Nursing facilities have been in the center of the COVID-19 pandemic and experienced sweeping policy changes. The pace of change has made it difficult to keep track of each new policy, so this post summarizes the key shifts from January through May.
Nursing facilities are attempting to protect residents by ramping up existing infection control measures, implementing new protocols, and securing vital supplies—a difficult task given staffing shortages, limited personal protective equipment (PPE), and asymptomatic carriers. Simultaneously, federal, state, and local governments have issued rapid policy changes aimed at improving facilities’ response. Medicare and Medicaid programs have released several requirements and recommendations related to encouraging social distancing, boosting the available workforce, managing administrative burden, and channeling the flow of patients into and out of facilities.
Physical Distancing – Limiting Outside Traffic
Physical distancing recommendations seek to limit the number of potentially infected people that contact nursing facility residents and staff. One of the earliest and most jarring adjustments was the federal guideline restricting access of all visitors and nonessential staff [PDF]. These restrictions effectively reduced the traffic in facilities while isolating residents. These guidelines allow for compassionate exceptions at end of life if visitors wear appropriate PPE. There has been lingering confusion, however, about when and how these exceptions apply.
Telehealth has taken a larger role, just as in the community. Medicare is reimbursing more than 80 services provided via telehealth, including nursing facility admission and discharge visits. The amended federal regulations allow physicians to provide care to both new and established patients via telehealth. The Office of Civil Rights also released a notice of nonenforcement for HIPAA requirements, allowing providers to use platforms not previously allowable. Several states have submitted waiver requests that also allow their Medicaid programs to reimburse for telehealth services more broadly.
Physical Distancing – Limiting Inside Exposure
While some measures focused on limiting the number of people entering nursing facilities, others maintain distance between residents. The federal government waived the requirement that residents be able to participate in in-person resident groups. Facilities have since canceled communal activities. Residents often share rooms, however, and few facilities have space to isolate residents on the scale needed to handle the COVID-19 pandemic. In March, CMS permitted facilities to use a variety of nonresident rooms, such as dining or conference rooms, to supplement their available space.
Restrictions were also eased [PDF] to allow new buildings to open. The federal government approved the certification of nonskilled nursing facilities to act as COVID-19 care sites. They also waived Medicare requirements so new facilities can open rapidly. CMS also broadened the ability of nursing facilities to cohort and transfer residents. Nursing facilities are not currently required to inform residents or families before they are transferred. If staff accompany the relocated resident, CMS still considers the transferring facility as the provider and that facility may bill Medicare for their services.
Nursing facility residents require hands-on care and staff interaction. Federal guidelines recommend that facilities use consistent assignments to limit the number of staff who interact with residents. This also enhances staff’s ability to detect changes in residents’ condition. They further recommend that staff not work across floors, units, or facilities and that staff caring for COVID-19 positive residents refrain from interacting with other residents.
Workforce Management
While social distancing efforts focus on preventing infection, additional changes have been made to handle increased care needs [PDF]. Nursing facilities traditionally struggle to maintain full staffing and minimize turnover, an issue exacerbated by the pandemic. The Centers for Medicare & Medicaid Services (CMS) has made allowances for direct care staff, waiving a requirement that nursing assistants cannot work for more than 4 months without becoming certified. However, those working as nursing assistants must still exhibit competency.
CMS also made Medicare enrollment easier for physician and nonphysician practitioners. CMS has established a toll-free hotline for enrollment and waived screening requirements, including application fees and criminal background checks. The government has expedited all new and pending applications while postponing all revalidation actions. Additionally, all licensed providers can render services outside of their state of enrollment.
Burden Reduction
Federal and state governments have aimed several efforts at reducing the administrative burden on nursing facilities. Federally required data submissions have been limited, including extended deadlines for cost reports, eased requirements for Minimum Data Set completion, excepted months from the quality reporting program [PDF], suspended submissions for the Payroll-Based Journal [PDF], modified timelines for providing patient records, and reduced quality assurance and performance improvement measures. Several states have applied for waivers that suspend mental health assessments [PDF] for newly admitted residents and transfers for 30 days. Finally, CMS has postponed routine survey inspections. They are holding nursing home compare scores constant while state staff perform infection control inspections.
To ease the economic effects, CMS expanded the Accelerated and Advance Payment Program [PDF], which provides advance payments when there is a disruption in claim submission or processing, to a broader group of Medicare Part A providers and Part B suppliers. The Coronavirus Aid, Relief, and Economic Security (CARES) Act suspends the 2% across-the-board sequestration cuts that have been in effect since 2013 until December. Some states are also shielding health care facilities from lawsuits related to COVID-19, although policies vary widely by state.
The federal and state governments have enacted some additional reporting requirements to help track the impact of the pandemic. In April, CMS announced a requirement that all nursing facilities report cases of COVID-19 [PDF] to the CDC, residents, and families.
Patient Flow
The COVID-19 pandemic changed the regular flow of patients into and out of nursing facilities. A few states have issued guidance that facilities may not decline admission to patients based solely on a diagnosis of COVID-19, while Louisiana temporarily prohibited hospitals from discharging [PDF] COVID-19 positive patients to nursing facilities. CMS has authorized hospitals to establish more skilled nursing facility (SNF) swing beds under the prospective payment system. Across the country, patients with COVID-19 are being separated in specialized units, facilities, or recovery centers.
Changes have not solely affected patients with COVID-19. Nursing facilities are seeing fewer admissions because of postponed elective surgeries [PDF] that would require SNF care for recovery. At the same time, the Medicare requirement for a 3-day hospitalization prior to SNF admission [PDF] has been waived, allowing facilities to admit individuals more quickly. CMS also authorized SNF coverage autorenewal without the start of a new benefit period, allowing beneficiaries who have exhausted their coverage to stay in place.
Facilities are also seeing changes related to discharge planning. The federal government has waived the requirement that facilities help residents select a post-acute care provider during discharge planning. Some states have updated additional policies for discharges aimed at increasing flexibility [PDF] and ensuring safety [PDF] during the pandemic.
Where do these changes leave nursing facilities?
The enormous challenges of the COVID-19 pandemic and the accompanying policy changes have transported nursing facilities into a new world. The changes have good intentions of supporting facilities through the pandemic, but many feel they fall short. Nursing facilities will need to establish stability, yet more changes lurk on the horizon, including input from the commission announced in May and the proposed Quality Care for Nursing Home Residents & Workers During COVID-19 Act. After just 5 months of regulation changes, it is clear that the effects of COVID-19 on nursing facility policy will be relevant for years to come.
Denise Tyler