State Updates LTC Facility Guidance

September 3 - Secretary of Health Dr. Rachel Levine released updated skilled nursing facility guidance that includes recommendations on COVID-19 routine (or, “screening”) testing strategies for facilities not experiencing an outbreak, Compassionate Caregivers, access to facilities for resident advocates and a revised reopening timeline after a mitigated outbreak.

The action comes after weeks of pressure from news media, legislators and families to get more information on what the state has done and what it plans for protecting those in long term care facilities from the COVID-19 virus.  Most recently, the Commonwealth has been under fire for a lack of “granular” data to support its actions, and confusing reports about universal testing at the nearly 2,000 LTC facilities across the state.

“We continue to practice a careful, measured approach in nursing homes so all staff and residents can safely welcome Compassionate Caregivers, in addition to visitors, and return to a more normal routine,” Secretary of Health Dr. Levine said. “Our updates on testing and compassionate caregiving follow the recommendations from the Centers for Medicare and Medicaid Services. We developed this guidance through collective input from stakeholders, interagency partners, industry leaders and facility representatives to allow safe caregiving, in addition to visitations with strong public health measures to balance the mental and physical well-being of Pennsylvania’s most vulnerable residents.”

The number of COVID-19 cases in the community surrounding a skilled nursing facility has a direct impact on the risk of COVID-19 introduction into a facility. Immediate testing of residents and staff experiencing COVID-19 symptoms is strongly recommended. The Centers for Medicare and Medicaid Services and the department recommend facilities that are not experiencing an outbreak continue testing asymptomatic staff and some residents. These new testing recommendations are:

· In a county with low COVID-19 activity, defined as less than 5 percent positivity rate within seven days according to federal data:

o Routine testing of asymptomatic residents is not recommended.

o Routine testing of asymptomatic staff is recommended every four weeks.

· In a county with moderate COVID-19 activity, defined as a seven day percent positivity between 5 and 10 percent according to federal data:

o Routine testing of asymptomatic residents is encouraged of all residents with outside contact in the last 14 days, if they have not otherwise been tested during that period.

o Routine testing of asymptomatic staff is recommended once a week.

· In a county with substantial COVID-19 activity, defined as a percent positivity greater than 10 percent according to federal data:

o Weekly testing is recommended of all asymptomatic residents with outside contact in the last 14-days, if they have not been otherwise tested during the period.

o Routine testing of all asymptomatic staff twice a week.

Facilities experiencing an outbreak should immediately begin universal testing, ideally of all staff and residents.

Skilled nursing facilities that are not operating under restrictions due to an outbreak should follow specific guidance regarding visitors. This includes restricting all visitors, except for those identified by the department. Those identified as permitted to access include clinicians; home health and dialysis services; Adult Protective Services investigators; the Long-Term Care Ombudsman; visitors during end of life situations; licensed providers within the facility, Department of Health and local public health officials; and law enforcement.

Compassionate Caregiving is allowed in limited situations per CMS’ FAQs on Nursing Home Visitation. The department recognizes the connection between mental and emotional health and physical health, and that the effects of prolonged isolation may have significant impacts on one’s physical health. In such instances, facilities are expected to work with the resident, family and staff to identify Compassionate Caregivers and provide the resident with access to care needed to improve their health status. Compassionate Caregivers are a family member, friend, volunteer, or other individual identified by a resident, the resident’s family or facility staff to provide the resident with compassionate care.

Compassionate Caregivers must follow a number of requirements, as outlined in the guidance, including proof of a negative COVID-19 test within the prior seven days, screening and universal masking.

The guidance also provides an update for facilities regarding when they may allow for safe visitation following an outbreak. These provide updated information on and clarify the previous reopening guidance for facilities.

In order to cautiously lift restrictions in skilled nursing facilities, the department will continue to require all LTCFs to meet several prerequisites before proceeding into the official three-step process of reopening. First, the facility must develop an implementation plan and post that plan to the facility’s website, if the facility has a website, that should include at a minimum, the following components:

· A comprehensive testing plan that includes information on when universal testing was completed, and the capacity and procedures to perform additional testing.

· A plan for cohorting or isolating residents diagnosed with COVID-19 in accordance with PA-HAN 509;

· Written screening protocols for all staff during each shift, each resident daily, and all persons entering the facility;

· A plan to ensure adequate staffing and supply of personal protective equipment for all staff;

· A plan to allow for communal dining and activities to resume; and

· A plan to allow for visitation.

Once a facility meets the required prerequisites, the facility will enter a three-step process of reopening as outlined below:

Step One: From the date the facility enters step one, a facility must maintain no new COVID-19 outbreaks among staff or residents for 14 consecutive days in order to enter step two.

Step Two: While in step two, facilities are required to maintain no new outbreaks of COVID-19 among staff or residents for 14 consecutive days to progress into the final step.

Step three: The final step allows nursing homes to operate as outlined for the remainder of the Governor’s COVID-19 Disaster Declaration as long as there are no new COVID-19 outbreaks among staff and residents for 14 consecutive days.

If a new COVID-19 case is known, facilities will cease implementing their reopening plan and wait until they have no new COVID-19 cases for 14 consecutive days before re-entering step two.

Each step of the plan includes specific criteria for conducting dining, activities, non-essential personnel, volunteers, visitors and outings.

Visitations are allowed in steps two and three as long as the facility determines a resident is able to safely see visitors and will prioritize those with diseases causing progressive cognitive decline and residents expressing feelings of loneliness, if they do not qualify for Compassionate Caregiving. A facility must designate visitation hours, locations (preferably outside or a pass-through not typically occupied or frequented by residents), and screenings to permit a visitor into the building. During the entirety of the visit, social distancing and infection control protocols must be followed along with enforcing the proper hand hygiene with alcohol-based hand sanitizer and universal masking. Facility staff will monitor visits to ensure all safety guidelines are met and enforced. After each visit concludes, staff will need to sign out the visitor and properly disinfect the designated visitation location.

Since the beginning of the COVID-19 pandemic, the Wolf Administration has taken a three-pillar approach to protecting the residents living in LTCFs by:

· Ensuring resident safety through testing, education and resources;

· Preventing and mitigating outbreaks; and

· Working in partnership with state agencies, local health departments and LTCF operators.

The department, along with additional state agencies, has provided long-term care facilities with the resources and expertise in order to prevent or control existing outbreaks. These include:

· Through the Department of Human Services (DHS), established the Regional Response Health Collaboration Program (RRHCP) to directly support COVID-19 continued readiness and response planning in long-term residential care facilities, improve quality of care related to infection prevention, expand COVID-19 testing to include asymptomatic staff and residents in facilities, and facilitate continuity of care and services provided by long-term care facilities in an attempt to mitigate the risk of spread of COVID-19 to staff or residents. This effort is a collaboration between DHS, the department, Centers for Disease Control and Prevention, and the Pennsylvania Emergency Management Agency.

· PEMA coordinates closely with the Department of Health as they evaluate various types of support that may be needed at facilities across the commonwealth. Once specific needs are identified, PEMA works with agencies, such as the Pennsylvania National Guard, to provide the support needed as quickly as possible.

· Staff from the quality assurance team, who conduct onsite visits to facilities and investigate complaints and concerns related to the safety of residents;

· The healthcare associated infection (HAI) team has provided direct consultation with facilities experiencing outbreaks. This team has worked with 100 percent of the healthcare facilities experiencing outbreaks across the state;

· Create rapid response strike teams using the state’s staffing contract with nurses to staff the facilities in need;

· ECRI, the infection control contractor working with the state, has provided additional technical assistance and support to more than 130 facilities;

· The Patient Safety Authority, an independent state agency, has used their knowledge to assist at least 90 facilities as well;

· Quality Insights, the Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Pennsylvania, is working with close to 100 facilities on infection control;

· The state’s healthcare coalitions, which exist in each region of the state, and regional coalition emergency managers, have worked to directly assess facilities and deliver PPE;

· Medical reserve corps and the Department of Human Services have also provided virtual mental health services to facilities;

· General Health Resources, a contractor working with the state to assist close to 60 long-term care facilities;

· CDC teams provided on-site assistance for at least 13 long-term care facilities using their infection prevention and control expertise and training of HHS teams; and

· HHS teams provided on-site assistance for at least 22 long-term care facilities using their infection prevention and control expertise and training of GHR teams.

· Operational assistance and guidance from the quality assurance team, healthcare acquired infection (HAI) team, ECRI, the Patient Safety Authority and the Pennsylvania National Guard;

· Sharing information through bulletin boards, nursing home associations, and our normal channels of communication such as Health Alert Network messages;

· Prioritizing nursing homes and long-term care facilities to receive PPE, and for testing among symptomatic individuals.