New DOH COVID-19 Guidance Aligns with CDC/CMS on Nursing Home Staff Testing, Continues Visitor Testing

The Department of Health (DOH) released updated guidance for nursing homes on Oct. 13, 2022 that aligned with many of the updates issued by the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare and Medicaid Services (CMS) in September. Most notably, DOH followed the lead of the CDC and CMS by eliminating the requirement that nursing homes routinely test asymptomatic staff for COVID-19. The new DOH guidance also addressed testing in other contexts, masking in health care settings, visitation, and cohorting. Although it generally aligned with the recent federal guidance, it also included several state-specific requirements and emphases.

The following are highlights of the updated DOH guidance. Members are encouraged to read the document and the related CDC and CMS guidance in their entirety.

Masking in Health Care Settings

The DOH guidance continues masking requirements for all personnel in facilities and agencies licensed under Public Health Law (PHL) Articles 28, 36, and 40. In addition, it states that all visitors age 2 and older and able to medically tolerate a face mask must wear masks in health care settings. It is unclear whether DOH is following the CDC guidance that would allow personnel to unmask in "well-defined areas that are restricted from patient access (e.g., staff meeting rooms)" under certain circumstances.

Testing in Nursing Homes

Routine Screening Testing of Staff: The guidance aligns with CMS QSO 20-38-NH revised and no longer recommends routine screening testing of asymptomatic staff. Accordingly, nursing homes do not have to routinely test asymptomatic staff, even if they are not up-to-date with COVID-19 vaccinations. However, facilities may conduct routine testing if they choose. For example, although this is not specified in the DOH guidance, a facility might choose to conduct routine testing as an additional precaution for staff who are exempt from vaccination. The DOH guidance specifies that staff should be instructed to report to the appropriate facility contact any positive COVID-19 test, symptoms of COVID-19, or a higher-risk exposure to COVID-19.
Testing of Symptomatic and Exposed Residents and Staff: The DOH guidance instructs nursing homes to test symptomatic individuals and those with close contacts to a person with a COVID-19 infection in accordance with CMS QSO 20-38-NH, Table 1.
Outbreak Testing: DOH directs facilities to follow CMS QSO 20-38-NH when a single new case of COVID-19 occurs among residents or staff. It notes that outbreak testing should begin immediately, but not earlier than 24 hours after an exposure. Facilities may continue to use either a contact tracing approach or a broad-based (i.e., unit-wide or facility-wide) approach to outbreak testing. Notably, the CDC guidance, which is referenced in the CMS QSO, provides more detailed instructions regarding outbreak testing:
- Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5.
- Empiric use of Transmission-Based Precautions (TBP) for residents and work restriction for health care personnel (HCP) are not generally necessary unless residents . . . [have symptoms of COVID-19 or close contact with someone with COVID-19 infection] or HCP meet criteria in the Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, respectively. However, source control should be worn by all individuals being tested.
- In the event of ongoing transmission within a facility that is not controlled with initial interventions, strong consideration should be given to use of Empiric use of TBP for residents and work restriction of HCP with higher-risk exposures. In addition, there might be other circumstances for which the jurisdiction’s public authority recommends these and additional precautions.
- If no additional cases are identified during contact tracing or the broad-based testing, no further testing is indicated. Empiric use of TBP for residents and work restriction for HCP who met criteria can be discontinued as described in Section 2 and the Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, respectively.
- If additional cases are identified, strong consideration should be given to shifting to the broad-based approach if not already being performed and implementing quarantine for residents in affected areas of the facility. As part of the broad-based approach, testing should continue on affected unit(s) or facility-wide every 3-7 days until there are no new cases for 14 days.
  - If antigen testing is used, more frequent testing (every 3 days), should be considered.

Both the DOH and federal guidance remind facilities that an outbreak is not triggered if a resident is admitted with known COVID-19 directly into TBP or a resident with a known close contact is admitted directly into TBP and develops COVID-19 while under TBP.

Recently Recovered Individuals: DOH, like the CDC and CMS, states that testing is not necessary for asymptomatic people who have recovered from COVID-19 in the prior 30 days. It notes that "testing should be considered for those who have recovered in the prior 31-90 days." If testing is performed on these individuals, an antigen test instead of a nucleic acid amplification test (NAAT) is recommended.

Screening at Entry

Unlike the CDC and CMS guidance, the DOH guidance continues active screening of visitors and staff upon entry into nursing homes. Active screening entails completion of a screening tool or questionnaire that elicits information related to current symptoms, exposures, and positive tests. In addition, signage should be placed throughout the facility and visitors and staff should be educated on COVID-19 signs and symptoms and infection prevention measures.

New Admissions and Readmissions

DOH directs facilities to the CDC guidance for instructions on new admissions, readmissions, and residents who leave the facility for 24 hours or longer. The CDC guidance provides the following:

Testing is recommended at admission and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. In general, admissions in counties where Community Transmission levels are high should be tested upon admission; admission testing at lower levels of Community Transmission is at the discretion of the facility.
Residents should also be advised to wear source control for the 10 days following their admission.
Residents who leave the facility for 24 hours or longer should generally be managed as an admission.
Empiric use of TBP is generally not necessary for admissions or for residents who leave the facility for less than 24 hours (e.g., for medical appointments, community outings) and do not . . . [have symptoms of COVID-19 or close contact with someone with COVID-19 infection].

Visitation and Visitor Testing

The DOH guidance takes a strong stance against restrictions on visitation. The guidance provides that a failure to facilitate visitation consistent with federal regulations, which provide a right to receive visitors "at the time of [the resident's] choosing and in a manner that does not impose on the rights of another resident," would constitute a violation. Any temporary visitation pause must be based on the "express direction of DOH.

However, DOH also requires nursing homes to "continue to make every effort to verify that visitors have received a negative SARS-CoV-2 test result within one day prior to visitation for antigen tests and within two days prior to visitation for PCR tests." This seems to be a slightly softer version of the Jan. 12, 2022 guidance that stated that all nursing homes "must verify" that visitors have received a negative test result.

The testing requirement does not apply to compassionate caregiving visitors and emergency medical services (EMS) personnel. Representatives of the Office of the Long Term Care Ombudsman were explicitly exempt under the prior guidance and likely remain exempt under the new guidance, although they are not mentioned.

Cohorting

The DOH guidance follows the CDC cohorting recommendation that residents with suspected or confirmed COVID-19 be placed in a single-person room. If limited single rooms are available, or if numerous residents are simultaneously identified to have known SARS-CoV-2 exposures or symptoms concerning for COVID-19, residents should remain in their current location. According to the CDC, residents with symptoms or exposures should not be cohorted with patients with confirmed SARS-CoV-2 infection unless they are confirmed to have SARS-CoV-2 infection through testing. The CDC further states:

Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom.
- If cohorting, only patients with the same respiratory pathogen should be housed in the same room. Multidrug-resistant organism (MDRO) colonization status and/or presence of other communicable disease should also be taken into consideration during the cohorting process.
Facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with SARS-CoV-2 infection when the number of patients with SARS-CoV-2 infection is high. Dedicated means that HCP are assigned to care only for these patients during their shifts. Dedicated units and/or HCP might not be feasible due to staffing crises or a small number of patients with SARS-CoV-2 infection.
Limit transport and movement of the patient outside of the room to medically essential purposes.
Communicate information about patients with suspected or confirmed SARS-CoV-2 infection to appropriate personnel before transferring them to other departments in the facility (e.g., radiology) and to other health care facilities.

DOH emphasizes that, although it is aligning with CDC guidance:

[N]ursing homes must exhaust all efforts to separate disparate testing roommates, meaning in rare circumstance when no other options are available, the exposed roommate can be left in place until such time that alternate accommodations are available. Nursing homes must fully inform residents and families of the circumstances and offer transfer out of the facility if unwilling to cohort. As such, facilities must continue to work closely with NYSDOH public health team regarding cohorting. Documentation and communication are critical.

We recognize that sometimes roommates refuse to be separated, and residents' rights are implicated by cohorting practices. We have asked DOH to allow flexibility in these situations.

Work Restrictions

The new DOH guidance does not address the change in CDC guidance regarding HCP who are exposed to COVID-19. We have asked DOH to provide their position on this change. The most recent DOH guidance on this topic, from February 2022, includes a chart that requires exclusion of not up-to-date personnel who are exposed to COVID-19. The CDC no longer recommends this. Until instructed otherwise by DOH, we believe that excluding these exposed personnel represents the conventional workforce capacity standard in New York. Facilities and home care agencies experiencing staffing shortages that need to shift to contingency or crisis strategies might consider following the CDC recommendation on exposed personnel. Members are reminded that if they are implementing crisis strategies, they should contact the DOH Surge and Flex Operations Center at 917-909-2676.

We will keep members informed as guidance evolves.

Contact: Karen Lipson, klipson@leadingageny.org