March 14, 2020

New materials for ID/DD providers. Until yesterday, there was little in the way of direction for ID/DD providers relative to COVID-19. Then the Department of Developmental Disabilities (DODD) released three memos and Director of Health Dr. Amy Acton amended her previous visitation order affecting SNFs and assisted living also to include ICFs/IID. The Director's order is discussed in more detail below. The DODD communications are as follows:

• An announcement that the Office of System Support and Standards (OSSAS) suspended all compliance reviews through the end of May. Instead, OSSAS will focus on technical assistance to providers on infection control and health and safety. They still will perform special compliance reviews if needed.
  

• Guidance to county boards that stresses minimizing in-person meetings and focusing on supporting providers, health and safety, and infection control measures, including tracking persons under investigation for COVID-19.

Later, CMS for the second time revised Quality, Safety, and Oversight (QSO) letter 20-14-NH, which establishes CMS guidance for SNFs relative to COVID-19, with considerable attention to visitation. The revisions are significant, so SNF providers (and assisted living providers) should download and review the QSO carefully. CMS restricts visitation more than under the previous version of the QSO: "[f]acilities should restrict visitation of all visitors and non-essential health care personnel, except for certain compassionate care situations, such as an end-of-life situation." The QSO contains additional direction, emphasizing screening and adding that visitors should wear facemasks.

The guidance details who is not considered a visitor, including hospice personnel and surveyors, but reiterates that everyone must be screened. The QSO provides that residents still have the right of access to the ombudsman, but adds that their access can be restricted per the guidance above, which presumably means screening, wearing a facemask, and only visiting the specific person's room.

The QSO addresses a number of other issues, significantly a statement that centers should "[c]ancel communal dining and all group activities, such as internal and external group activities."

While QSO 20-14 only applies to SNFs, assisted living communities should consider strongly implementing the same precautions. For assisted living, home health agency staff providing necessary care to residents should be consider essential health care personnel.

Government assistance to providers. In their respective press conferences yesterday afternoon, Governor Mike DeWine and President Donald Trump touched on measures to give assistance and relief to providers. At the federal level, the President declared a national emergency, and CMS published a fact sheet listing the relief measures, which would be accomplished through a "blanket" 1135 waiver. They include waiving 3-day stay and benefit period requirements for SNFs, time frames for submitting MDS assessments, and licensure requirements for health professionals to practice across state lines.

For home health agencies, the fact sheet states that CMS will provide relief OASIS transmission time frames and allow Medicare Administrative Contractors to extend the auto-cancellation date of Requests for Anticipated Payment (RAPs).

Please note that none of these changes are in effect yet because they require formal issuance of an 1135 waiver. The fact sheet also invites states to request certain additional relief. 

At the state level, Governor DeWine and Lieutenant Governor Jon Husted sent a letter to the President requesting relief on a variety of items, many not germane to long-term services and supports, with the notable exception of suspending surveys.

OHCA yesterday sent separate letters to both the Governor and DODD Director Jeff Davis requesting relief and clarification on a number of points in light of the COVID-19 outbreak and the Governor's order closing schools.

Survey suspension. While not mentioned in the CMS fact sheet above, a separate press release yesterday includes the statement, "CMS will temporarily suspend non-emergency survey inspections, allowing providers to focus on the most current serious health and safety threats, like infectious diseases and abuse." This will require revision of QSO 20-12, which only suspends certain complaint visits, not other surveys, but the intent appears to cover annual or other routine surveys as well. The Governor's letter to the President specifically asks to suspend recertification surveys for SNFs, home health agencies, hospices, and ICFs/IID.

SNF admissions. AHCA released a document discussing the controversial topic of admission and discharge of patients who have COVID-19 or respiratory infections. The document restates existing guidelines from CMS and the Centers for Disease Control and Prevention (CDC), which unfortunately press SNFs to admit and to retain these patients. ODH also currently takes this position, notwithstanding the risk to the rest of the patient population.

Staff quarantine. If a local health department attempts to quarantine one or more members of your staff who have contact with a person under investigation for COVID-19, but who is not confirmed to have the disease, please know that this is not acceptable. CDC guidelines on this topic do not require quarantine if the health care worker is asymptomatic and the patient has not been confirmed to have COVID-19. ODH intervened to stop a quarantine yesterday after we brought it to their attention.

Conserving PPE. The Health Department sent a letter on conserving personal protective equipment that is directed at hospitals, but also applies to other providers. The letter mainly repeats CDC guidelines on N95 respirators.