Updates from CMS - Interview with Evan Shulman – February 11, 2021

Regulation | February 11, 2021 | by Jill Schumann

Evan Shulman, Director, Division of Nursing Homes, Centers for Medicare and Medicaid Services, joined the LeadingAge Coronavirus Update Call on February 11, 2021.

Listen to the interview here.

Evan Shulman, Director, Division of Nursing Homes, Centers for Medicare and Medicaid Services, joined the LeadingAge Coronavirus Update Call on February 11, 2021. He responded to questions from Ruth Katz and from callers.

Q: Now that residents and staff are being vaccinated a frequent question is, “When will visitation and other guidance be revised?”

A: It is the question of the hour and we are hearing it a lot. The answer is – not yet, not now - but we want to do it as soon as we possibly can because we understand the concerns. Here’s why we aren’t revising the guidance yet:

  1. It’s too early – we need to get everyone a second dose and wait two weeks after that and we aren’t there yet. The decline in cases began prior to vaccination – so it is not attributable solely to vaccines.
  2. We don’t yet know if vaccines prevent transmission. We do know that it prevents people from getting sick, but it is possible that a person who has been vaccinated can transmit the virus to others.
  3. It is too early to know if the vaccines protect against the variants.

Therefore, we can’t change visitation guidance yet, but we will as soon as we can. Remember – the guidance does not prohibit all visitation. As community cases fall, more visitation is possible.

Q: Social isolation is a tough struggle and some states have developed Essential Caregiver programs. How does this square with the CMS guidance?

A: Federal law does not differentiate between one type of visitor and another. We understand that some states have established Essential Caregiver programs to identify regular visitors who follow particular rules. Visitation should be person-centered. If a person needs a visitor to help them, that resident does not have more rights to a visit than other people in the facility. Essential Caregiver approaches can be done, but they need to be done in light of person-centered care and also in light of infection control concerns and federal guidance.

Q: If 100% of staff and residents are fully immunized, can nursing homes open internally for dining, activities, etc.?

A: I would again give the same answer as I did to the first question. It is too early – but existing guidance does allow for dining with social distance, appropriate infection control, etc.

Q: It would be great to see more collaborative and less punitive surveys. That seemed to happen during COVID in the infection control surveys. What is your perspective?

A: At CMS we do not support collaborative surveys because the foundation of oversight depends on accountability from an objective regulator who holds a facility accountable. That does not mean that surveyors shouldn’t be professional. I would use an example of police whose job is to enforce the law in an objective manner. Similarly, the survey process needs to be objective, not a consultative training session. There are other avenues for consultation and training including CIOs, recorded trainings for surveyors, and so many avenues for technical support and collaboration.

Q: Pushing back a little – in the police example there may be different goals – I want to speed and the officer wants to uphold the law. In nursing home care surveyors and the nursing home have the same goal -to provide good care. This shared goal might make things a bit different don’t you think?

A: No – CMS does not see it that way. The police officer is there to prevent someone from causing injury and that is the surveyor’s role as well. There are lots of avenues for free technical support and training.

Q: What are your reccomendations for providers as they get ready for surveys?

A: Start systemically using the QAPI processes and teams. Look at the whole house since you are only as strong as the weakest breach in the facility. Take a holistic approach and understand that each person is a key link in the infection control chain. And, of course that applies to all aspects, not just infection control.

Q: Do you have updates on Phase 3 Requirements of Participation and guidance?

A: We do not yet have guidance and we are still looking at what we can put out. Use your best efforts to comply with Phase 3 starting with the big pieces like infection preventionists and work toward full compliance with all of Phase 3.

Q: Are nursing homes required to report vaccinations of staff and residents into NHSN?

A: It is not a formal requirement. However, we encourage everyone to do that as that information accelerates out ability to release relaxed guidance. You will not get cited for not entering it, but the more we know the sooner we can make updates to guidance.

Q; Could Essential Caregiver visits be compassionate care visits?

A: CMS describes compassionate care visits as non-routine. The definition of compassionate care is pretty liberal, but depending on how visits are structured, it may or may not be appropriate.

Q: How is CMS addressing inconsistencies between surveyors?

A: We are looking at this. When we look for consistency that does not just mean bringing the top down, it also means bringing the bottom up and working toward consistent interpretation of regulations and guidance.

Q: Does a facility that tests a visitor as positive count as an outbreak that changes the testing frequency?

A: No, it is only residents and staff that trigger an outbreak response. However, it would be important to do some follow up to check on visitor interactions and so forth.