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 Questions Answered on COVID-19 Reporting Requirements

The American Health Care Association/National Center for Assisted Living (AHCA/NCAL) reiterated the importance for long term care providers to report accurately on COVID-19 to the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN). 

“In Update #65, we provided guidelines on accurately reporting staffing and PPE [personal protective equipment] shortages to NHSN COVID-19 LTC module,” the association said. “As stated in the update, it is important the data reported to NHSN give an accurate picture as this data will be used by state, federal governments, and other stakeholders.”
  
In response to questions about the staffing guidance and further information from CDC on NHSN reporting, AHCA/NCAL said the following may be helpful to providers.   

NHSN asks, “Does your organization have a shortage of staff and/or personnel?” Any of the following situations support a YES response:  

1.       Staffing less than your facility needs or internal policies for staffing ratios (despite efforts made by the facility to secure staff)  

2.       Employing crisis strategies for staffing shortage 

3.       Using any temporary positions per waiver allowances (such as temporary nurse aide or temporary feeding assistant) or agency staff, yet staffing ratios for facility needs and internal policies are still not met 

“As a reminder, keep documentation of efforts to secure more PPE as well as staffing. Report to your local and state health departments if employing contingency and crisis strategies to conserve PPE and staffing,” the association said. 

Separately, the Centers for Medicare & Medicaid Services (CMS) has released a new toolkit intended to serve as a catalog of resources dedicated to addressing the specific challenges facing nursing centers as they combat COVID-19.

CMS said the toolkit provides resources and direction for quality improvement assistance and can help in the creation and implementation of strategies and interventions intended to manage and prevent the spread of COVID-19 within nursing centers.

The toolkit outlines best practices for a variety of subjects, ranging from infection control to workforce and staffing. It also provides contact information for organizations that stand ready to assist with the unique challenges posed by caring for individuals in long term care settings, AHCA/NCAL said. 

Also, on May 11, CMS issued additional waivers for the health care community that provide the flexibilities needed to take care of patients during the COVID-19 public health emergency (PHE). This is in addition to the waivers that were released on April 30. The following blanket waivers are in effect, with a retroactive effective date of March 1, 2020, through the end of the emergency declaration. 

Paid Feeding Assistants 

CMS is modifying the minimum time frame requirements for feeding assistant training to allow the training to be a minimum of one hour in length. CMS is not waiving any other requirements related to paid feeding assistants or the required training content, which contains infection control training and other elements. Additionally, CMS is also not waiving or modifying the requirements that require that a feeding assistant must work under the supervision of a registered nurse (RN) or licensed practical nurse (LPN). 

With this waiver, AHCA/NCAL’s 
Temporary Feeding Assistant training is allowable. However, additional state requirements may need to be waived to permit individuals completing this program to assist with care in your location. We encourage you to contact your state survey agencies and state occupational licensing agencies, where applicable.  

Specific Life Safety Code (LSC) for Multiple Providers

CMS is waiving and modifying waivers under for intermediate care facilities for individuals with intellectual and developmental disabilities (ICF/IIDs) and skilled nursing facilities (SNF/NFs). Specifically, CMS is modifying these requirements as follows:  

Alcohol-based Hand-Rub (ABHR) Dispensers. CMS is waiving the requirements for the placement of ABHR dispensers for use by staff and others due to the need for the increased use of ABHR. However, ABHRs contain ethyl alcohol, which is considered a flammable liquid, and there are restrictions on the storage and location of the containers. This includes restricting access by certain patient/resident populations to prevent accidental ingestion.  

Due to the increased fire risk for bulk containers (over five gallons), those will still need to be stored in a protected hazardous materials area. In addition, facilities should continue to protect ABHR dispensers against inappropriate use.  

Fire Drills. Due to the inadvisability of quarterly fire drills that move and bring staff together, CMS will instead permit a documented orientation training program related to the current fire plan, which considers current facility conditions. The training should instruct employees, including existing, new, or temporary employees, on their current duties, life safety procedures, and the fire protection devices in their assigned area.  

Temporary Construction. CMS is waiving requirements that would otherwise not permit temporary walls and barriers between patients. 

Hospital Swing Bed Waiver 

The new blanket waivers include a waiver expanding the ability of hospitals to offer long term care services to patients who do not require acute care but meet the SNF level of care criteria at 42 CFR 409.31. CMS is waiving the eligibility requirements for hospital providers of long term care services (swing beds) at 42 CFR 482.58(a)(1)-(4) to allow hospitals to establish SNF swing beds payable under the SNF prospective payment system (PPS). This waiver provides additional options for hospitals with patients who no longer require acute care but are unable to find placement in a SNF. 

The waiver includes an array of limitations on hospital use of the waiver, including applying to the Medicare Administrative Contractors (MACs) for additional swing beds and attesting: 

1.      They have made a good faith effort to exhaust all other options; 

2.      There are no skilled nursing facilities within the hospital’s catchment area that under normal circumstances would have accepted SNF transfers, but are currently not willing to accept or able to take patients because of the COVID-19 PHE; 

3.      The hospital meets all waiver eligibility requirements; and 

4.      They have a plan to discharge patients as soon as practicable, when a SNF bed becomes available, or when the PHE ends, whichever is earlier.  

AHCA/NCAL said its members who are concerned about inappropriate hospital use of the waiver should contact their MACs. Find the list of MACs and contact information here.

Guidance on Documentation for Use of COVID-19 SNF Reimbursement Waivers

The CMS waivers also consider requirements that would normally be in place for providers to receive reimbursement under Medicare or Medicaid. Most significant were the waiver of the three-day prior inpatient hospital stay and the 60-day break in spell-of-illness requirements for SNF Part A benefit eligibility, AHCA/NCAL said. 

Documentation will be critical to demonstrate an organization’s rationale for the use of the waivers. In a 
previous update, AHCA/NCAL offered visual flowchart guidance to help with coverage determinations of these 1135 waivers. AHCA/NCAL has provided key documentation guidelines for supporting the employment of these waivers as it is foreseeable that after the emergency declaration is rescinded, CMS either through the Officer of Inspector General or through contractors will look to ensure that Medicare dollars were spent appropriately without fraud, waste, and abuse.

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