required SNFs to report line-level, point-of-care antigen test results to the National Healthcare Safety Network (NHSN). This decree removes reporting to ODH as an option. HHS wrote:

CMS-certified long-term care facilities shall submit point-of-care SARS-CoV-2 testing data, including antigen testing data, to CDC’s National Healthcare Safety Network (NHSN). This requirement to submit data to CDC’s NHSN applies only to CMS-certified long-term care facilities. Test data submitted to NHSN will be reported to appropriate state and local health departments using standard electronic laboratory messages. Other types of LTC facilities may voluntarily report testing data in NHSN for self-tracking or to fulfill state or local reporting requirements, if any.

NHSN's pathway for POC test reporting is not yet available (training scheduled for today and tomorrow was canceled) and requires Secure Access Management Service (SAMS) Level 3 access. See this page for instructions on how to increase your access level. According to data supplied by AHCA, 389 Ohio SNFs have not applied for SAMS Level 3.

The ODH reporting process will continue to apply to assisted living communities using antigen testing, unless they voluntarily chose to report to NHSN.

HHS Liberalizes PRF Reporting/Use-of-Funds Requirements. HHS today revised its Coronavirus Aid, Relief, and Economic Security (CARES) Act Provider Relief Fund (PRF) reporting requirements originally issued on September 19. The most significant change is to allow providers to use PRF money to offset the full amount of lost revenues from 2019 to 2020, even if it results in the provider being more profitable in 2020 than in 2019. HHS wrote in an explanatory memo:

This decision to prohibit most providers from using PRF payments to become more profitable than they were pre-pandemic, in order to conserve resources to allocate to providers who were less profitable, has generated significant attention and opposition from many stakeholders and Members of Congress. There is consensus among stakeholders and Members of Congress who have reached out to HHS that the PRF should allow a provider to apply PRF payments against all lost revenues without limitation.

In consideration of this feedback, HHS has amended its reporting instructions to provide for the full applicability PRF distributions to lost revenues.

Another change in the guidance is to allow consolidated reporting by a parent organization with subsidiaries that received PRF payments.

EMS and Mandatory Testing. While OHCA awaits further interpretive guidance from ODH and CMS on Quality, Safety, and Oversight letters (QSOs) 20-38-NH and 20-39-NH, we attempt to the best of our ability to interpret CMS's direction, including how to deal with non-emergency transportation providers who remain challenged with complying with CMS's testing mandate. One of our interpretations was that transferring residents “at the door” so emergency medical services (EMS) personnel would not need to enter the building obviated the need to be tested. 

OHCA spoke today with the EMS Board, which expressed concerns about this interpretation because of perceived increased liability should the resident be injured, particularly with a stretcher transfer. When asked why EMS personnel are unwilling to comply with the CMS testing mandate, the EMS Board representative pointed to fear of a false positive and losing a worker for up to 14 days. They felt, however, that if the SNF immediately administers a PCR test, collects the EMS worker's insurance information (this is a diagnostic test and would be covered), and ships the test to their lab for quick processing, it potentially could help make EMS personnel more comfortable with complying. Pending further guidance from CMS, please be aware that the EMS Board is telling transport providers to work with their facility partners to determine the best way to comply.

An Explosion of Red. As usual on Thursday, the state refreshed the Ohio Public Health Advisory System (OPHAS) color-coded map. Thirty-five of Ohio's 88 counties are red, including all of the major metropolitan counties, and only 4 remain yellow. The state once again set a record for the daily number of COVID-19 cases. OHCA did not update our combined CMS/OPHAS table because Ohio moved away from the mismatch county concept with the new testing cadence discussed above.

The OPHAS color scheme also is irrelevant for SNF visitation because under QSO 20-39, it is red status (positivity) under the CMS system that matters, not red status under OPHAS. OPHAS does remain significant for assisted living and ICFs/IID, both of which can consider county prevalence under their respective state visitation orders. 

CDC Changes Definition of Close Contact. In revised guidelines, the Centers for Disease Control and Prevention (CDC) changed the definition of close contact with a person with COVID-19 from 15 minutes within six feet to 15 minutes within six feet over a 24-hour period. CDC explained:

Someone who was within 6 feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period* starting from 2 days before illness onset (or, for asymptomatic patients, 2 days prior to test specimen collection) until the time the patient is isolated.

* Individual exposures added together over a 24-hour period (e.g., three 5-minute exposures for a total of 15 minutes). Data are limited, making it difficult to precisely define “close contact;” however, 15 cumulative minutes of exposure at a distance of 6 feet or less can be used as an operational definition for contact investigation. Factors to consider when defining close contact include proximity (closer distance likely increases exposure risk), the duration of exposure (longer exposure time likely increases exposure risk), whether the infected individual has symptoms (the period around onset of symptoms is associated with the highest levels of viral shedding), if the infected person was likely to generate respiratory aerosols (e.g., was coughing, singing, shouting), and other environmental factors (crowding, adequacy of ventilation, whether exposure was indoors or outdoors). Because the general public has not received training on proper selection and use of respiratory PPE, such as an N95, the determination of close contact should generally be made irrespective of whether the contact was wearing respiratory PPE. At this time, differential determination of close contact for those using fabric face coverings is not recommended.

It should be noted that CDC published this definition for contact tracing in the general public and left the 15-minute standard in the definition of close and prolonged contact in the guidelines for healthcare personnel. The healthcare guidance also takes personal protective equipment use into consideration. We will inquire of ODH which standard they intend to apply on survey.