Dr. Dan Budnitz of the Centers for Disease Control and Prevention (CDC) Division of Healthcare Quality Promotion joined the Nursing Home Advisory Group call on May 25, 2021 to review the COVID-19 vaccine reporting module in the National Healthcare Safety Network (NHSN) system and answer questions on reporting relative to the newly released interim final rule CMS-3414-IFC. Dr. Budnitz’s presentation was then followed by policy updates from LeadingAge staff and a facilitated discussion with group participants on implementation of guidance related to activities and dining, and continued access to COVID-19 vaccine for residents and staff.

COVID-19 Vaccine Reporting in NHSN

Dr. Budnitz provided an overview of key points covered in the latest training on the COVID-19 vaccine reporting module in NHSN. Slides for this training can be accessed here. Dr. Budnitz gave an overview of the module and explained why CDC seeks this data and how it can be used. Preliminary data on COVID-19 vaccine coverage in nursing homes was provided to CDC through the Long-Term Care Pharmacy Partnership; however, since that program ended, there was no consistent data source at the federal level and a relatively small number of nursing homes were choosing to report data voluntarily through the NHSN system. Data collected can be used at the state and federal levels to determine coverage gaps and supply issues and to help drive policy. Nursing homes and organizations can use the data on the individual level to help track rates, identify areas for improvement, and tailor communications for more effective vaccine uptake.

Dr. Budnitz explained that data is reported on a weekly basis to reflect the current picture of vaccination status in the nursing home. Discharged residents and terminated staff need not be counted in these rates if they were not in the nursing home at least one day during the reporting week, and weekly data includes residents and staff who have ever been vaccinated, regardless of the date or location of vaccination, not simply those who are newly vaccinated during the reporting week. Dr. Budnitz further explained that while the module contains a breakout for vaccination rates by staff type, completion of this section is voluntary to assist in more detailed tracking.

In NHSN, the reporting week runs Monday through Sunday; however, recall that in order to comply with CMS requirements a provider must simply report once per week and the chosen day of reporting is at the discretion of the provider. Dr. Budnitz also noted that vaccination rate data is aggregate data, so Level 3 SAMS access is not required. Staff with Level 1 SAMS access can submit vaccination rate data.

Dr. Budnitz also noted that CDC has developed tools to assist providers in tracking and reporting this data. Tools are available here. The module will continue to be updated in the coming weeks to address identified issues. For example, the option to select the Janssen/Johnson & Johnson vaccine will be added and while some providers have noted that flu vaccine reporting is currently outlined in red to indicate required reporting, this reporting is voluntary at this time.

Policy Updates

CMS Administrator Confirmed. Congress confirmed Chiquita Brooks LaSure today as the new administrator of CMS. Brooks-LaSure was nominated in the early days of the Biden administration and had a relatively uncontentious confirmation hearing, but confirmation was held up by concern over a Medicaid issue that was unrelated to Brooks-LaSure. Brooks-LaSure previously served HHS and CMS during the Obama Administration and was instrumental in implementation of the Affordable Care Act. One priority identified for CMS at the outset is to permanently adopt some of the telehealth flexibilities employed through emergency waiver during the public health emergency.

Interim Final Rule on Vaccines and Therapeutics. CMS released an interim final rule with comment period on May 11 that requires long-term care facilities and intermediate care facilities for individuals with intellectual disabilities to provide education on COVID-19 vaccination to all residents/clients and staff. The rule also requires that these providers offer residents/clients and staff the vaccination and if the provider is unable to provide the vaccine, they must provide information on where/how to access the vaccine. Additionally, the rule requires that nursing homes report rates of resident and staff vaccination and resident use of therapeutics to NHSN on a weekly basis. LeadingAge will host a special Nursing Home Advisory Group call on Thursday, June 3 to discuss this rule and solicit feedback from members.

FY 2022 SNF PPS Proposed Rule. CMS released the FY 2022 SNF PPS proposed rule on April 8. This rule was reviewed on last month’s Nursing Home Advisory Group call and a special Nursing Home Advisory Group call was held on April 30 to discuss the rule in greater detail and solicit feedback from members. LeadingAge will submit comments on this rule prior to the June 7 comment deadline. Read LeadingAge analysis of this rule here. If you wish to provide feedback for consideration for LeadingAge comments on this rule, please email Jodi Eyigor jeyigor@leadingage.org.

1135 Waivers. As discussed on the April Nursing Home Advisory Group call, CMS terminated 4 specific federal blanket waivers effective May 10. These waivers included notice of discharge/transfer, notice of room/roommate change, MDS submission, and care plan completion. All other federal blanket waivers including the 3-day qualifying hospital stay waiver and the nurse aide training waiver remain in effect at this time. CMS has stated that waivers are available to be used when necessary. When considering whether to use a waiver or when to sunset the use of a waiver and resume non-waived compliance, providers may consider a variety of factors including case and vaccination status within the nursing home; case and vaccination status in the surrounding community; staffing levels; access to PPE, vaccination, and testing; and hospital capacity among other factors. More information on federal blanket waivers is available here.

Government Accountability Office Report on Nursing Homes. The Government Accountability Office (GAO) released a report this month on COVID-19 in nursing homes. This report found that during the months of May 2020 through January 2021, 94% of nursing homes experienced more than one outbreak and on average, nursing homes experienced 3 COVID-19 outbreaks. When assessing duration of outbreaks, GAO found that nursing homes’ longest outbreaks had a duration of more than 5 weeks in 85% of nursing homes. In 66% of nursing home outbreaks, the outbreaks began with a staff member testing positive. LeadingAge notes that outbreaks in nursing homes have decreased significantly since the advent of COVID-19 vaccination.

Abbott BinaxNOW Cards. Abbott has announced that the shelf-life for Abbott BinaxNOW cards has been extended to 12 months. Providers may have received notification of this extension from Abbott and should check the lot numbers of kits currently in their possession to determine new expiration dates.

Member Feedback

On the April Nursing Home Advisory Group call, we reviewed new recommendations from CDC and corresponding updated guidance from CMS on source control and social distancing during activities and dining for fully vaccinated and unvaccinated residents. Following the release of this guidance, we heard from members who were concerned about compliance due to the multiple layers and levers involved in this guidance. Challenges included determining vaccination status of individuals arriving in an activity or dining space after protocols have been established, how to enforce different protocols for individuals within the same group (e.g. unvaccinated residents are required to social distance but vaccinated residents are not), and how to handle conflicting messaging (providers must take the vaccination status of staff into account when determining protocols though this is not stated in guidance).

Consistent with these early concerns, several members on the call confirmed that implementation of this guidance has been challenging and that they are still working out how to fully implement these recommendations. At this time, providers may be piloting hybrid implementation strategies, such as following recommendations for residents, but maintaining source control and social distancing for staff regardless of vaccination status; implementing one part of recommendations while maintaining the other (e.g. allowing source control to be removed but maintaining social distancing or vice versa); or creating systems such as color-codes to assist in identifying vaccination status. Members are also managing confusion and frustration from staff, residents, and families over conflicts between recommendations for healthcare settings and general public health recommendations.

To guide LeadingAge advocacy around these recommendations, we have been soliciting feedback from members on continued access to COVID-19 vaccinations for residents and staff. We are hearing varying degrees of success, with some providers reporting no issues with continued access to vaccines while others are experiencing a great deal of difficulty. One barrier to vaccine access identified early on is reaching demand thresholds. Some pharmacies may be unable to provide vaccine unless the provider has enough expectant residents and staff to complete an entire vial of product.

We continue to welcome feedback on these issues. If you are a LeadingAge nursing home member and wish to provide feedback or would like information on how to join this group, please email Jodi Eyigor jeyigor@leadingage.org. Our next monthly call will take place Tuesday, June 29 at 2pm ET.