LeadingAge Nursing Home Roundtable - February 23, 2021

Regulation | February 24, 2021 | by Jodi Eyigor

CMS Director of the Division of Nursing Homes, Evan Shulman, joined LeadingAge nursing home members on February 23 for the monthly roundtable call.

The new LeadingAge Nursing Homes Monthly Roundtable held its first call on Tuesday, February 23, 2021. At the request of LeadingAge, CMS Director of the Division of Nursing Homes, Evan Shulman, joined as a special guest speaker to present on several of the current hot topics and answer questions from members. Mr. Shulman’s presentation was following by policy updates from LeadingAge staff. This month’s call reached maximum capacity and arrangements have been made to increase capacity for future calls.

News from CMS

CMS is working with CDC on the conditions under which CMS guidance can be revised to allow more visitation. Mr. Shulman reported that CMS is eager for nursing home visitation to be expanded and vaccination will help. Mr. Shulman pointed out 3 factors that have complicated the process. First, vaccination is not fully effective until approximately 2 weeks after the final dose in a vaccine series. However, Mr. Shulman admitted that this concern is diminishing as time goes on. Secondly, we know that vaccines prevent severe illness and even death, but we still do not know much about how effective vaccines are at preventing transmission. Lastly, with staff turnover and new resident admissions, there will always be new individuals in the nursing home who have not yet been vaccinated.

CMS is well aware of the devastating effects of isolation caused by visitation restrictions in terms of weight loss, loss of function, and depression. CMS recognizes that “the risk of dying from COVID is not as high as the impact of isolation” now that many residents and staff are vaccinated. Cases are plummeting and it’s time for a change in policy. CMs is working to adjust visitation guidance and Mr. Shulman pointed out, “Testing will be very important in changing visitation policy.”

Nursing Home Compare is now under the new Care Compare. The old “Nursing Home Compare” site was retired in December and all information remains available under the new Care Compare site introduced by CMS in 2020. The information on Care Compare is consistent with what was presented on Nursing Home Compare, but in a more user-friendly fashion. In December, CMS announced that all components of the Five Star Quality Rating system would resume with the January 2021 update. (Read the LeadingAge review of these changes here).

Mr. Shulman noted that findings from focused infection control surveys are now included in the health inspection domain and star rating calculation. These types of surveys will continue in the future. Mr. Shulman expressed the importance of staff holding one another accountable for infection control practices and urged members not to let their guard down just because they’ve stepped off the clinical unit. Mr. Shulman also hinted that the staffing domain will evolve to include information on nursing home staff turnover. Staff turnover remains a concern for CMS. Mr. Shulman stated, “We know that lower turnover leads to better quality. That’s in the data. It’s something to think about for the future.”

Interpretive Guidance is coming. CMS was working on releasing interpretive guidance for phase 3 of the Requirements of Participation when COVID hit. They are soon returning to work on that guidance again, as well as some changes to phase 2 guidance. Mr. Shulman pointed out that providers should work on the things that are clear in regulation, even without guidance. For instance, every nursing home should have a trained infection preventionist on site. The question of whether this means “part time” or “sufficient time” is yet to be resolved. (Recall, this question was introduced in the proposed rule from July 2019. The rule has not yet been finalized. You can read the LeadingAge review of this rule here.) Mr. Shulman confirmed that the guidance will include a prescribed time for infection preventionist and recommended that providers start with what is clear in regulation, then work down to what might need guidance.

Questions from Members. The following questions from members were moderated for Mr. Shulman:

Q: Some primary care physicians refuse to do in-person visits with nursing home residents because the providers don’t want to be tested. Do you have any recommendations?

A: With the advent of vaccines, testing is more important than ever. Do everything you can to compel them to be tested. Use the rapid antigen testing machines – there is an advantage to quick tests sometimes -- or PCR. Show the physicians the CMS memo and CDC guidance.

Call participants suggested requiring all health care providers to be tested, not just those in long-term care; and asked that CMS send primary care doctors and certified providers information about why testing is necessary.

Q: Regarding visitation, many family members want to come in to provide care, such as being able to feed their loved ones. How should this be handled?

A: This is a very difficult question because all visitors are equal, whether they are there to help the resident with ADLs [activities of daily living], help them eat, or just to say hi. Every resident has the same right to a visitor. Of course, there is nothing to prohibit family members from visiting and helping the resident eat – except to note that this is the job of the nursing home technically. Visitor programs should not supplant the nursing home. To complicate matters, if visitors are specifically there to help with feeding they would have to be designated as volunteers and treated as staff, causing challenges for the provider. I am especially concerned about Essential Caregiver programs because if everyone has one, we have a big infection control concern. It’s like just opening up with no extra considerations. There is not a lot of space for CMS in terms of essential caregivers. But if you use a person centered approach, there are ways to enable visits from people who may meet the definition of an essential caregiver. So, there may be ways to integrate some of the concepts.

Q: Is there any consideration at CMS about adjusting visitation guidance during an outbreak to limit visits only in the affected units?

A: CMS is aggressively working with CDC now on how to adjust the guidance. This is an important question. CMS is looking at two areas: first, the same thing that caused nursing homes to be the epicenter of COVID is the thing that has let us help nursing homes get ahead of the curve of positivity in the entire community. Visitation guidance that relies on community positivity is not a good barometer anymore. Second, when you have a good amount of people vaccinated, and outbreak is contained, do you need to shut down the whole facility because you have one case? We believe there possibly is a way that safe visitation could be enabled even when there’s a new case. CMS is looking at all of this closely and is trying to get something out very soon.

Policy Updates

Following Mr. Shulman’s presentation and member questions, LeadingAge reviewed several policy updates that have occurred over the past several weeks.

Vaccine Access After the Long-Term Care Pharmacy Partnership Program. The Long-Term Care Pharmacy Partnership Program is set to wrap up final clinics by the end of March. The Retail Pharmacy Program will be the next step in vaccine allocation. Learn more about what comes next here.

Expanding Access to Monoclonal Antibody Treatments in Long-Term Care. Operation SPEED is working to expand access to monoclonal antibody treatments for nursing home residents by partnering with long-term care pharmacies, home infusion companies, and the medical reserve corps. Learn more about this initiative here.

CDC Guidance on Post-Exposure Quarantine for Vaccinated Persons. CDC updated guidance on February 10 regarding post-exposure quarantine for vaccinated persons. This guidance does not apply to residents in nursing homes. These residents should continue to quarantine for the full 14 days following exposure. This guidance may be applied to healthcare personnel in nursing homes to mitigate staffing shortages. Read more here under “Public health recommendations for vaccinated persons”.

CDC Guidance on TB Testing and Vaccination. CDC guidance recommends delaying 4 weeks post-vaccination for routine TB testing if the vaccination was placed prior to TB testing. Read more on this recommendation here under “Laboratory testing”. LeadingAge has clarified with CMS that under federal guidance, TB screening and testing occurs according to nationally-accepted standards, thus following the CDC guidance to delay TB testing is acceptable. However, members should check state regulations to ensure compliance at the state level.

LeadingAge Advocacy. LeadingAge has launched the 100 Days of Advocacy to advocate for aging services policies at the federal, state, and local levels. Find out more here. Make your voice heard with our Action Alert here urging Congress to pass expanded COVID relief. Mark your calendars for April 21, 2021 for our Virtual Lobby Day event. And don’t forget to check out our 2021 Policy Priorities here. Policy Priorities are formed with input from LeadingAge members across the country and guide our work throughout the year.

The Nursing Home Roundtable call will take place on the last Tuesday of every month at 2:00pm ET. If you are interested in joining, please email Jodi Eyigor jeyigor@leadingage.org to be added to the mailing list. Also, be sure to email Jodi or Janine Finck-Boyle jfinck-boyle@leadingage.org with any suggestions for topics or feedback on format of the calls. As this call is new, we expect it to evolve over the coming months and encourage member input on this process.