Additional SNF guidance and FAQ from CMS. The Centers for Medicare and Medicaid Services (CMS) issued a new Quality, Safety, and Oversight (QSO) letter 20-28-NH specific to SNFs. The letter addresses data reporting issues and includes a set of frequently-asked questions (FAQ) on previous SNF guidance.

CMS clarifies in the QSO that the suspension of normal surveys means the survey stars in the 5-Star Quality Rating System will not be updated as part of the scheduled April 29, 2020, data refresh to add the few complaint and targeted infection control surveys. The agency does note that the results of those surveys will be reported publicly at some time. CMS points out that although it waived Payroll-Based Journal and MDS submissions at the end of March, the data used in the refresh for the staffing and Quality Measures are from before that time, so those stars will be updated.

Next, CMS writes that they released (Excel download) direct-care staff and resident counts by facility for use in determining personal protection equipment (PPE) needs, combined with the Centers for Disease Control and Prevention's PPE burn rate calculator. The data, however, are pre-COVID-19 and may not be of much value for this purpose.

The FAQ gives CMS's position on a number of issues:

• While a test-based strategy is preferred for SNF admissions, it is not required, and admission decisions should be made clinically on a case-by-case basis.
• CMS gives ideas for helping patients and families stay connected and discusses the new civil money penalty grant availability of up to $3,000 for technology to assist. The QSO links to a list of state contacts for these grants, who for Ohio are Amy Hogan and Shirley Williams at the Department of Medicaid.
• Across several questions, CMS explains its intent around visitation for compassionate care situations and entry by essential health care personnel. This boils down to case-by-case decision-making as well. Relative to visitors, CMS emphasizes that, "[u]nless it is absolutely necessary to go into a nursing home, people should not." For health care personnel and contractors entering the building, CMS writes that, "due to the risk COVID-19 poses to nursing home residents, we recommend facilities only continue critical services, and only allow individuals who are essential to provide those critical services into the facility." Please see the QSO for detailed discussion of these points on pages 4-6. In all cases, appropriate precautions and screening must be applied, and individuals with symptoms cannot enter under any circumstances.
  
• In questions 8-10, CMS addresses patients leaving the building. While stressing that this should occur only when absolutely necessary, CMS reiterates that patients have the right to leave "against medical advice" and should be quarantined for 14 days upon return. CMS also hints that a SNF may discharge a patient in such a case.
• The FAQ covers CMS blanket waivers supporting cohorting and transfer/discharge, giving several examples of cohorting practices.
• CMS clarifies that the prohibition on communal dining does not mean all patients must eat in their rooms. The dining room may be used for asymptomatic patients who have not tested positive, so long as they can stay 6 feet apart.
• Questions 15-19 pertain to the suspension of surveys, infection control-focused surveys, and the infection control self-assessment. Among other things, CMS clarifies how the self-assessment is to be used, that surveyors should be screened before entering the building, and that patient monitoring does not require taking blood pressures every shift.
  

Importance of pulse oximetry. Speaking of patient monitoring, because COVID-19 is an unusual respiratory infection that kills by destroying the lungs' ability to supply the body with oxygen, monitoring blood oxygen levels of COVID-19-positive patients is vitally important. The infection is unusual because patients often have dangerously low blood oxygen levels without experiencing noticeable difficulty breathing. Once they reach that point, they are in critical condition. Use of pulse oximeters for COVID-19-positive patients allows clinicians to identify when their blood oxygen level reaches 90 or below, which should trigger more aggressive intervention even in the absence of breathing difficultie