In a memo to state officials on May 18, CMS released phased reopening guidance for nursing homes. This guidance is crosswalked to the White House’s Opening Up America Again guidelines and describes the various activities, services, and survey activity that may be implemented in each phase. CMS also released an FAQ document to answer questions related to reopening, visitation, and testing.

State officials will determine how nursing homes in each state progress through the phases of reopening. State officials may choose:

  • All nursing homes in the state progress through the phases together. Nursing homes do not enter or advance through a phase unless all nursing homes have met criteria.
  • All nursing homes in a given region, such as a county, progress through the phases together. Nursing homes in the county do not enter or advance through a phase unless all nursing homes in the county have met criteria.
  • Nursing homes progress through the phases on an individual basis. A nursing home enters or advances through a phase when it has met the criteria.

CMS states that decisions to relax restrictions on nursing homes should be made in collaboration with state and/or local health officials and nursing homes. Given the constantly evolving nature of this pandemic, state and local leaders should be constantly re-evaluating and modifying plans as needed.

The following factors should be considered in this decision-making:

  • Case status in community, including state-based criteria to determine community transmission.
  • Case status in the nursing home(s), including no new nursing home onset of COVID-19 cases among residents or staff.
  • Adequate staffing with no staffing shortages. The nursing home(s) are not operating under a contingency staffing plan.
  • Access to adequate testing. The nursing home(s) should have a plan in place for testing, as outlined below under “Testing”.
  • Universal source control. All residents and visitors should wear a cloth face covering or facemask, maintain social distancing, and practice hand hygiene upon entering the nursing home.
  • Access to personal protective equipment (PPE). The nursing home(s) may be utilizing contingency strategies (as outlined in CDC’s Strategies to Optimize the Supply of PPE and Equipment) but should not be operating at crisis-capacity strategies.
  • Local hospital capacity, including the hospital’s ability to accept transfers from nursing homes.

Testing

Along with the Trump Administration’s recent recommendation to governors regarding universal testing of nursing homes, CMS has included in the reopening guidance a recommendation that nursing homes should have a testing plan in place considering the following:

  • Resident testing: All residents receive a single, baseline test for COVID-19. Residents are subsequently re-tested upon the identification of a single individual with symptoms consistent with COVID-19 or a staff member who tests positive for COVID-19. Residents will be re-tested until all residents test negative.
  • Staff testing: All staff receive a single, baseline test for COVID-19. “Staff” includes any vendors or volunteers who are in the nursing home on a weekly basis. Staff are subsequently tested on a weekly basis thereafter. State or local officials may adjust the frequency of staff testing based on community data.
  • Screening protocols: Nursing homes must have written protocols for screening all residents daily, all staff each shift, and all others upon entering the facility.
  • Arrangements with labs: Nursing homes must have arrangements with labs to process tests. Tests must be able to detect the virus with greater than 95% sensitivity and 90% specificity. Results must be obtained within 48 hours and antibody tests should not be used for diagnostic purposes.
  • Refusals: Nursing homes must have written procedures for residents or staff who decline or are unable to be tested.

Nursing homes should remain in the current state of highest mitigation while the surrounding community is in phase I of Opening Up America Again. Baseline testing of all residents and staff is required prior to a nursing home advancing through phases or relaxing any restrictions. For nursing homes that have experienced a significant outbreak, the state should survey the nursing home prior to reopening. Nursing homes should spend a minimum of 14 days in a given phase prior to advancing to the next phase. If a nursing home experiences a new nursing home onset case at any point in time, that nursing home returns to the highest level of mitigation and must start over.

Further analysis of the phases, including the reintegration of survey activity, is available here. Nursing homes should also refer to the chart in QSO-20-30-NH for full information on each phase.

What This Means for Nursing Homes

Nursing homes now have a plan for recovery and reopening. However, recall that this guidance is to be accepted and implemented at the state level. Implementation, and therefore recovery, may vary drastically from state to state and nursing home to nursing home. The phased reopening of nursing homes will be complex and complicated at best. Certain recommendations, such as adequate staffing, adequate PPE, and a testing plan including baseline testing for all residents and staff, will prove insurmountable without significant support for nursing homes. LeadingAge will continue advocacy efforts for tangible resources to assist nursing homes in protecting the vulnerable populations in their care.