ICYMI: CMS Presents Nursing Homes Session at Annual Meeting

Regulation | November 19, 2020 | by Jodi Eyigor

Evan Shulman of CMS presented a session on nursing home regulation at LeadingAge Annual Meeting 2020.

Director, Division of Nursing Homes at CMS Evan Shulman helped wrapped up the LeadingAge annual meeting with a break-out session entitled “Preparing for Your Next Nursing Home Survey”, followed by a live Q&A chat session. Mr. Shulman reviewed current nursing home guidance and provided clarification to some pressing questions.

Outbreak Testing

Mr. Shulman reviewed guidance for testing of nursing home residents and staff in response to onset of symptoms, outbreak within the nursing home, and routine staff testing based on county positivity rates. Mr. Shulman clarified that outbreak testing is not triggered by a resident who is admitted to the nursing home with a COVID-19 diagnosis, but rather by a resident who contracts COVID-19 inside the nursing home or while living at the nursing home.

Further, outbreak testing would not necessarily be triggered by a staff member who tests positive but has not been inside the nursing home at any point during the time when the staff member was potentially contagious. For example, a staff member who has been on vacation for two weeks and tests positive prior to return, or a per diem staff member who has not been in the nursing home at any point over the past 2 weeks would not trigger outbreak testing.

If a positive test result is suspected of being a false positive and there are no other active cases of COVID-19 in the nursing home at that time, the nursing home may delay the initiation of outbreak testing until a confirmatory test result is received. Remember, confirmatory tests must be conducted within 48 hours of the initial test. Likewise, the nursing home may delay notification to residents and families and reporting through NHSN until the confirmatory test result is received. If the result pending confirmation is for a resident, the nursing home should delay moving the resident to the COVID-positive unit until the confirmatory result is received; however, transmission-based precautions should be implemented immediately.

Mr. Shulman also noted that while CMS has specified that test result turn-around times should be 48 hours or less, this time-frame is relative. Test results returned within a more general “two days” is acceptable. Test results that take 3 days or more are not acceptable.

Staff Testing

Mr. Shulman acknowledged that due to CMS’s intended definition of “staff” and the reality that many individuals fitting this definition are not in the nursing home on a regular basis, requiring these individuals to present for regular testing may not be reasonable, and these individuals should be inserted into the nursing home’s testing schedule upon return to the nursing home. For example, a contracted staff member who enters the nursing home once per month would be tested prior to entry, but not required to present for testing otherwise.

Mr. Shulman described 2 additional considerations for the staff testing rule. As included in previous guidance, EMS personnel who are responding to an emergency at the nursing home are not required to be tested prior to entry. These individuals are also exempt from screening to ensure they can attend to the emergency without delay. However, staff providing non-emergent transportation should be tested. Mr. Shulman noted that although these individuals might never enter the nursing home, they pose a risk of transmission to the resident due to the closed environment of the transport vehicle and the consideration that transportation staff may be in contact with multiple residents and multiple healthcare settings. With this in mind, LeadingAge encourages members to reach out to transportation providers to discuss testing and screening procedures. Additionally, one may consider requesting assigned drivers to further limit exposure.

When asked about testing of surveyors, Mr. Shulman stated that CMS is looking into this issue but confirmed that no federal requirement for testing of surveyors currently exists. As with all individuals entering the nursing home, surveyors should be screened for symptoms and exposure and nursing homes should refer any concerns to the state survey agency.


Guidance and restrictions around visitation remain in place, even during the upcoming holidays. Mr. Shulman reiterated that outdoor visits remain the preferred method of visitation but noted changing seasons make outdoor visitation trickier. Nursing homes in colder climates may consider creative solutions for visitation such as external or adjacent structures and should continue to utilize virtual visitation methods. Nursing homes should use their best judgment in determining whether to cancel outdoor visitation during an outbreak. Mr. Shulman also reminded members that CMS does not recognize a special, exempt role of “essential family caregiver” but nursing homes should keep in mind their discretion to allow compassionate care visits when necessary.

Many members have begun to ask about management of residents who have recovered from COVID-19. While these individuals may not be at as great of a risk for infection (or rather, reinfection) as residents who have not previously recovered from COVID-19 infection, these residents do not warrant exceptions to visitation restrictions, as any visitors to these residents continue to pose a risk of transmission to other residents and staff.

Other Regulatory Matters

Mr. Shulman commended nursing homes for their inventiveness and innovation during this pandemic from resident activities like family parades and outdoor activities to clinical strategies like streaming hand hygiene videos in staff break rooms. He encouraged providers to “keep ears and eyes open” for hints at any regulatory changes that may be coming. Pay attention to the flow of attention to see where regulation might be focused next. He added that with health inspections resuming, health inspection ratings will soon follow, though CMS is not ready at this time to resume quality measures ratings.