CMS Outlines Key Activities of Nursing Home Reopening

Regulation | May 19, 2020 | by Jodi Eyigor

CMS has released recommendations to state and local officials on a phased nursing home reopening, including key activities that characterize each phase.

CMS issued recommendations to state and local officials on May 18 related to reopening of nursing homes. These recommendations are to be considered along with a number of other community- and nursing home-specific factors and must be adopted and implemented by the state. CMS released a FAQ document to accompany this memo. LeadingAge provided a high-level analysis of these recommendations, available here.

Recall that states may choose from a number of options for how nursing homes within the state will progress through the phases of reopening. States must also consider a number of factors in determining when nursing homes may begin reopening. Reopening is contingent upon a testing strategy outlined by CMS, in which all nursing home residents and staff receive an initial baseline COVID-19 test. The testing strategy then outlines subsequent testing of residents and staff, which will be maintained throughout the 3 phases of reopening. The feasibility of this testing strategy and other factors such as adequate PPE and staffing, will impact reopening.

What follows below is an overview of each of the 3 phases, as outlined by CMS. These phases include a description of community status, nursing home restrictions, and survey activity at each phase.

Current State: Significant Mitigation

Nursing homes remain at the highest level of vigilance. The surrounding community may be in phase 1 of Opening Up America Again. Visitation is generally prohibited except in certain compassionate care situations. Non-essential healthcare personnel are restricted. Communal dining is limited to COVID-19 negative or asymptomatic residents only, with social distancing enforced. Group activities are restricted, though some activities may be conducted for negative or asymptomatic residents only, with social distancing enforced. Non-medically necessary trips should be avoided and for medically necessary, unavoidable trips, residents must wear a facemask or cloth face covering. The nursing home must inform the transportation service and the receiving provider of the resident’s COVID-19 status.

All residents, staff, and any individual entering the nursing home are screened for temperature and signs and symptoms of COVID-19. Staff and other individuals entering the nursing home are additionally screened for potential exposure to COVID-19. Universal source control is implemented for all individuals in the nursing home. Residents and visitors entering for compassionate care wear cloth face coverings. Staff wear all indicated personal protective equipment (PPE). Staff wear cloth face coverings if facemasks are not indicated.

After initial baseline testing, all staff are tested weekly for COVID-19. Residents are re-tested upon identification of an individual with COVID-19 symptoms or if a staff member has tested positive for COVID-19. Residents are re-tested weekly until all residents test negative. Residents are cohorted according to COVID-19 status, including a designated space to manage new admissions/readmissions with unknown COVID-19 status and residents who develop symptoms.

Survey activity is prioritized to complaints and facility-reported incidents triaged at immediate jeopardy-level, including any necessary revisits; focused infection control surveys; initial certification surveys; and any state-based priorities such as local hot-spots or strike teams.

Phase 2

The surrounding community has met criteria for phase 2 of Opening Up America Again, meaning there has been no rebound in cases after 14 days in phase 1. The nursing home has had no new nursing home onset of COVID-19 cases in 14 days and has adequate access to COVID-19 testing. The nursing home is not experiencing any staffing shortages and has adequate supplies of PPE and essential cleaning and disinfection supplies. Referral hospitals have capacity to accept residents from nursing homes, including capacity on intensive care units.

Visitation continues to be generally restricted, as above in “current state: significant mitigation.” Communal dining remains limited as above. Resident appointments continue to be limited to medically necessary appointments and residents must continue to wear a cloth face covering or face mask, with COVID-19 status being communicated to transportation and receiving providers.

Screening and testing continue, as above, and universal source control remains in place for all residents, staff, and individuals entering the building. Staff continue to wear PPE as indicated and a cloth face covering when a mask is not indicated. Cohorting continues, as above.

Phase 2 does introduce a few changes into nursing home operations. Limited numbers of non-essential healthcare personnel and contractors as determined necessary by the nursing home may be permitted entry. These individuals will follow the precautions outlined for all others entering the building: screening and temperature check at entry, social distancing, hand hygiene, and use of a cloth face covering or facemask. Phase 2 also allows for limited group activities and outings, though these groups should be limited to 10 people or fewer and all must continue to practice universal source control including wearing cloth face coverings or facemasks, social distancing, and appropriate hand hygiene.

Survey activity will also continue reintegration. Phase 2 will reintroduce investigation into complaints and facility-reported incidents (FRI) alleging actual harm to residents, though CMS has not indicated that revisits not related to immediate jeopardy will resume. CMS provides guidance to states to prioritize complaint/FRI surveys as follows:

  1. Abuse or neglect
  2. Infection control, including failure to comply with new requirements for reporting COVID-19 information to residents, representatives, and families
  3. Violations of transfer/discharge requirements
  4. Insufficient staffing or competency
  5. Other quality of care issues (e.g. falls, pressure ulcers, etc.)

Phase 3

The surrounding community has met criteria for entering phase 3 of Opening Up America Again, meaning there have been no rebound in cases while the community was in phase 2. The nursing home has had no new nursing home onset of cases in at least 28 days while in phases 1 and 2 of Reopening Nursing Homes and has adequate access to testing. The nursing home is not experiencing any staffing shortages and has adequate supplies of PPE and essential cleaning and disinfection supplies. Referral hospitals have capacity to accept residents from nursing homes, including capacity on intensive care units.

In phase 3, communal dining remains limited. Medically-necessary resident appointments continue as above. Screening and testing continue. Universal source control remains in place for all individuals inside the nursing home. Staff continue to wear all appropriate PPE, with cloth face coverings in use when a facemask is not indicated. Cohorting of residents, including new admissions/readmissions with unknown COVID-19 status and residents who develop symptoms, continues.

Phase 3 does see a few more changes in restrictions. Visitation resumes, though additional precautions remain in place. All visitors will be screened and required to perform hand hygiene upon entry. Visitors will wear cloth face coverings or facemasks during visits and practice social distancing. Non-essential personnel/contractors will be admitted as determined necessary by the nursing home and will be subject to the same screening and precautions. Lastly, group activities and outings are further relaxed, though numbers are limited by considerations such as the ability to maintain social distancing. Only residents who are COVID-19 negative or asymptomatic are permitted, and all residents must practice hand hygiene and wear cloth face coverings or facemasks.

Normal survey activity resumes in phase 3. Infection control surveys and state-based priorities such as hot-spots and strike teams, remain in the survey activity milieu. CMS provides guidance to states to prioritize standard recertification surveys as follows:

  1. Facilities that have had a significant number of COVID-19 positive cases
  2. Special Focus Facilities
  3. Special Focus Facility candidates
  4. Facilities that are overdue for a standard survey and have a history of harm-level noncompliance in abuse or neglect, infection control, violations of transfer/discharge requirements, insufficient staffing or competency, and other quality of care issues (e.g. falls, pressure ulcers, etc.).

What This Means for Providers

What is outlined in the 3-phase framework by CMS constitutes the entirety of nursing home reopening guidance at this time. It remains unclear how long the “new normal” such as universal source control, screening of staff and visitors, testing protocols, infection control surveys, and limitations to dining and group activities, will remain in place. Additionally, it seems unlikely that the survey activity will follow the course outlined by CMS, since the potential exists that not all nursing homes in the state will be in the same phase at the same time. 

What is also unclear is how nursing homes are expected to realistically meet recommendations and requirements without significant support. For example, testing all staff on a weekly basis requires access to rapid-result testing and access to supplies required for testing. Adequate PPE has been an issue for nursing homes since the beginning of this pandemic and no relief is in sight. Even the care packages being issued by FEMA provide only a 7-day supply, and do not include the CDC-recommended PPE, such as the N95 respirator.

While this framework will be invaluable as we consider recovery in nursing homes, support is needed on a federal level in order to make these recommendations reality while maintaining the safety of residents.