Coronavirus Update #37
Continuing to Prepare, MDH Transmittals, CMS Updates, and More
Thank you for all you and your teams are doing to care for people without COVID-19, with COVID-19 and to manage containment. This is where preparation pays off. Our sector is beginning the most challenging time of this pandemic. Make no mistake, for the next several weeks we will be sprinting a marathon—no small undertaking. You and your teams are truly up for the challenge.

A few reminders:

  • We continue to urge centers to take non-COVID-19 med/surg patients from Maryland hospitals. It is critically important that Maryland post-acute providers accept routine and hard to place non-COVID-19 hospital transfers now in order to help free-up acute care in hospitals for COVID-19 patients.

  • It is a MUST that SNFs now create separate wings, units, or floors by moving current residents to handle admissions from the hospitals, and to keep current residents separate, if possible. HFAM has asked the state for a waiver of the 30-day involuntary discharge rule to accommodate the clinically prudent separation of patients and residents.

  • Proactively over-communicate with staff, patients, residents, and families.

  • Employees cannot come to work if they are symptomatic or are directly linked to the increasingly reported positive cases.
MDH Transmittals

The Maryland Department of Health (MDH) released yesterday two important transmittals regarding COVID-19.

  • The first transmittal from OHCQ shares reminders about infection control, readmissions, testing, and more for both nursing homes and assisted living communities.

  • The second transmittal shares information about the readmission of patients returning from hospitals when transported by ambulance for both nursing homes and assisted living communities.

Providers are also reminded to review residents' advance directives and Maryland MOLST orders to ensure these documents are up-to-date. 
Diamond Medical Labs Nursing Home Testing
 
Diamond Medical Labs, located in Owings Mills, has the capacity to do in-residence test collection for seniors during the COVID-19 outbreak so that they do not have to go out. Contact Andy Diamond at [email protected] or 443-992-2782 if there is demand at your center or if you would like additional information. 
Prepare for the Toll COVID-19 Can Take on Residents, Families, and Staff

As we have seen in the outbreak in Washington state, nearly half of all residents infected were hospitalized and approximately 20-25% died. While some SNFs in parts of the nation are seeing similar widespread outbreaks, others are experiencing only a small number of residents infected. Regardless, long term care staff need to prepare for residents becoming ill with COVID-19, possibly needing hospitalization, and unfortunately for some residents, succumbing to the virus. You can take the following steps to help prepare.

During this COCA Call, clinicians will provide an overview of the clinical characteristics of COVID-19 patients, including case presentations of critically ill adults and clinical management challenges, and summarize recently published guidelines on clinical management of critically ill adults.
 
Clinical Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19)
Thursday, April 2 
2:00 p.m. –3:30 p.m. (EDT) 

Some long-term care providers have been asking if CMS has made any changes to the MDS coding guidance associated with item O0100M – Isolation for active infectious disease (does not include standard precautions) located in Chapter 3 of the MDS 3.0 RAI Manual v 1.17.1 October 2019 . Below is an excerpt from the current coding requirements describing the four specific conditions that must be met to check the O0100M item box for the presence of isolation for active infectious disease.
Code for “single room isolation” only when all of the following conditions are met:

  1. The resident has active infection with highly transmissible or epidemiologically significant pathogens that have been acquired by physical contact or airborne or droplet transmission.
  2. Precautions are over and above standard precautions. That is, transmission-based precautions (contact, droplet, and/or airborne) must be in effect.
  3. The resident is in a room alone because of active infection and cannot have a roommate. This means that the resident must be in the room alone and not cohorted with a roommate regardless of whether the roommate has a similar active infection that requires isolation.
  4. The resident must remain in his/her room. This requires that all services be brought to the resident (e.g. rehabilitation, activities, dining, etc.).

In a recent email that AHCA received from CMS, the Agency indicates that providers should continue to code residents for the O0100M isolation item per current MDS-RAI manual instructions . 

AHCA recognizes that many providers have applied recent CMS and CDC guidance and 1135 waivers during the COVID-19 emergency and have sometimes cohorted beneficiaries in the same isolation room when the residents have tested positive for COVID-19 or are presumed to be positive. We also recognize that with respect to payment models including PDPM, State case-mix, and Medicare Advantage, the current inability to code for isolation in situations where residents were required to be cohorted into the same room may result in a lower payment rate. CMS is aware of this concern. AHCA will share updates as they become available.   
CMS Updates PDPM ICD-10 Mappings for New COVID-19 Diagnosis Code

CMS has responded to concerns that the ICD-10-CM diagnosis codes identified by the CDC as appropriate to code for COVID-19 were not compatible with the Medicare Part A SNF PPS PDPM payment model. Specifically, none of the CDC identified codes could be used to represent the Primary Reason for SNF Stay on the MDS assessment Item I0020B.

On March 31, CMS posted an updated FY 2020 PDPM ICD-10 Mappings file (.zip ) which adds the ICD-10-CMS code ‘U07.1 - 2019-nCoV acute respiratory disease’ as an appropriate code to enter in the MDS I0020B Primary reason for SNF stay item field. If entered, this code will map to the PDPM ‘Pulmonary’ default clinical category used for the PT, OT, and SLP components. This new code does not impact the PDPM Nursing or NTA component classifications at present. 

This new code U07.1 is ONLY in effect for assessments with target date April 1, 2020 and later. For assessments with an assessment reference date March 31, 2019 or earlier, providers will need to enter the most appropriate ICD-10 code available that is not listed as a ‘return to provider’ code in the MDS I0020B item field. 

Additional files related to coding specifications necessary for software companies to implement this change are located on the MDS 3.0 Technical Information webpage . Providers do not need to review these files but should check with their MDS software vendors to confirm when these updated have been applied or you will see a ‘return to provider’ error in your MDS software . 
CMS Suspends Most Medicare Fee-For-Service Medical Review

CMS released a COVID-19 Provider Burden Relief FAQ document that states that the Agency has suspended most Medicare Part A and Part B Fee-For-Service (FFS) medical review during the emergency period due to the COVID-19 pandemic. This includes pre-payment medical reviews conducted by Medicare Administrative Contractors (MACs) under the Targeted Probe and Educate program, and post-payment reviews conducted by the MACs, Supplemental Medical Review Contractor (SMRC) reviews and Recovery Audit Contractor (RAC). No additional documentation requests will be issued for the duration of the PHE for the COVID-19 pandemic. Targeted Probe and Educate reviews that are in process will be suspended and claims will be released and paid. Current postpayment MAC, SMRC, and RAC reviews will be suspended and released from review. 

This suspension of medical review activities is for the duration of the PHE. However, CMS may conduct medical reviews during or after the PHE if there is an indication of potential fraud. Other topics in the FAQ are related to proof of delivery beneficiary signature waivers for drugs and DME, and for pausing non-emergent ambulance and home health review choice demonstrations Providers should contact their Medicare review contractor if there are questions. 
ADDITIONAL REMINDERS
Updated COVID-19 Resource Request Process

This afternoon, the Maryland Department of Health (MDH) shared important clarifying information regarding the current process that hospitals and other healthcare entities should use to request PPE and other health related equipment or supplies, except for ventilators. Requests for ventilators will be routed differently and as soon as the Hospital Surge Team completes their process, it will be shared.

The process for requesting health and hospital related materials should be routed from the requester to their respective local health department using THIS FORM.

The local health department (LHD) will provide the requested items if available. If the LHD is unable to fulfill the request, the form should be forwarded to the local office of emergency management (OEM). Prior to sending to the OEM, the LHD should ensure that all required information is completed and that the request is appropriate.  For example, requesting N-95 respirators when CDC and state guidelines indicate that only surgical masks are to be used. The OEM should enter the request into WebEOC and attach the request form.

The ordering form assists the local OEMS to input the requests and provides data needed for MEMA and MDH to respond to numerous federal requests for data and certifies that the requesting agency is conforming to CDC’s PPE conservation guidance.

Here is the detailed explanation of the ordering process, the order form and a contact list for local OEMS for your convenience. 

MDH acknowledges that the changing requesting processes present lots of challenges we must, in this instance, comply with the guidelines of the various federal agencies. MDH is trying to best comply with minimal impacts on providers and is trying to make each request serve as many purposes as possible.

The data that providers supply with request helps to inform the required PPE burn rate that must be submitted daily as well as assuring that MDH is doing their best to comply with conservation guidelines. Both are required for continued eligibility to receive federal assets.

As this crisis evolves, be prepared for the system to change again.

Thank you for all that you are doing and for you continued flexibility to ever-changing federal guidance.

IMPORTANT NOTE : Please do not use previously provided request form or contact sheet. If your request is not documented on the updated sheets and contact emails, it will NOT be processed.
Special Thank You Audio Message

HFAM has recorded a  special thank you  to those of you working in Maryland skilled nursing and rehabilitation centers and on assisted living campuses. Please distribute broadly to your teams.

We are all navigating together in these uncharted waters of the COVID-19 pandemic.  Now more than ever, it is important that we recognize we are in this together, and that we are stronger together.
Temporary Nurse Aide Training & Competency Checklist 

As AHCA/NCAL shared in Update #26 recently, the Centers for Medicare and Medicaid Services (CMS) issued a blanket waiver that includes an allowance for nursing centers to temporarily employ individuals who have completed alternative training paths, as long as they are competent to provide relevant nursing and nursing related services. 

Along with AHCA/NCAL, we have have been advocating for CMS to issue such a waiver to assist in addressing staffing shortages due to the COVID-19 pandemic. This is now allowed on the federal level. State approvals, such as state occupational licensing and state regulatory requirements, may also need to be granted. 

AHCA/NCAL has a training program ready to use as state occupational and licensing agencies approve these waivers. This 8-hour online Temporary Nurse Aide training course is free to all participants.
  
AHCA/NCAL has also developed a skills competency checklist  for facilities to use on-site when they hire individuals to work as Temporary Nurse Aides. It is important to know the federal requirement at §483.35(c) is still in effect , which requires facilities to ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents’ needs, as identified through resident assessments, and described in the plan of care. 
COVID-19 Case Study (Not Maryland)

Please see this  Case Study that HFAM wrote after being contacted by a SNF provider in another part of the country.

Please review this case study and share with your teams -- it includes critical insight and real time experience.
Child Care for Essential Personnel

Maryland Family Network (MFN) is partnering with the Maryland State Department of Education (MSDE) to make it fast and easy for essential personnel to find safe quality child care during the State of Emergency.

Maryland’s child care providers are essential to stemming the spread of and finding a cure for the COVID-19 pandemic. Our region is teeming with the Nation’s top researchers, doctors, and policy makers. As the Coronavirus continues to spread and demands on these and other essential personnel grows, they need to know their children are safe in order to stay focused on keeping the rest of us safe and healthy.

Visit this  site  to learn more or call 877-261-0060 to locate child care.

While all child care is closed for the general public, child care is  not closed for essential personnel. In addition to new programs being developed by the State, MSDE recently launched a program to allow child care providers that would otherwise be closed to open to serve children of essential personnel exclusively. There will be additional child care providers approved under this new provision and available to provide child care.   LOCATE will have the listing of approved sites for these services for your stakeholder's staff to identify child care services.

Please urge your staff to visit:   http://marylandpublicschools.org/Pages/default.aspx for more information on these child care options.
Did you miss HFAM's previous alerts?

Visit our website to view all previous HFAM alerts, as well as guidance
from our federal and state partners.
Please email [email protected] for additional questions, and visit
www.ahcancal.org/coronavirus for additional information and resources.
Thank you.

We cannot thank you enough for the dedication and diligence in doing all that you can for the residents in your communities. HFAM continues to monitor the COVID-19 pandemic with our state and national partners and will do all we can to support you during this time.