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September 20, 2020


Aging Posts Additional AL Testing Materials. The Department of Aging (ODA) posted the slides from Friday's webinar on mandatory assisted living staff testing, along with a set of frequently-asked questions (FAQ). As of this morning, the FAQ was taken down from ODA's page, probably because of an error relating to resident testing (see below), but a copy is available here. Most of the policy directions in the FAQ are similar to those in the state's SNF testing program. Here are a few key points:

  • All licensed residential care facilities should complete the state's survey to specify if they wish to opt in or opt out and the number of staff and residents to be tested by tomorrow at 5:00 p.m. ODA plans to complete and to post the testing schedule Tuesday, with testing to start the following Monday, September 28.
  • Residents are to be tested strategically, not en masse. Item 9 on page 3, stating that residents must be tested every two weeks, is erroneous and likely is the reason the FAQ was taken down. Item 10 in the FAQ and slide 18 from the webinar confirm the plan is to test residents strategically.
  • Only staff (meaning employees), not outside contractors or consultants such as home health agencies or hospices providing services to residents, are required to be tested at the two-week frequency. See FAQ, page 2, item 7. ODA strongly recommends, but does not require, anyone coming into an assisted living community to provide services be tested.
  • The state is not paying for testing directly, as was the case with the short-lived saliva testing program. The FAQ contains the following statement: "The State is the payer of last resort for those facilities participating in state-supported testing. While reimbursement from third-party payers will be sought whenever possible, neither the person being tested, nor the facility will be charged for testing." We reminded Director of Aging Ursel McElroy that when a provider is self-insured for health care, the facility and the third-party payer are the same. She agreed that this situation needs to be addressed.

Reminder: Webinar Tomorrow on Reporting Requirements for COVID-19 POC Antigen Testing. This webinar is appropriate not only for SNFs but also for assisted living communities because it applies to the BinaxNOW antigen tests.

At OHCA's request, Bill Storm, ODH Electronic Laboratory Reporting Coordinator, will present a webinar tomorrow, Monday, September 21, from 3:00-4:30 p.m., on the reporting requirements under the Clinical Laboratory Improvement Amendments (CLIA). To participate in this free Microsoft Teams presentation, use this link to log in on Monday. The purpose of the webinar is to explain the reporting requirements that facilities must follow once they start performing COVID-19 testing on the point-of-care (POC) antigen testing devices, including BD Veritor Ag, Quidel Sofia Ag, and Abbott BinaxNOW Ag Card. The agenda will include a brief discussion on case/line-level reporting and aggregate count reporting and a demo on creating the CSV file for electronically submitting POC device results at the line level. There will be a question-and-answer session at the end of the webinar. We highly recommend that everyone who has a POC testing device participates in the webinar to ensure compliance with the CLIA requirements.

Do the New Federal SNF Visitation Guidelines Conflict with the State Order? We do not believe that there is any conflict between the order and Centers for Medicare and Medicaid Services (CMS) Quality, Safety, and Oversight (QSO) letter 20-39-NH. In other words, the QSO does not put facilities into a Catch-22 by prohibiting something that the order requires or vice versa.

  • The state order allows outdoor visitation but not indoor visitation. The QSO generally requires SNFs to offer visitation of some kind but does not require it to be indoor. Outdoor visitation as specified in the order meets the requirement. While the state order does not mandate facilities offer outdoor visitation, it obviously does not prohibit it.
  • The state order does not require centers to allow visitation at all, so the QSO's exception to the CMS visitation requirement for buildings in red counties per the federal system or with COVID-19 cases in the last 14 days does not conflict. The order authorizes SNFs to ban visitation for these reasons.
  • The QSO's definition of essential workers who must be allowed to enter a SNF is more specific than the similar provision on essential workers in the state order, but there are no personnel that the QSO permits to enter who the state order prohibits. 
  • The federal guidelines have a more extensive definition of compassionate visits than the state order, which is limited to end-of-life situations. On this point, however, the federal guidelines are not mandatory, but provide a recommendation. This recommendation is not new (see QSO 20-28-NH, page 4, item 4). Ohio currently maintains a more restrictive definition.

HHS Issues PRF Reporting Guidance. After delaying for a month, the Department of Health and Human Services (HHS) released guidance on reporting COVID-19-related expenses and lost revenue as required under the Provider Relief Fund (PRF). The guidance applies to all HHS PRF awards that OHCA members received except for the SNF Infection Control Targeted Distribution. It also does not apply to state Coronavirus Relief Fund payments. The guidance works in conjunction with the July 20 HHS announcement listing the reporting timeframes. Given the delay in their issuance, the new guidelines are somewhat underwhelming at only 6 pages, leaving some areas that still lack clarity. A couple of key points to note:

  • Providers with unused PRF money at the end of 2020 may continue to use it in the first six months of 2021.
  • HHS defines lost revenue as year-over-year changes in revenue net of expenses.
  • Providers who received less than $500,000 in PRF payments (at the Tax/Employer Identification Number level) have a significantly lower reporting burden. Providers who received less than $10,000 do not have to report at all.
Transportation Personnel and SNF Testing Requirements. We hear from numerous members, as well as transportation companies, that these providers refuse to have their employees tested for COVID-19 and think the testing requirements in QSO 20-38 do not apply to them. With the current state of federal guidance, we believe this opinion is erroneous and transportation personnel coming into SNFs (other than in an emergency situation) must meet the QSO's testing requirements. We realize that this requirement creates a variety of challenges, but that does not make it disappear. Failure to comply could lead to survey sanctions on the facility, which ultimately is responsible for meeting the testing requirements.

Some of the confusion apparently arises from QSO 20-39, which includes the following paragraph:

Health care workers who are not employees of the facility but provide direct care to the facility’s residents, such as hospice workers, Emergency Medical Services (EMS) personnel, dialysis technicians, laboratory technicians, radiology technicians, social workers, clergy etc., must be permitted to come into the facility as long as they are not subject to a work exclusion due to an exposure to COVID-19 or show signs or symptoms of COVID-19 after being screened. We note that EMS personnel do not need to be screened so they can attend to an emergency without delay. We remind facilities that all staff, including individuals providing services under arrangement as well as volunteers, should adhere to the core principles of COVID-19 infection prevention and must comply with COVID-19 testing requirements.

This provision requires SNFs to permit entry of emergency medical services personnel and does not require screening when they are responding to an emergency, but that exception does not apply to routine transports. Moreover, the QSO requires transport personnel to comply with COVID-19 testing requirements. The link takes one to QSO 20-38.

QSO 20-38 defines facility staff who must be tested regularly and in response to an outbreak very broadly: "'Facility staff' includes employees, consultants, contractors, volunteers, and caregivers who provide care and services to residents on behalf of the facility, and students in the facility’s nurse aide training programs or from affiliated academic institutions." The key wording here is "contractors ... who provide care and services to residents on behalf of the facility ...." It is hard to argue that personnel of a company contracted with the facility who provide transportation services to residents do not meet this definition. As a result, they are considered facility staff who must meet the testing requirements. It is possible that in the future, CMS may narrow the definition of facility staff, but we cannot ignore the existing definition simply because we don't like it.

So what options does a SNF have when the transportation company refuses to test employees? First, explain the federal requirements to company management. OHCA may be able to help here. If that does not work, here are the only options we see:

  • Find another transportation company that will test employees in accordance with the CMS requirements.
  • Test these workers yourself when they arrive, using point-of-care antigen tests or laboratory tests. All that is necessary at time of entry is to start the process by swabbing the individual.
  • Document the transportation company's refusal to provide testing. We do not recommend this option under the current state of the guidance because of the potential survey consequences.