COVID-19 UPDATE #187
September 14, 2021
CMS REVISIONS TO QSO MEMO IMPACT SNF TESTING REQUIREMENTS
On September 10, 2021, CMS made revisions to QSO-20-38-NH related to Long Term Care Facilities. The revisions mirror CDC guidance that came out the same day. Two important changes are effective immediately. Those changes are:
  • COVID-19 staff testing is now based on a facility’s county level of community transmission instead of the county test positivity rate. The frequency of testing has also been updated; and
  • Facilities now have two options to conduct outbreak testing, through either contact tracing or a broad based testing approach.

With respect to revision of the staff testing requirement, routine testing of unvaccinated staff should be based on the extent of the virus in the community. According to the QSO Memo, fully vaccinated staff do not have to be routinely tested. Facilities should now use their community transmission level as the trigger for staff testing frequency. Reports of COVID-19 level of community transmission are available on the CDC COVID-19 Integrated County View site. The levels of community transmission are characterized as blue (low); yellow (moderate); orange (substantial) and red (high). When community transmission levels are low (blue) testing frequency is not recommended. Moderate (yellow) community transmission requires once a week testing of unvaccinated staff. Substantial (orange) and high (red) transmission levels will require twice weekly testing.
 
The facility should test all unvaccinated staff at the frequency prescribed in the Routine Testing table found in the QSO memo, based on the level of community transmission reported in the past week. Facilities should monitor their level of community transmission every other week (e.g., first and third Monday of every month) and adjust the frequency of performing staff testing according to the routine testing table.
  • If the level of community transmission increases to a higher level of activity, the facility should begin testing staff at the frequency shown in the table routine testing table as soon as the criteria for the higher activity level are met.
  • If the level of community transmission decreases to a lower level of activity, the facility should continue testing staff at the higher frequency level until the level of community transmission has remained at the lower activity level for at least two weeks before reducing testing frequency.

The guidance above represents the minimum testing expected. Facilities may consider other factors, such as the level of community transmission in an adjacent (i.e., neighboring) county to test at a frequency that is higher than required.

With respect to options to conduct testing, facilities have the option to perform outbreak testing through two approaches, contact tracing or broad-based (e.g. facility-wide) testing.

If the facility has the ability to identify close contacts of the individual with COVID-19, they could choose to conduct focused testing based on known close contacts. If a facility does not have the expertise, resources, or ability to identify all close contacts, they should instead investigate the outbreak at a facility-wide or group level (e.g., unit, floor, or other specific area(s) of the facility). Broader approaches might also be required if the facility is directed to do so by the jurisdiction’s public health authority, or in situations where all potential contacts are unable to be identified, are too numerous to manage, or when contact tracing fails to halt transmission.

For further information on contact tracing and broad-based testing, including frequency of repeat testing, see CDC guidance "Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes."

For individuals who test positive for COVID-19, repeat testing is not recommended to discontinue TBP or work restrictions. A symptom-based strategy is intended to replace the need for repeated testing. Facilities should follow the CDC guidance “Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic” for residents and “Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2” for staff.
DOH UPDATES GUIDANCE ON PPE USE WITH AEROSOL-GENERATING PROCEDURES
On September 13, 2021, DOH updated guidance on PPE use with aerosol-generating procedures (AGP). This guidance is designed to minimize spread of COVID-19.

In general, the following should occur when entering a room where AGP is being done:
  • HCP wears a NIOSH-approved N95, eye protection, gloves, and gown
  • Limit the number of HCP in the area
  • Staff entering the room, for at least three hours after the AGP is completed, must wear full PPE including a NIOSH-approved N95
  • The room’s surfaces should be cleaned and disinfected promptly using an approved disinfectant

The update allows for some personnel exemptions to wearing a NIOSH-approved N95 when entering the room where an AGP is or has been administered. HCP do not have to wear a N95 when:
  • The resident is not known or suspected of having COVID-19, AND
  • The resident has not had any known exposure to COVID-19 in the last 14 days, AND
  • 100% of the HCP in the facility are fully vaccinated or have been exempted per the governor’s proclamation, AND EITHER ONE OF THE FOLLOWING:
  • The resident has been tested for COVID-19 within the past 24 hours and the results were negative, OR
  • The resident is fully vaccinated against COVID-19

The update also allows for non-HCP or residents and visitors to enter the room where the AGP took place, before the three hours has passed, if the following are in place:
  • The resident is not known or suspected of having COVID-19, AND
  • The resident has not had any known exposure to COVID-19 in the past 14 days, AND
  • Subsequent residents, visitors, and other non-HCP entering the room where the AGP was performed are fully vaccinated against COVID-19, AND EITHER OF THE FOLLOWING:
  • The resident has been tested for COVID-19 within the past 24 hours and the results were negative, OR
  • The resident is fully vaccinated against COVID-19

Finally, the update highlights that, should a nebulizer machine have a HEPA filter attached, it would not be considered an AGP.
CDC UPDATES INFECTION PREVENTION AND CONTROL GUIDANCE FOR HEALTHCARE SETTINGS
On September 10, 2021, the CDC issued a revision of its Infection Control Guidance for Healthcare Professionals about Coronavirus (COVID-19). In general, this update does not reflect substantial changes to recommended practices. Rather, the changes have been made to further clarify, consolidate, and simplify existing healthcare infection prevention and control (IPC) guidance.

As a part of this update, multiple setting-specific guidance documents such as those for dental offices, assisted living communities, EMS, and dialysis clinics have been streamlined and combined into the main IPC guidance for healthcare settings. This was done to make it easier for healthcare personnel to find relevant guidance for the duration of the COVID-19 response. The CDC Guidance states that:

Assisted Living providers should note that the guidance explicitly states that in circumstances when healthcare is being delivered (e.g., by home health agency, staff providing care for a resident with SARS-CoV-2 infection), assisted living communities should follow the Infection, Prevention and Control (IPC) recommendations in this guidance. WHCA has reached out to the Washington State Department of Health (DOH) and DSHS for additional guidance and direction on applying this CDC Guidance in the Assisted Living setting. We expect clarification within the next day or two. At that time we will be providing additional information for our Assisted Living members.   

 Vaccination, testing, use of source control by healthcare personnel, patients, and visitors, and use of appropriate personal protective equipment (PPE) by healthcare personnel caring for patients with suspected or confirmed SARS-CoV-2 infections continue to be emphasized.
 
A summary of some highlights is provided below but please refer to the full guidance documents (Infection Control: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) | CDC) for the exact recommendations. The highlights include:
  • CDC continues to recommend having a process to identify healthcare personnel, patients, and visitors with symptoms or exposure to SARS-CoV-2 prior to entering a facility.
  • CDC continues to recommend source control for everyone in a healthcare setting, and has clarified recommendations for healthcare personnel, patients, and visitors, to better align with community guidance. This includes a few limited circumstances where fully vaccinated individuals in counties with low to moderate community transmission could choose not to wear source control.
  • There are no changes to the PPE recommended for the care of patients with suspected or confirmed SARS-CoV-2 infection.
  • Quarantine is no longer recommended for fully vaccinated patients with exposure to SARS-CoV-2 or those patients who have had SARS-CoV-2 infection in the prior 90 days.
  • The timing of SARS-CoV-2 testing after higher-risk exposure for healthcare personnel and close contact for patients has been clarified.
 
CDC ISSUES GUIDANCE ON RISK ASSESSMENT AND WORK RESTRICTIONS
On September 10, 2021, the CDC issued its Interim U.S. Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel with Potential Exposure to SARS-CoV-2 | CDC There are no real changes to the guidance for managing healthcare personnel with SARS-CoV-2 infection (return to work guidance) or exposure to SARS-CoV-2 (risk assessment guidance), including the definition of “higher-risk exposure.” In general, healthcare facilities should continue to follow the IPC recommendations for unvaccinated individuals (e.g., use of Transmission-Based Precautions for those that have had close contact to someone with SARS-CoV-2 infection) when caring for fully vaccinated individuals with moderate to severe immunocompromise due to a medical condition or receipt of immunosuppressive medications or treatments.

According to the Guidance:
  • A symptom-based strategy for determining when HCP with SARS-CoV-2 infection could return to work is preferred in most clinical situations.
  • In general, asymptomatic HCP who have had a higher-risk exposure do not require work restriction if they have been fully vaccinated or if they have recovered from SARS-CoV-2 infection in the prior 90 days.
CDC ISSUES INTERIM INFECTION PREVENTION AND CONTROL RECOMMENDATIONS FOR NURSING HOMES

Key takeaways include:
  • Updated outbreak response guidance to promote use of contact tracing approach. Alternative broad-based testing approaches to outbreak response at a facility-wide or unit level are also described.
  • Updated expanded screening testing recommendations for healthcare personnel (HCP).
  • Updated recommendations for quarantine of fully vaccinated residents.
  • Updated visitation guidance.

These recommendations supplement CDC’s Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic and are specific for nursing homes, including skilled nursing facilities, but may also be applicable to other post-acute care settings like assisted living.
Employers should be aware that other local, state, and federal requirements may apply, including those promulgated by OSHA.
HOME AND COMMUNITY SERVICES RESUME TELEPHONIC CARE ASSESSMENTS
In a Dear Administrator letter dated September 10, 2021, assisted living and skilled nursing providers are informed due to the rising COVID cases in skilled nursing and assisted living facilities, Home and Community Services (HCS) is temporarily stopping in-person visits and resuming telephonic CARE assessments for Medicaid residents in these setting types effective September 13. HCS will continue to work with Adult Family Home and Enhanced Service Facility providers on a case-by-case basis, evaluating the most appropriate response between in-person and telephonic visits based on provider/client needs.

The letter also explains HCS staff will contact you as part of the assessment process to ensure accuracy in assessing and care planning. If you have electronic medical records, please continue to provide HCS staff access to the records upon notification that an assessment has started. 
ADDITIONAL RESOURCES
WHCA continues to post resources and information as it becomes available on our website. If you have questions or need additional information, please call the WHCA office at (800) 562-6170.