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October 7, 2020

CDC Testing FAQ. The Centers for Disease Control and Prevention (CDC) added a section on SNF testing to their clinical frequently-asked questions document (FAQ) on COVID-19. The FAQ is well worth reviewing, as it addresses key issues such as false positive antigen test results, outbreak testing, testing past-positive individuals, and staff who refuse to test. There do not appear to be any significant policy changes from the material scattered across other guidelines, but the FAQ compiles these key questions in one place.

EIDC Notice on Reporting Test Results. Rebecca Sandholdt of the Department of Health (ODH) told us yesterday that some providers sent individual employees' test results to her email and others at ODH. There is no requirement today to report individual test results to ODH, and it is a violation to do so via non-secure email to an inappropriate recipient. In the near future, line-level (individual) reporting of antigen test results will be required, but it will be done in a secure manner specified by ODH. ODH sent an Enhanced Information Dissemination and Collection System (EIDC) notice on this topic:

Please STOP  sending line level testing data to the following individuals:




 or any other individual. We should not receive individual test results for any individual working or residing with in a long-term care facility.

Quarantine in Assisted Living. We reported previously that the ODH Bureau of Infectious Disease (BID) forwarded CDC's response to a question about quarantining assisted living residents who go out to the community (known as the "Walmart greeter question"). CDC's response suggested that guidelines targeted specifically to SNFs or other settings are not mandatory for assisted living, but may be informative: "Although these guidance documents were created specifically for nursing homes, the content might also be informative for ALFs."

We subsequently asked BID to confirm that this principle applies to the the provision in CDC's "Preparing for COVID-19 in Nursing Homes" that requires quarantining new SNF admissions and readmissions - in other words, it is informative but not mandatory for assisted living. BID saw this as a regulatory question and forwarded it to the ODH survey arm, where Jill Shonk wrote, "[m]any infection control guidelines are not in rule, regulation, or orders (both COVID and non COVID related). Facilities are required to establish and implement infection control policies and procedures to prevent the development and transmission of disease. If they are not using CDC guidelines or Health Department guidelines then what are they using? Also are they using CDC guidelines for some of their policies but choosing to ignore CDC guidelines for others?" 

This answer is less than definitive because the question is not whether assisted living communities can choose not to use or to ignore the CDC guidelines for SNFs, but how they should use them. Are they informative, as CDC wrote, or are they mandatory, so a community would be open to citation for a person-centered decision not to quarantine a new admission for 14 days after considering the guidelines and the individual facts and circumstances?

Ms. Shonk's response nonetheless indicates that the ODH survey branch may wish to draw a bright line. We continue to push back on this issue, but want members to be aware of ODH's perspective.

Masks in Offices. On the other hand, Sarah Mitchell of BID provided the following response to a different question:

Your question was, if a facility has a policy that office staff who work alone in offices where a door can be shut and staff are required to knock and wait to enter do not have to wear a mask, would this be allowed? From an infection prevention and control perspective, yes, if an office employee is working alone in an office with a closed door, they can remove their mask, as long as they put it on before allowing others into the office or when exiting their office. I also checked with Survey and Certification to be sure that there isn’t a regulatory concern, and was told that there is not.

CMS Releases Hospice Nursing Shortage Survey Guidance. This week, CMS issued Quality, Safety, and Oversight letter (QSO) QSO-21-01-Hospice relating to nursing shortages as an “extraordinary circumstance” per 42 CFR 418.64 (Core Services). In isolated instances, a hospice agency may find a shortage of nurses temporarily affects its ability to provide nursing services, which in turn may create an access-to-care concern for hospice beneficiaries. Findings from the Bureau of Labor Statistics continue to forecast a shortage of nurses through 2024, with a faster-than-average job growth rate. Section 418.64 allows a hospice to use contract staff, if necessary, to supplement hospice employees in meeting patients' needs under extraordinary or other non-routine circumstances without a waiver or exemption from the Survey Agency (SA) or CMS. QSO 21-01 clarifies that the hospice agency is not required to notify or to submit justification to the SA or CMS when they use contract staff during extraordinary circumstances, as the previous guidance required. When contract services are utilized, the hospice agency maintains all professional, financial, and administrative responsibility for the services.

ODH/Ombudsman Updates. The following are some recent updates of interest.

  • Ms. Sandholdt reported that some SNFs still refuse to allow surveyors to enter unless they furnish negative test results. This is not permitted and can lead to severe consequences. ODH is testing surveyors, but they are not required to carry the results with them.
  • ODH is hiring 21 additional surveyors, who will begin their training at the end of the month.
  • Ombudsmen began doing complaint visits selectively. The state office supplies personal protective equipment for the ombudsmen. They are not tested presently, but the state plans to do so.
  • The Department of Aging postponed the 2020 mail-in family satisfaction survey of SNFs and residential care facilities until spring or summer 2021. They alerted the Department of Medicaid of this decision.
  • Because the Survey Monkey for reporting an outbreak in a SNF and requesting state-supported outbreak testing (after the first round) is not yet available, SNFs with outbreaks should email with the subject line "OUTBREAK TESTING REQUIRED."

Important Points in HHS PRF FAQ; AHCA/NCAL Webinar to Include Phase 3. The Department of Health and Human Services (HHS) published changes to its Provider Relief Fund (PRF) frequently-asked questions (FAQ) to address the Phase 3 General Distribution. AHCA/NCAL's Mike Cheek identified some significant points in the revised FAQ:

  • Support for Providers Missing PRF Funds. Phase 3 is intended to offer funds to providers who: a) have not yet received any PRF funds; or b) have not received 2% of their annual revenue from patient care as part of previous phases of the General Distribution.   

Implications. The FAQs mean providers who:  

  1. Are missing payments from previous allocations as well as providers who began operations in December 2019 or in 2020;  
  1. Received no PRF dollars but who meet the eligibility criteria may submit an application to secure such funds; and  
  1. Have not received 2% of their annual revenue from patient care, may submit requesting an amount up to 2% of their annual revenue from patient care.

  • Methodology/Formula Overview. HHS indicates that the actual percentage paid to providers will be in part dependent upon now many providers apply for Phase 3. HHS approach will vary by provider scenario.   

Implications. HHS described the amount paid as “a percentage of their change in operating revenues from patient care minus their operating expenses. The terms, “operating revenues” and “operating expenses” are defined in the FAQs. In terms of provider scenario payment calculation, if providers have not received 2% of annual revenue from patient care, the providers will submit up-to-date financial information as outlined by HHS, even if similar information has been submitted before, as well as PRF dollars received to-date. HHS will calculate the award based upon this information. If a provider has received no PRF dollars, the provider will submit all needed financial information and request the full 2% of annual revenue from patient care.  

  • Eligibility and Receipt of Other Funding. HHS discussed Medicaid allocations and receipt of FEMA and SBA loans, specifically, the Payroll Protection Plan (PPP) loan program. HHS discusses receipt of these funds in the updated FAQs as in previous statements indicating that health care providers must “substantiate that the PRF payments were used for increased health care related expenses or lost revenue were not reimbursed from other sources or other sources were not obligated to reimburse.”  

Implications. Medicaid allocation recipients are eligible to apply for Phase 3. The FEMA and SBA language is identical to previous HHS statements about treatment of these funds. Additionally, this language links to PRF Reporting Guidance which appears to indicate that PPP funds, and possibly FEMA, must be accounted for when reconciling PRF use.  

  • VBP and Lost Revenue. In the context of stay at home orders, HHS provides guidance on lost revenue and VBP programs. HHS states, “lost revenue estimates should be based on budget-to-actual or year-over-year,  and should include revenue from all sources that can be attributed to COVID-19. This may include value- based payments, such as quality measure achievement payments.” 

Implications.  HHS will need to issue additional guidance on how they Department will apply this policy.  

  • Infection Control May Pay for Current Staff. Payments from the Nursing Home Infection Control Distribution may be used to cover “hiring” expenses related to both recruiting new hires and the continued payment and retention of existing staff to provide patient care or administrative support. 

Implications.  For current staff, providers may use PRF funds for infection control activities.  However, as with all PRF use, providers should develop time and attendance tracking to account for current staff time used for infection control efforts.  

Mr. Cheek said AHCA/NCAL's second webinar on PRF reporting requirements, scheduled for this Friday, October 9, at 3:00 p.m., also will cover Phase 3. A recording of the first webinar is available here.