As part of a series of announcements, the Centers for Medicare & Medicaid Services (CMS) issued several new blanket waivers for long term care providers, according to the latest update from the American Health Care Association/National Center for Assisted Living (AHCA/NCAL) on COVID-19 rules and regulations. 

The following blanket waivers are in effect, with a retroactive effective date of March 1, 2020, through the end of the emergency declaration.

1.     Quality Assurance and Performance Improvement (QAPI) 

CMS is modifying certain QAPI program requirements—specifically, §483.75(b)–(d) and (e)(3)—to the extent necessary to narrow the scope of the QAPI program to focus on adverse events and infection control. The following sections are waived:

§483.75(b) Program design and scope, which includes “address all systems of care and management practices”;

§483.75(c) Program feedback, data systems, and monitoring;

§483.75(d) Program systematic analysis and systemic action; and

§483.75(e)(3) Performance improvement projects

2.     In-Service Training 

CMS is modifying the requirement that the nurse assistant must receive at least 12 hours of in-service training annually by postponing the deadline for completing this requirement until the end of the first full quarter after the declaration of the COVID-19 Public Health Emergency concludes. 

3.     Detailed Information Sharing for Discharge Planning for LTC Facilities 

CMS is waiving the discharge planning requirement that requires long term care (LTC) facilities to assist residents and their representatives in selecting a post-acute care provider using data, such as standardized patient assessment data, quality measures, and resource use. CMS is maintaining all other discharge planning requirements, including the discharge plan.  

4.     Clinical Records 

CMS is modifying the requirement that requires LTC facilities to provide a resident a copy of their records within two working days (when requested by the resident) by allowing facilities 10 working days to provide the requested record.

5.     Inspection, Testing, and Maintenance (ITM) under the Physical Environment

CMS is waiving certain physical environment requirements for providers including ICF/IIDs (intermediate care facilities for individuals with intellectual disabilities) and SNFs/NFs (skilled nursing facilities/nursing facilities) to the extent necessary to permit facilities to adjust scheduled ITM frequencies and activities for facility and medical equipment required by the Life Safety Code (LSC) and Health Care Facilities Code (HCFC).

The following LSC and HCFC ITM are considered critical and are not included in this waiver:

--Sprinkler system monthly electric motor-driven and weekly diesel engine-driven fire pump testing.

--Portable fire extinguisher monthly inspection.

--Elevators with firefighters’ emergency operations monthly testing.

--Emergency generator 30 continuous minute monthly testing and associated transfer switch monthly testing.

--Means of egress daily inspection in areas that have undergone construction, repair, alterations, or additions to ensure its ability to be used instantly in case of emergency.

ICF/IIDs and SNFs/NFs are required to have an outside window or outside door in every sleeping room. CMS will permit a waiver of these outside window and outside door requirements to permit these providers to use facility and non-facility space that is not normally used for patient care for temporary patient care or quarantine.

AHCA/NCAL noted that providers should be aware that federal waivers such as these may not be applicable to state and/or local Authorities Having Jurisdiction.

Updates to Previously Issued Regulatory Blanket Waivers: CMS updated some language to blanket waivers that were previously issued at the end of March, AHCA/NCAL said. 

Resident Transfer and Discharge: CMS continues to waive requirements to allow a LTC facility to transfer or discharge residents to another LTC facility solely for the following cohorting purposes. Scenario two has added language regarding resident’s care plans in bold below. 

1.     Transferring residents with symptoms of a respiratory infection or confirmed diagnosis of COVID-19 to another facility that agrees to accept each specific resident, and is dedicated to the care of such residents; 

2.     Transferring residents without symptoms of a respiratory infection or confirmed to not have COVID-19 to another facility that agrees to accept each specific resident, and is dedicated to the care of such residents to prevent them from acquiring COVID-19, as well as providing treatment or therapy for other conditions as required by the resident’s plan of care; or 

3.     Transferring residents without symptoms of a respiratory infection to another facility that agrees to accept each specific resident to observe for any signs or symptoms of a respiratory infection over 14 days. 

Waive Pre-admission Screening and Annual Resident Review (PASARR): CMS is allowing nursing centers to admit new residents who have not received Level 1 or Level 2 Preadmission Screening. Level 1 assessments may be performed post-admission. On or before the 30th day of admission, new patients admitted to nursing facilities with a mental illness (MI) or intellectual disability (ID) should be referred promptly by the facility to State PASARR program for Level 2 Resident Review.

Note: This language is included in the 
summary waiver list for all providers and differs slightly from the text in the LTC specific waiver summary, AHCA/NCAL said.

Updates to Previously Issued Reimbursement Blanket Waivers:

1.     CMS Facility without Walls (Temporary Expansion Sites)—Transfer of COVID-19 Patients

--The transferring SNF need not issue a formal discharge in this situation, as it is still considered the provider and should bill Medicare normally for each day of care. 

--The transferring SNF is then responsible for reimbursing the other provider that accepted its resident(s) during the emergency period. 

--Processing Manual to submit a discharge bill to Medicare.

--View a CMS QSO memo on transfers

2. Cost Report Delay

--CMS will delay the filing deadline of Fiscal Year End (FYE) 10/31/2019 cost reports due by March 31, 2020, and FYE 11/30/2019 cost reports due by April 30, 2020. The extended cost report due dates for these October and November FYEs will be June 30, 2020. 

--CMS will also delay the filing deadline of the FYE 12/31/2019 cost reports due by May 31, 2020. The extended cost report due date for FYE 12/31/2019 will be July 31, 2020. 

3. Telehealth

--CMS is waiving the requirements of section 1834(m)(4)(E) of the Act and 42 CFR §410.78 (b)(2), which specify the types of practitioners that may bill for their services when furnished as Medicare telehealth services from the distant site. 

--This waiver expands the types of health care professionals who can furnish distant site telehealth services to include all those eligible to bill Medicare for their professional services. 

--This allows health care professionals who were previously ineligible to furnish and bill for Medicare telehealth services, including physical therapists, occupational therapists, speech language pathologists, and others, to receive payment for Medicare telehealth services.

--May impact SNFs that furnish outpatient therapy in assisted and independent living and the community. CMS did not provide billing guidance, and AHCA/NCAL recommends SNF providers contact their Medicare Administrative Contractor for guidance.

In other developments, CMS has delayed implementation of new Minimum Data Set (MDS) items adopted for the SNF Quality Reporting Program (QRP) for two years.

The Interim final rule from CMS issued last week also delays implementation of new MDS items for SNF QRP as described below:

--This delay will enable SNFs to continue using the current version of the MDS 3.0 v1.17.1.

--CMS will require SNFs to collect data on the transfer of health information measures and SPADES (Standardized Patient Assessment Data Elements) data on Oct. 1 of the first of the year that is at least two full fiscal years after the end of the COVID-19 public health emergency.

--CMS will work with SNFs prior to implementation to address questions related to training and software update needs.

Comments are due 60 days after date of publication in the Federal Register

AHCA/NCAL said it is reviewing the rule and will share further information as soon as it is available. In the meantime, the association said members should register for NHSN and review current processes in place for informing residents and families of COVID-19 infections or related symptoms.

Separately, over the weekend, CMS informed AHCA/NCAL of new information on what providers must do in reporting COVID-19 cases. In  Update #56, AHCA/NCAL said it communicated about the CMS release of an interim final rule with comment period that revises §483.80, establishing explicit reporting requirements for LTC facilities to report information related to COVID-19 cases among facility residents and staff. These reporting requirements are applicable on the effective date of this interim final rule, which is the date of the publication in the Federal Register. 

“CMS has informed AHCA that the new requirements for nursing homes in this rule was effective as of May 1,” the association said. CMS’ intention is that the first of the weekly reporting to Centers for Disease Control and Prevention (CDC) in the National Healthcare Safety Network (NHSN) COVID-19 module are submitted by May 8.

“We are advocating that there be a grace period for enforcement of this rule given the lack of clarity on the notifications to residents, their representatives, and families, as well as the technical complexities and quantity of information that must be submitted to CDC for NHSN COVID-19 reporting,” AHCA/NCAL said.

The association also said it is developing resources to help members with the new requirements, including a template communication for notifications to residents, their representatives, and families. AHCA/NCAL added that it is working with the team to get resources to members on using NHSN. 

In that vein, CDC NHSN has released more materials for nursing facilities to prepare for this new reporting requirement, including a guide to using the COVID-19 module. Visit the CDC website to sign up for updates.

AHCA/NCAL said there are two upcoming webinar trainings for the new long term care facility (LTCF) LTCF COVID-19 Module. The training webinars will be recorded and posted to the LTCF COVID-19 Module webpage with a PDF of the slide presentation. 

COVID-19 Module for Long Term Care Facilities Enrollment Guidance 
May 4 from 2 – 3:30 p.m. EDT.

COVID-19 Module Overview for Long Term Care Facilities 
May 5 from 3 – 4:30 p.m. EDT.

Learn how to join these webinars on the 
CDC NHSN website. If providers have any questions, email CDC at and include LTCF COVID-19 in the subject line.

Lastly, the personal protective equipment (PPE) consumption rate calculator is now available as a mobile app. Facilities can use the National Institute for Occupational Safety and Health (NIOSH) PPE Tracker app to calculate their average PPE consumption rate, or “burn rate.” The app estimates how many days a PPE supply will last given current inventory levels and PPE burn rate, AHCA/NCAL said. For the Excel version, visit the CDC website.​