CMS Issues Guidelines for Mandatory SNF Testing Rule. The Centers for Medicare and Medicaid Services (CMS) today released Quality, Safety, and Oversight (QSO) letter 20-38-NH, guidance that implements the SNF testing provisions of the interim final rule with comment period issued yesterday. The rule outlines CMS's mandatory SNF testing program but leaves key details to today's guidelines. The QSO specifies that it is effective immediately, but the rule that it implements does not take effect until it is published in the Federal Register.

Here is an overview of the QSO, but readers should review the 22-page document carefully to get all the details.

• SNFs that have a Clinical Laboratory Improvement Amendments (CLIA) Certificate of Waiver and have received a point-of-care (POC) antigen testing machine may use it to comply with the rule's testing mandate.
• Facility staff who must be tested include "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." This is a broader definition than Ohio uses presently.
• CMS conclusively answers a recent question in Ohio about interpreting Centers for Disease Control and Prevention (CDC) guidlelines: whether all residents and staff must be tested when there is one positive case. The QSO provides, "[u]pon identification of a single new case of COVID-19 infection in any staff or residents, all staff and residents should be tested, and all staff and residents that tested negative should be retested every 3 days to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result." A recent interpretation by the Health Department's (ODH's) survey unit went the opposite direction.
• As suggested in the rule itself, the guidance specifies that the required testing frequency for each building will be based on county-level positivity in the preceding week. CMS will publish the county-level data starting Friday.
  
• For SNFs in counties with positivity under 5%, routine testing of all staff is required monthly (i.e., less often that the two-week frequency required by Ohio). For SNFs in counties with positivity of 5% or more but less than 10%, weekly testing is required. For SNFs in counties with positivity of 10% or more, staff must be tested twice a week. Ohio's current statewide positivity, according to the commonly-used Johns-Hopkins University metric, is 4.14%, but counties likely vary widely.
• The guidelines make the weekly and semi-weekly testing contingent on possession of a POC unit or availability of laboratory testing with turn-around of 48 hours or less. "If the 48-hour turn-around time cannot be met due to community testing supply shortages, limited access or inability of laboratories to process tests within 48 hours, the facility should have documentation of its efforts to obtain quick turnaround test results with the identified laboratory or laboratories and contact with the local and state health departments."
• The QSO gives instructions on how centers are to monitor county positivity and when they are to adjust their testing schedules.
• CMS does not require or recommend routine testing of asymptomatic residents, except possibly in certain situations in which the resident leaves the building frequently. Symptomatic residents of course must be tested.
• The QSO affirms a patient's right to refuse testing and gives direction on how to handle these patients for either symptom-based or outbreak testing. Staff who refuse routine testing are deferred to state and local health jurisdictions.
• CMS affirms the 3-month rule for past-positive individuals, but states that testing should be encouraged after that period. "Individuals who are determined to be potentially infectious should undergo evaluation and remain isolated until they meet criteria for discontinuation of isolation or discontinuation of transmission-based precautions, depending on their circumstances."
  
• The QSO includes requirements for conducting tests, including recognition that antigen tests are diagnostic. It also outlines the procedures for CLIA-waived laboratories (i.e., SNFs) to report test results.
  
• CMS specifically lists documentation facilities must maintain for purposes of survey compliance.
• Finally, the guidelines specify how surveyors are to survey for compliance with the new tag, F886, on Focused Infection Control surveys. The primary focus is on the documentation specified in the QSO, but the guidance includes other tasks like observing testing if possible. The latter part of the QSO contains revisions to the Focused Infection Control survey process to incorporate the testing requirements.

AHCA also provided a summary of QSO 20-38.

In addition, CMS issued a separate QSO, 20-37-CLIA, NH, that addresses the new rule's requirements for laboratories and the enforcement provisions for both labs and SNFs.

Notice to licensed residential care facilities came earlier this afternoon through the Enhanced Information Dissemination and Collection (EIDC) system.

The key portion of the joint letter reads:

Therefore, we have initiated a review to evaluate the results of saliva-based PCR tests performed recently at assisted living facilities. While we undergo review, we will pause the saliva-based PCR testing schedule for facilities. Similarly, we will pause on reflecting testing data for your facility on the Ohio Department of Health long-term care facility dashboard until we complete the analysis.

For facilities that received results, we ask that you follow the established CDC protocols based on your test results. If you are currently scheduled for testing, we ask that you await further instructions following our review. We plan on completing our review as quickly as possible.

As part of the review and evaluation mentioned in the letter, Director McElroy is conducting a trial comparing saliva tests and nasal swab-based tests among staff in volunter assisted living communities. We will keep you posted on this developing story via our COVID-19 Updates and weekly assisted living Zoom meetings.

Survey Monkey for Reporting SNF Testing Results Available. ODH published on EIDC the following notice that a Survey Monkey for SNFs to report the results of their repeat staff testing is now ready for use.

The survey monkey has been developed for nursing homes to report their testing results.  This should be done after each instance of all staff testing. If you have questions please email ccurt@odh.ohio.gov. The link will not change between entries unless an update needs made at which point we will communicate the new link.

https://www.surveymonkey.com/r/MT2SCCX

Medicaid Director Corcoran to Offer Telehealth Update. State Medicaid Director Maureen Corcoran invites interested providers to a webinar on Tuesday, September 1, from 1:00-2:00 p.m. in which she and Department of Medicaid (ODM) staff will provide an update on ODM’s goals and objectives for telehealth services as part of the DeWine Administration’s Responsible RestartOhio. Please use this link to register for the session. 

ODM Emails ICFs/IID and SNFs About Upcoming Overpayment Process. ODM's Mark Graves informed us that the department sent the following email today to all SNFs and ICFs/IID for which the they identified overpayments for State Fiscal Years 2017 and 2018. This will begin ODM's recovery process, which is revised because of COVID-19. If you did not receive such an email, it should mean that you do not have an overpayment.

Dear Long-Term Care Provider:

ODM will begin releasing these reports the week of September 14, 2020. Please be aware of the following;

• Reports, letters and response forms will be sent via encrypted email from a Medicaid auditor;
• Encrypted emails must be opened within 14 days or the email will expire / no longer be accessible;
• Response forms are due to LTCAudits@medicaid.ohio.gov within 30 days;
  • Supporting/dispute documentation is not required to be submitted with response form;
  • Please carefully review the updated response forms;
• Organizations receiving reports for both fiscal years;
  • This will be reflected in the language contained in the email;
  • Separate emails will be sent on the same day for each fiscal year;
• Organizations receiving a report for one fiscal year only; this will be reflected in the language contained in the email;
• ODM is aware of recent challenges being addressed by all associated with delivering Medicaid-related services.  Our aim is to complete this round of overpayment audits while acknowledging there will be new or unique circumstances to consider.  To facilitate this, communications between our organizations will be essential.     

Please feel free to contact JEFFREY.FUKUDA@medicaid.ohio.gov or Mark.Graves@medicaid.ohio.gov if you have questions or concerns.