COVID-19 UPDATE #9
March 16, 2020
COMMUNAL DINING RESTRICTIONS
CMS and AHCA/NCAL are directing nursing homes to drastically change the way residents dine in order to minimize the likelihood of COVID-19 spread. These directions are highly recommended for assisted living facilities too, as communal dining and other group gatherings can lead to the spread of the virus no matter the care setting.
  
Of note, residents who can safely eat and drink without assistance or supervision should do so in their rooms/apartments. This includes independent living residents, for facilities who serve both independent and assisted living residents.

For all other residents needing assistance and/or supervision with dining, safety and logistics expectations are provided. The full guidance and recommendation can be found here .  
SURVEY, INVESTIGATIONS, AND INSPECTIONS
Last week we continued to hear from our WHCA members that Residential Care Services (RCS) was moving forward with routine licensing and survey inspections. This issue, considering the pandemic health crisis in our state, is of significant concern and has been raised with firm conviction to the DSHS and RCS management team. We believe that RCS is reconsidering its position on survey, but at this time we have no new information to share. We will update you when additional information is received.
WORKFORCE UPDATE - SEEKING WAIVERS AND FLEXIBILITIES FOR PROVIDERS
Last week we reached out to Governor Inslee about the need for regulatory relief related to workforce training and certification. Click here for the letter. In addition to seeking licensing and certification waivers for those health professionals certified in other states, we are seeking waivers on testing and certification timelines and are asking that the 24/7 RN and 3.4 hour per resident day staffing requirements are waived. We understand that DSHS and the Department of Health agree on a number of these issues. We will update you once we have details. 

If you are having problems with timely credentialing, licensing or certification, please email all questions to nursing@doh.wa.gov or leave a detailed voice message (360) 236-4700 and a customer service representative will respond in one business day.  If you want to check the status of your pending application, please check the Department of Health’s Provider Credential Search .
EMERGENCY VOLUNTEER HEALTH PRACTITIONERS
The Department of Health is supporting enrollment and activation of emergency volunteer health practitioners for the COVID-19 response. Under RCW 70.15.050, while an emergency proclamation of the Governor is in effect, a volunteer health practitioner who is licensed in another state may practice in Washington without obtaining a Washington license if he or she is in good standing in all states of licensure and is registered in the volunteer health practitioner system. 

The first step for a volunteer to register is to complete the  Emergency Volunteer Health Practitioners Application . Applications will be screened to ensure the potential volunteer’s health license is in good standing in each state in which they are licensed. After that, the volunteer will be entered into a database of approved emergency volunteer health practitioners. The Washington State Department of Health will activate approved volunteers as needs arise while an emergency proclamation is in effect.
 
If you have issues or concerns about childcare or workforce, please email Brenda Orffer .  Our goal is to advance issues and help assist with timely resolution.
ESSENTIAL HEALTHCARE WORKER CHILDCARE UPDATE
Public Schools to Support Essential Health Care Worker Childcare: We have been informed that the Office of the Superintendent of Public Instruction (OSPI) has charged local school districts to continue nutritional services and to provide childcare for essential healthcare workers and first responders. Your workers who are facing childcare problems because of school closures should look for communication and information from their child’s local school district related to plans to support essential healthcare worker childcare. For ease of reference, here is the statewide list of school districts with contact information.

Department of Children, Youth, and Families (DCYF) Seeks Emergency Childcare Providers: WHCA members have expressed an interest in helping workers with childcare, given the statewide school closures. If you are interested in setting up childcare for essential health care workers, immediate licensing consultation and assistance is available through DCYF. DCYF is also tracking those who are in need of childcare. They have dedicated staff who will be monitoring requests twice daily. Here is contact information: 

EMERGENCY CHILDCARE - DCYF
Telephone: (509) 544-5712
NOW IS THE TIME TO PRESERVE PPE
Really, you say? We don’t have any masks and gowns; you’re telling me now? Yes. As other states will be facing now or in the very near future what our Washington facilities have been dealing with for the last few weeks, the scarcity of PPE and supplies will become even scarcer than they already are (or non-existent). You already know you can’t do business as usual. But this pandemic is a marathon, not a sprint. Every use of PPE needs to be thoughtful and judicious. We are in this for months, not days or weeks.

Washington State has been tapping the nation’s stockpile of emergency goods for the last two weeks. As more and more states face this challenge, the quickly-dwindling supply will be exhausted. What supplies were sent to Washington have been and will continue to be prioritized to those facilities with confirmed positive COVID-19. 

According to Emergency Management, it is important for our first responders and healthcare system partners to know that even with these efforts, they will not meet the full need in our state. Over 655 resource requests for PPE have been received and they have been able to fill 52 of them. Washington State previously received 25% of its portion of the Strategic National Stockpile; that allocation is currently prorated based on state population. On Friday March 13, 2020, the Department of Health submitted a request for an additional 25% of the state’s current portion.
 
Emergency Management has stated that as they make the difficult decisions on how to distribute these limited resources, they will continue to follow the Guidelines for Prioritization of Allocation of PPE . They will also prioritize distribution to those that can document the follow criteria:
  1. Exhausted all supplies at facility and at local level.
  2. Documentation that entity has an active order into their normal supply chain.
  3. Documentation that there is an approved conservation plan in place and implemented.
  4. Reduction/elimination of all non-urgent medical procedures.

All indicators show that the health of our supply chain is exceptionally limited and will worsen over time. It is not a matter of if , it is a question of when . Now is the time to be one, two, and even three steps ahead looking and implementing alternatives to traditional disposable PPE disbursement and use. This question has been posed to the CDC by AHCA and we are awaiting further guidance in the next couple of days as to what recommended measures are to be taken when the PPE supply is exhausted. Between then and now, take active steps to consider the following:
  1. Inventory what PPE your facility has and current daily use. Know what you have and how long it will last. Plan NOW and implement to minimize and cut the daily use of PPE.
  2. Prioritize use based on resident conditions and staff assignments. If you have residents on precautions, what absolutely needs done and how often?
  3. For AL, is there a way to avoid needing to enter a resident’s room or apartment by leaving trays, linens at the door if they are on a 14-day monitoring? 
  4. Look at shared tasks and coordination of assignments between nurses, direct care staff, housekeeping, etc. Can one person do multiple tasks upon entrance and eliminate the need for others and use of PPE? 
  5. As hand sanitizers may become more scarce, reinforce active handwashing.
  6. Start thinking now about what your facility facility will do without PPE. What can be used and what can be used instead?  
  7. If you are in immediate danger of exhausting your supply of disposable/surgical masks, consider assigning one mask per staff member, per shift. Change only if soiled or dispose when leaving the building. This is, of course, a last resort when exhaustion of masks is imminent. 
CMS ISSUES WAIVERS OF 3-DAY STAY AND SPELL OF ILLNESS
On March 14, the Centers for Medicare and Medicaid Services (CMS) issued two waivers to aid skilled nursing facilities in addressing the national COVID-19 outbreak. CMS is waiving both the 3-Day Stay and Spell of Illness requirements – nationally.  

These waivers mean that skilled nursing facility (SNF) care without a 3-day inpatient hospital stay will be covered for beneficiaries who experience dislocations or are affected by the COVID-19 outbreak. Due to the current crisis, CMS also is utilizing the authority under section 1812(f) providing renewed SNF coverage to beneficiaries without starting a new spell of illness and allowing them to receive up to an additional 100 days of SNF Part A coverage. More detail and background information is available here .

The goal of the Section 1812(f) Waiver is to free up as many hospital beds as possible, nationwide . Therefore, the waiver is nationwide and applies to all hospitals and all SNFs regardless of whether or not there is COVID-19 present in the hospital. So this is blanket and broad-based.
 
The Parameters that remain in place are:
 
  1. Patients must continue to meet the criteria for skilled care located in the Medicare Benefit Policy Manual Chapter 8 - Coverage of Extended Care (SNF) Services Under Hospital Insurance located here. It is criteria this continues to be documented.  
  2.  Long-Stay patients may be converted to Part A stays as long-stays as long as there is clinical evidence to support conversion to Part A. We specifically described the scenario of just converting long-stay folks to Part A. The response was – if the patient meets the skilled care criteria noted above, they can be converted to Part A with no hospital stay.

With regard to payment:

  1. Timeframe: The waiver is retroactive to March 1, 2020, and is in place for 60 days with the option for renewal as needed; and
  2. Billing: In terms of claims, to ensure payment and so CMS may track these stays, the “DR” condition code should be used by institutional providers (but not by non-institutional providers such as physicians and other suppliers) in all billing situations related to a declared emergency/disaster. The “DR” condition code is intended for use by providers (but not by physicians and other suppliers) in billing situations related to a declared emergency/disaster.
LONG TERM CARE OMBUDSMAN
By now many WHCA members have received a communication from your local Ombudsman. The communication demands that providers immediately provide the local Ombudsman with a list of resident names, room numbers, and the contact information of each resident’s representative. The communication broadly defines “representative” as legal decision makers, supported decision makers, and individuals chosen by the resident to access medical, social, or other information or to receive notifications or to manage financial matters. We have attempted to contact the State LTC Ombudsman regarding these notices, but we have not received the courtesy of a return phone call. 

A link to the Ombud's Policy is here .

WHCA wants to be very clear. The Ombuds has the right to obtain this information. But there’s no reason for an Ombudsman to demand it immediately in light of the crisis we are all facing. If you receive a similar demand we ask you to consider emailing the Ombud’s with a message along these lines:  

“Thank you for your support of our residents; we appreciate your continued efforts to represent residents in our setting. As you can appreciate, we are inundated with additional tasks that come with the Governor’s proclamation, including daily symptoms checks of all residents and additional cleaning to minimize the likelihood of COVID-19 transmission in the facility. Combine that with limited staffing, and we are doing our very best. Rest assured that we are ensuring residents have access to activities and socialization to meet their emotional needs and limit the sense of isolation. Combined efforts on our part should get the information you’ve requested to your inbox as soon as possible, hopefully within two to three days. Again, I appreciate your patience as we all work to best care for the residents here.”
 
There are no guarantees that the type of communication outlined above will not result in some citation or action by RCS. However, we are living in desperate times. We continue to advise our members that their primary focus should be keeping your residents safe and the virus out of your buildings. If you run into issues with your Ombudsman don’t hesitate to refer them to WHCA CEO Robin Dale . 
INFORMATION FOR EMPLOYERS AND EMPLOYEES SEEKING WORKERS' COMPENSATION COVERAGE AMID COVID-19
The Industrial Insurance Act allows for treatment of COVID-19 when work-related activity has resulted in probable exposure to the virus and certain criteria are met. Documentation must include a probable work-related exposure.  Read more here. Thanks to Employer Resources NW for providing this information.