Maintenance Vaccination Webinar - Questions Remain. Today, the state held its promised webinar on maintenance vaccinations for SNFs and assisted living communities. The intent is to vaccinate new residents and staff as well as those who initially were hesitant about the vaccine but later change their minds. The state's webinar first addressed the Federal Retail Pharmacy Program, which according to Centers for Disease Control and Prevention (CDC) guidance is an option for facilities to gain access to vaccine. This program, however, apparently is not activated yet.
Director of Aging Ursel McElroy then laid out three options in the state program:
- Long-term care pharmacy handles storage, delivery, administration, and reporting. The pharmacy must be enrolled as a vaccine provider with ODH.
- Long-term care pharmacy handles storage, delivery, and reporting. Facility contracts with the pharmacy to administer the vaccine. Both the pharmacy and the facility must be enrolled as vaccine providers.
- Facility stores, administers, and reports. The facility must be enrolled as a vaccine provider. This option is not available at this time.
Each of these options will be governed by a monthly enrollment survey, leading to a scheduled allocation of vaccine to each vaccine provider. The survey includes the facility's choice of option, choice of pharmacy, and questions about demand. Facilities should confirm their pharmacy's vaccine provider status before selecting the pharmacy. Director McElroy said the survey is available now, and the first iteration will close at 11:59 p.m. on Tuesday, February 23. Only SNFs or assisted living communities that have completed all three clinics in the Pharmacy Partnership for Long-Term Care are eligible to participate.
Jonathon George of the Board of Pharmacy said the state will use the Moderna vaccine for this program. Not all long-term care pharmacies will be included initially. The state will dedicate an allocation of vaccine to this program, beginning February 22.
There are some significant outstanding questions about the state program, including:
- Which long-term care pharmacies are participating (Director McElroy said the state will post a list).
- What does a facility do if its pharmacy is not participating?
- In option 2, why does the facility have to enroll as a vaccine provider when it is merely contracting with the pharmacy to vaccinate residents and staff.
We are trying to get answers to these and other questions. We anticipate most facilities will select option 2, because long-term care pharmacies are unlikely to agree to option 1 and option 3 isn't available. Option 2, however, requires the facility to enroll as a vaccine provider, which is burdensome and seems unnecessary. Few assisted living communities or SNFs currently are enrolled. As a result, we recommend holding off completing the survey until early next week, when hopefully we will have more answers.
Also relative to COVID-19 vaccine, ODH's Lance Himes reported that the state received 214,525 first doses last week and is expecting 223,025 first doses this week, although the shipments have been delayed because of the weather. Mr. Himes added that the state anticipates Pfizer will increase its shipments significantly by the end of the month and potentially even more in March.
Long-Term Care COVID-19 Cases, Deaths. Again this week, the state's COVID-19 dashboard for long-term care showed declines in both cases and deaths. Both the 992 resident cases and 705 staff cases were the lowest since the week of October 14. The state reporded 1,294 COVID-19-related deaths in long-term care, but approximately 1,150 of them were from the October-December period when they were not recorded timely. The actual total for this week was lower than last week. We expect continued reductions as long-term care vaccinations progress.
SNF Visitation: the Percentage or the Color? As reopening Ohio SNFs to visitation proceeds week by week, some members ask about the criteria for visitation, specifically the Centers for Medicare and Medicaid Services (CMS) positivity ratings. In CMS Quality, Safety, and Oversight letter (QSO) 20-39, which governs visitation, CMS refers to specific county-level positivity percentages, with 10% being the cut-off point for high community positivity. On the CMS positivity table, however, high community positivity is denoted by the color red. Not all counties with positivity percentages above 10% are shown as red because CMS determined in September 2020 that it does not consider the positivity percentage valid unless the county meets a threshold number of tests. Later, CMS clarified in frequently-asked questions (FAQs) that language in QSO 20-38 tying 10% positivity to more frequent testing should be interpreted as meaning a red designation, not the percentage. Although CMS in the FAQs did not address visitation and QSO 20-39 specifically, the logic holds: if a minimum number of tests is needed for a positivity percentage over 10% to be considered valid for testing, it would be illogical to ignore the validity threshold for visitation. We therefore maintain that the CMS-designated county color, not the positivity percentage, should be consulted to determine whether to provide residents with visitation. This interpretation also has the advantage of being the more humane approach.
More on SNF Visitation. Governor Mike DeWine commented today that he intends to address visitation for SNF patients in some fashion. The post-press conference release put it this way:
Governor DeWine announced that he has assembled a team of doctors and nurses to develop a plan for safe nursing home visitation. Members of the team are experts in infectious disease control, skilled nursing, and other types of long-term care settings.
Ohio's existing visitation order does allow compassionate care visits. Examples of compassionate care situations could include:
- A resident who was living with their family before recently being admitted to a home, is struggling with the change in environment and lack of physical family support.
- A resident who needs cueing and encouragement with eating or drinking, previously provided by family or caregiver(s), is experiencing weight loss or dehydration.
- A resident, who used to talk and interact with others, is experiencing emotional distress, seldom speaking, or crying more frequently.
The Office of the State Long-Term Care Ombudsman is available to assist citizens with questions about compassionate care visits. The office can be reached at OhioOmbudsman@age.ohio.gov or 1-800-282-1206.
It is not clear what the state could add, as for SNFs (unlike assisted living), visitation is regulated thoroughly by CMS through QSO 20-39.
ODH Interpretation on Eye Protection. For a number of months, ODH surveyors have enforced the CDC guidelines recommending eye protection for health care personnel working in facilities located in areas with moderate to substantial community transmission. Recently, we asked how ODH determines community transmission on survey. ODH's Jill Shonk responded. Here are the question and the answer.
Q. Relative to the CDC guidance on eye protection throughout the building in areas of moderate or significant community spread, is ODH still enforcing this? If so, is it the CMS colors or the Ohio colors that apply?
A. We are continuing to follow the previous information and it is based on CMS positivity rate.
Because CDC recommends eye protection in both moderate (yellow) and substantial (red) community spread areas, only SNFs in green counties would be able to dispense with eye protection in circumstances that do not involve "anticipated exposures [or] suspected or confirmed diagnoses."
CDC on Double-Masking. Three recent updates to CDC guidelines address the practice of double-masking (wearing one face mask over another). The main guidelines, which are intended for the general public and were updated within the last week, are "Improve How Your Mask Protects You" and "Improve the Fit and Filtration of Your Mask to Reduce the Spread of COVID-19." CDC recommends several techniques to improve fit of cloth face coverings and disposable facemasks, including double-masking with two cloth masks or one disposable and one cloth mask. CDC recommends against wearing two disposable masks or two KN95s. For health care personnel (HCP), CDC updated "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic" on February 10 to include similar recommendations, although they are somewhat inconspicuous within a rather lengthy guideline. The relevant section reads:
One of the following should be worn by HCP for source control while in the facility and for protection during patient care encounters:
An N95 respirator OR
A respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering facepiece respirators OR