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December 2, 2020

CDC Changes Quarantine Guidance. The Centers for Disease Control and Prevention (CDC) today issued new guidelines lowering the recommended quarantine period for people who may have been exposed to COVID-19 (e.g., new admissions to SNFs). CDC previously telegraphed this change, suggesting that the evolving science of COVID-19 supports it. In the new guidance, CDC explains the rationale in detail. The specific new timing guidelines are:

CDC recommends the following alternative options to a 14-day quarantine:
  • Quarantine can end after Day 10 without testing and if no symptoms have been reported during daily monitoring.
    • With this strategy, residual post-quarantine transmission risk is estimated to be about 1% with an upper limit of about 10%.
  • When diagnostic testing resources are sufficient and available (see bullet 3, below) [not reprinted here], then quarantine can end after Day 7 if a diagnostic specimen tests negative and if no symptoms were reported during daily monitoring. The specimen may be collected and tested within 48 hours before the time of planned quarantine discontinuation (e.g., in anticipation of testing delays), but quarantine cannot be discontinued earlier than after Day 7.
    • With this strategy, the residual post-quarantine transmission risk is estimated to be about 5% with an upper limit of about 12%.

CDC further emphasizes continuing symptom monitoring and all recommended non-pharmaceutical interventions. Please review the full guidance to get the complete picture of CDC's current position on quarantine.

BID Weighs in on N95s. The Department of Health's (ODH's) Bureau of Infectious Disease (BID) provided guidance on an issue that has been troubling recently on SNF surveys: using a surgical mask/facemask over an N95. BID's Amanda Smith said this is an appropriate way to conserve N95s on an isolation unit or another situation in which an unprotected respirator would need to be changed between patient rooms. A face shield is another option for protecting the respirator. If a surgical mask is used to cover the N95, it should be discarded between patients. If a face shield is used, it should be cleaned between patients. In a COVID-19 unit, however, there is no need to change N95s (or to cover the N95) unless a resident has another pathogen as well. Sarah Mitchell of BID went so far as to say they will recommend CDC change the June 20, 2020, National Institute for Occupational Safety and Health (NIOSH) blog post, which surveyors have used to suggest that surgical masks should not be used to cover N95s, because it conflicts with other CDC guidance.

Ms. Smith added that she felt most facilities in Ohio are at contingent or crisis capacity for N95s because of the high burn rate and potential supply disruption. She does not believe, however, that this is presently the case for gowns.

Ms. Smith further noted that CDC clarified the "5 use" standard for N95s. It is defined as 5 donnings, even if they take place during the same day. The reason for the limit is a respirator can lose its tight fit through repeated donnings and doffings.

Jill Shonk of the survey bureau said the Centers for Medicare and Medicaid Services (CMS), in a recent meeting with state survey agencies, said SNFs should not be cited for not having dedicated staff for a COVID-19 unit unless it led to other infection control violations such as not using personal protective equipment appropriately. 

Physician Final Rule Expands Telehealth, Retains Therapy Cuts. Late last night, CMS released the CY2021 Physician Fee Schedule Final Rule. This rule contains some important changes and impacts for post-acute care providers.

  • Therapy cuts: Most notably, the final rule retains the proposed 9% rate reduction for outpatient (Part B) therapy services. Legislation (H.R. 8702) is current pending in Congress to stop the payment cuts during COVID-19.
  • Category three telehealth services: Many telehealth expansion services are in a new designation, category three, which describes services added to Medicare telehealth during the Public Health Emergency (PHE) for COVID-19. These services will remain on the list until the end of the calendar year during which the PHE ends. As the current PHE runs through January 2021 and could be expanded further, we can look forward to having the expanded telehealth listed below for the entire year of 2021. This list only reflects services relevant to post-acute care providers:
    • Custodial care, rest home, or domiciliary services for established patients
    • Home visits for established patients
    • Therapy services, physical (PT) and occupational (OT)
  • Frequency limitation on SNF telehealth visits: Changed to one visit every 14 days (from 30 days).
  • Virtual check-ins for PTs, OTs, and speech-language pathologists (SLPs): Two new Healthcare Common Procedure Coding System (HCPCS) G codes are established (G2010, G2012) for remote evaluation of patient-submitted video or images and virtual check-ins.
  • Maintenance therapy: Allows PTs and OTs to delegate performance of maintenance therapy services, as clinically appropriate, to a therapy assistant.
  • Therapy documentation delegation: PTs, OTs, SLPs, and other clinicians who bill Medicare directly can review and verify, rather than re-document, information already entered by other members of the clinical team into a patient’s medical record. Officials say this will allow practitioners flexibility to delegate certain types of care, reduce duplicative documentation, and supervise certain services they could not before.
  • Home infusion therapy: CMS decided not to mandate a certain form, manner, or frequency for physicians to notify patients of available, alternate treatment options before initiating home infusion therapy.

NAHC Drafts Letter to State Governors, Health Departments Urging Prioritization of HH and Hospice for COVID-19 Vaccine Distribution. The National Association for Home Care and Hospice (NAHC) joined with other leading home care and hospice organizations to send a letter supporting the recommendations of CDC’s Advisory Committee on Immunization Practices (ACIP) on prioritization of vaccine access. Home care and hospice staff of all disciplines are included in the first group (Phase 1a) with access to the COVID-19 vaccine since the workforce is properly included in ACIP’s definition of health care workers. NAHC’s Bill Dombi said this letter was sent to state health departments and governor’s offices, since the states ultimately will determine the distribution and allocation of vaccine.  OHCA continues to press the DeWine Adminstration for clarity on the timelines and prioritization of long-term service and supports providers, including home health and hospice.

Infection Control Webinar for DODD Services. The Department of Developmental Disabilities (DODD) and ODH are partnering to offer a webinar for DD providers entitled, “Applying Infection Control for Department of Developmental Disabilities Settings.” The webinar will be held on Wednesday, December 9, 2020, from 10:00-11:30am and will provide important infection control information for DD providers, including how to apply infection control procedures during COVID-19. DD providers can register for the webinar here. 

LTC COVID-19 Infections Continue to Rise. Today's report on the ODH dashboard listed more than 7,000 new cases in Ohio long-term care facilities (SNFs, assisted living communities, and ICFs/IID) in the past week. This figure is 1,000 more than last week's record number. The state has recorded more than 26,000 total cases among residents and more than 18,000 cases among staff since ODH began publishing the data on April 15. Nearly 3,500 deaths have been tallied, including 155 more this week.

Medicaid Home Health Rules Would Solidify Telehealth Benefit, NPPs as Ordering Providers. This week, the Department of Medicaid released several proposed rules that would expand telehealth services for home health and would add non-physician practitioners (NPPs) as ordering providers for the plan of care on a permanent basis. There are no major revisions to the expansions afforded under the existing emergency rules, but the changes codify the telehealth flexibilities past the PHE. ODM previously made similar revisions to the hospice care program rules. All rules listed below have a public hearing on December 21, 2020. 

  • 5160-12-05 (reimbursement for home health services). The place of service code 02 will be used to indicate a visit was completed using telehealth.
  • 5160-12-04 (home health and private duty nursing: visit policy). Language is added to include telehealth encounters as reimbursable home health or private duty nursing visits. 
  • 5160-12-08 (registered nurse assessment and registered nurse consultation services). The rule would add “advance practice nurse or physician's assistant in accordance with the Coronavirus Aid, Relief, and Economic Security (CARES) Act, S.3548 (2020)” as a treating physician for development of the plan of care under Medicaid home health. This already is in place for Medicare home health services. ODM also proposed to allow use of telehealth to complete the registered nurse assessment.
  • 5160-1-40 Electronic Visit Verification (EVV). The amendment would remove the requirements for individual visit verification of the start and end time and for new providers to complete EVV training before receiving their Medicaid provider numbers.