March 10th COVID-19 Update

Governor Issues COVID-19 Executive Order Declaring Emergency and Waiving Certain Health Care Regulations

On March 6^th, Governor Cuomo signed an executive order declaring the COVID-19 outbreak a state disaster emergency and waiving a variety of health care, procurement, and highway safety regulations to enable the State to respond rapidly and effectively to the virus. The order is effective until April 6, 2020.

The provisions of the executive order that are most relevant to long-term/post-acute care (LTPAC) providers are:

Authorizing unlicensed individuals who received approved training to collect specimens for COVID-19 testing and to perform nursing tasks otherwise limited to a licensed or registered nurse, under the supervision of a nurse;
Authorizing non-patient-specific orders for COVID-19 specimen collection and for care of patients suspected of infection with COVID-19;
Waiving regulations to permit hospitals and nursing homes to rapidly admit, transfer, and discharge patients and allowing the Patient Review Instrument (PRI) to be completed "as soon as practicable";
Allowing nursing supervision visits of personal care services delivered to patients affected by COVID-19 to be made "as soon as practicable";
Authorizing the adoption of emergency regulations concerning hospitals and nursing homes and waiving Part 405 of the general hospital regulations as necessary to treat or contain patients affected by COVID-19;
Waiving Medicaid preferred drug prior authorization provisions to enable patients to access medications quickly; and
Authorizing community paramedicine, emergency medical service (EMS) telemedicine, and EMS transportation to sites other than general hospitals.

In addition, the executive order authorizes the following:

Purchase of goods and services, including building design and construction and leasing of space, without following standard procurement requirements;
Expansion of access to Child Health Plus;
Individuals who meet federal requirements for high complexity testing to conduct testing of specimens collected from people suspected of COVID-19 infection;
Expansion of access to telemental health services;
Waiver of procurement requirements and laws requiring the use of environmentally sensitive cleaning products in schools;
Meetings and actions by the Public Health and Health Planning Council (PHHPC) and the State Emergency Medical Services Council without satisfying quorum and in-person access requirements;
Waiver of vehicle registration and size limitations; and
The Governor to regulate traffic and movement of vehicles on local roads.

PHHPC Votes to Approve Emergency Quarantine Regulations

PHHPC voted on March 9^th to approve emergency regulations to establish procedures for isolation and quarantine orders in response to the COVID-19 outbreak. The regulations also clarify the roles of the State and local health departments in investigating communicable disease cases and update requirements on labs, physicians, and hospitals regarding reporting of cases.

The emergency regulations include the following provisions:

Sets forth actions that local health departments must take to investigate a case, suspected case, or outbreak of a communicable or unusual disease.
Clarifies the authority of the Commissioner of the State Department of Health (DOH) to lead investigation activities.
Clarifies that the State DOH as well as local health departments have the authority to issue isolation and quarantine orders when necessary to control the spread of a highly contagious communicable disease.
Provides for isolation or quarantine of individuals and groups who are infected with or exposed to the disease.
Clarifies that isolation or quarantine may be appropriate in a home or residential or temporary housing location that the health authority determines appropriate, where symptoms or conditions indicate that medical care in a general hospital is not expected to be required. The Department indicated that local health departments are contracting with hotels and other premises to provide quarantine and isolation sites for homeless individuals and others who cannot be isolated or quarantined in their regular homes.
Sets forth requirements for the content of isolation and quarantine orders.
States that violation of an isolation or quarantine order constitutes grounds for civil and/or criminal penalties.
Requires attending physicians to report cases and suspected cases to the local health department and to provide instructions concerning how to protect others.
Requires the Commissioner to designate those communicable diseases that require prompt action and to post them on the State DOH website.
Requires laboratories to immediately report positive test results for communicable diseases designated by the Commissioner as requiring prompt attention.
Mandates hospitals to report syndromic surveillance data during an outbreak of a highly contagious communicable disease.
Permits the Commissioner to require hospitals to accept patients during an outbreak of a highly contagious communicable disease.
Prohibits the removal of potentially infected articles from isolation or quarantine premises unless the local health department has determined that they have been properly disinfected or there is no risk of contamination.

The regulations specify that home quarantine or isolation orders must include instructions for maintaining appropriate distance from others and for taking other actions to prevent transmission. If the order requires home isolation or quarantine in a multiple dwelling, the person must remain in their specific dwelling and avoid coming within six feet of any other person. If necessary, the State or local health department must provide people in isolation or quarantine with appropriate supports, supplies, and services, including food, laundry, medical care, and medications.

The regulations will be in effect for 90 days, at which time they may be extended, modified, or allowed to expire.

DOH Requires ACFs and Nursing Homes to Complete Daily Survey and Suspends Visitors in New Rochelle Area

On March 9^th, DOH issued an alert for nursing homes and adult care facilities (ACFs) activating the first of what will be a daily Health Electronic Response Data System (HERDS) survey. The activity is called “COVID 19 ACF Daily” and “COVID 19 NH Daily.” DOH is requiring that the survey be completed daily by 3 p.m. until further notice. Please see the alert for further guidance. Additionally, DOH asks that those providers with Health Commerce System (HCS) accounts ensure that their contact information in the HCS is accurate and up to date.

DOH also issued a notice on March 8^th, effective immediately, to nursing homes and ACFs in the New Rochelle area requiring them to suspend visitors. In order to minimize resident exposure to COVID-19, all nursing homes and ACFs in the New Rochelle area must suspend all visitation, including by family and other resident guests. Only staff, residents, and staff of the State and local health departments should be permitted access to facilities, except in an emergency, through March 22, 2020.

After the notice was issued, DOH expanded the affected areas to include:

Larchmont
Eastchester
Scarsdale
Mamaroneck town
Pelham village
Pelham Manor

This action is necessary based on the susceptibility of older individuals, particularly those with underlying health conditions, to the virus and their heightened risk of developing serious illness. All facilities should take any steps necessary to permit alternative means of allowing residents to communicate with family and friends, such as the use of the telephone and electronic communication applications wherever possible.

Click here to view the directive. A separate DOH directive outlining the minimum criteria for discontinuation of quarantine of patients with COVID-19, also issued on March 9^th, is available here.

This is a quickly evolving issue, and members are encouraged to stay alert to communications from DOH and other official sources of information. LeadingAge NY has developed this site to keep members apprised of the various communications and resources available. We know that members have many questions, which have been directed to DOH on your behalf. A Dear Administrator Letter (DAL) for ACFs with additional guidance is anticipated shortly. DOH is also in the process of finalizing guidance for home and community-based services (HCBS) providers and plans to hold an informational webinar; LeadingAge NY will keep members updated as to when this webinar is scheduled.

DOH Issues Special COVID-19 Edition of Medicaid Update and Interim Facility Cleaning Guidance

On March 10^th, DOH issued a special edition of the Medicaid Update focused on State Medicaid coverage and reimbursement policy for services related to COVID-19 as well as interim guidance related to the cleaning and disinfection of public and private facilities. The documents can be accessed here and here.

DOH to Offer COVID-19 Webinar for Nursing Homes on March 11^th

On March 11^th from 3 to 4 p.m., DOH will host a webinar to provide guidance on the precautions and procedures that should be taken to protect and maintain the health and safety of nursing home residents and staff during the COVID-19 outbreak. Nursing home administrators, infection control practitioners, medical directors, and directors of nursing are strongly encouraged to attend.

Registration is required and available here. To listen to the session, dial 844-512-2950.

CMS Issues Restricted Visitation Guidance

On March 9^th, the Centers for Medicare and Medicaid Services (CMS) issued additional guidance to nursing homes to help them improve their infection control and prevention practices to prevent the transmission of COVID-19, including revised guidance for visitation. The following encompasses a summary of the guidance:

Visitor Screening

Facilities should actively screen and restrict visitation by those who meet the following criteria:

Signs or symptoms of a respiratory infection, such as fever, cough, shortness of breath, or sore throat.
In the last 14 days, has had contact with someone with a confirmed diagnosis of COVID-19, or under investigation for COVID-19, or ill with respiratory illness.
International travel within the last 14 days to countries with sustained community transmission.
Resides in a community where community-based spread of COVID-19 is occurring.

Individuals who meet any of the above criteria should not be allowed in the facility at all, until they no longer meet the criteria.

Additionally, facilities should ask the following:

Have you taken any recent trips (within the last 14 days) on cruise ships or participated in other settings where crowds are confined to a common location?

If the answer is yes, facilities should suggest deferring the visit to a later date. If the visitor’s entry is necessary, they should use Personal Protective Equipment (PPE) while onsite. If the facility does not have PPE, the facility should restrict the individual’s visit and ask them to come back after at least 14 days with no symptoms of COVID-19.

For those individuals that do not meet the above criteria, facilities can allow entry but may require visitors to use PPE such as facemasks (see expanded guidance below).

CMS Visitor Recommendations

For providers located in counties, or counties adjacent to, where a COVID-19 case has occurred: CMS recommends limiting visitation. [Limiting means that visitors should not be allowed to enter the facility except for end-of-life situations or when a visitor is essential for the resident’s emotional well-being and care. Example: a daughter who visits her mother every Monday would cease these visits and limit her visits to only those situations when her mom has a significant issue. Also, during the visit, the daughter would limit her contact with her mother and only meet with her in her room or a place the facility has specifically dedicated for visits.]
For providers NOT located in counties, or counties adjacent to, where a COVID-19 case has occurred: CMS recommends discouraging visitation. [Discouraging means that the facility allows normal visitation practices (except for those individuals meeting the restricted criteria); however, the facility advises individuals to defer visitation until further notice (through signage, calls, etc.).]

Remember: Residents still have the right to access the Ombudsman program. If in-person access is allowable, use the guidance below. If in-person access is not available due to infection control concerns, facilities need to facilitate resident communication (by phone or other format) with the Ombudsman program or any other entity listed in 42 CFR § 483.10(f)(4)(i) (e.g., resident’s physician, DIA, DHS, resident’s representative).

If Visitation Is Allowed, CMS Recommendations

Offer PPE for individuals entering the facility (if supply allows).
Provide instruction, before visitors enter the facility and residents’ rooms, on hand hygiene, limiting surfaces touched, and use of PPE according to current facility policy while in the resident’s room.
Instruct visitors to limit their movement within the facility to the resident’s room (e.g., reduce walking the halls, avoid going to dining room).
Promote safe visitation by suggesting limited physical contact (practice social distances with no handshaking or hugging and remaining six feet apart).
If possible (e.g., pending design of building), create dedicated visiting areas (e.g., “clean rooms”) near the entrance to the facility where residents can meet with visitors in a sanitized environment. Facilities should disinfect rooms after each resident-visitor meeting.

Alternative Strategies In Lieu of In-Person Visitation

Offer alternative virtual means of communication (phone, video communication, etc.).
Create/increase listserv communication to update families, such as advising to not visit.
Assign staff as primary contact to families for inbound calls and conduct regular outbound calls to keep families up to date.
Offer a phone line with a voice recording updated at set times (e.g., daily) with the facility’s general operating status, such as when it is safe to resume visits.

CMS Recommended Actions (Revised Guidance, March 9, 2020)

Increase visible signage at entrances/exits consistent with visitor screening and visitor recommendations above.
Restrict, limit, and discourage visitors consistent with information above.
Offer temperature checks.
Increase availability to hand sanitizer.
Advise visitors to report to the facility any signs and symptoms of COVID-19 or acute illness within 14 days of visiting the facility.
Advise exposed visitors (e.g., contact with COVID-19 resident prior to admission) to monitor for signs and symptoms of respiratory infection for at least 14 days after last known exposure and if ill to self-isolate at home and contact their health care provider.

Non-Resident Visitors

CMS recommends that facilities review and revise how they interact with volunteers, vendors and receiving supplies, agency staff, EMS personnel and equipment, transportation providers (e.g., when taking residents to offsite appointments), and other practitioners (e.g., hospice workers, specialists, physical therapy) and take necessary actions to prevent any potential transmission consistent with the Centers for Disease Control and Prevention (CDC) Guidelines for Transmission-Based Precautions. For example:

Have vendors drop off supplies at a dedicated location like a loading dock rather than transporting supplies inside the facility.
Hospice workers can enter a facility when using PPE properly.

LeadingAge NY Holds Webinar on Best Practices in Infection Control

Finally, on March 9^th, Dawn Carter, RN, LeadingAge NY ProCare Consultant, presented a webinar on what providers need to know about COVID-19 as well as how to prepare and protect their residents and employees. A recording of the hour-long presentation is available here, and the slides are here.