COVID-19 UPDATE #29
May 5, 2020
UPDATED CDC GUIDANCE RELEASED ON RETURN TO WORK AND CLINICAL CARE
The Centers for Disease Control and Prevention (CDC) released two updated guidance documents on April 30, 2020, around criteria for returning to work for healthcare personnel (HCP) with confirmed or suspected COVID-19 and the discontinuation of transmission-based precautions and disposition of patients with COVID-19.

Decisions about return to work for HCP with confirmed or suspected COVID-19 should be made in the context of local circumstances. The updated guidance includes the following:
  • Changed the name of the ‘non-test-based strategy’ to the ‘symptom-based strategy’ for those with symptoms and the ‘time-based strategy’ for those without symptoms.
  • Updated these to extend the duration of exclusion from work to at least 10 days since symptoms first appeared. 

The CDC specifically notes that after returning to work, HCP should:
  • Wear a facemask for source control at all times while in the healthcare facility until all symptoms are completely resolved or at baseline. After this time period, these HCP should revert to their facility policy regarding universal source control during the pandemic. 
  • Self-monitor for symptoms, and seek re-evaluation from occupational health if respiratory symptoms recur or worsen.

CDC also has information  focused around strategies to mitigate healthcare personnel staffing shortages you might be interested in reviewing. 

This updated guidance includes the following:
  • Changed the name of the ‘non-test-based strategy’ to the ‘symptom-based strategy’ for those with symptoms and the ‘time-based strategy’ for those without symptoms, and updated these to extend the duration of Transmission-Based Precautions to at least 10 days since symptoms first appeared. 
  • Added criteria for discontinuing Transmission-Based Precautions for patients who have laboratory-confirmed COVID-19 but have not had any symptoms of COVID-19.

According to the CDC, if a patient is discharged to a nursing home or other long term care facility (e.g., assisted living community), AND transmission-based precautions:
  • are still required, they should go to a facility with an ability to adhere to infection prevention and control recommendations for the care of COVID-19 patients. Preferably, the patient would be placed in a location designated to care for COVID-19 residents.
  • have been discontinued, but the patient has persistent symptoms from COVID-19 (e.g., persistent cough), they should be placed in a single room, be restricted to their room to the extent possible, and wear a facemask (if tolerated) during care activities until all symptoms are completely resolved or at baseline.
  • have been discontinued and the patient’s symptoms have resolved, they do not require further restrictions, based upon their history of COVID-19.
MEDICAID RATE ADD-ON FOR ASSISTED LIVING
Pursuant to a Dear Administrator letter dated May 4, 2020, in light of the unprecedented emergency circumstances associated with the COVID-19 pandemic, the Department of Social and Health Services (DSHS), will be issuing a temporary rate increase to Medicaid-contracted residential care providers.

The temporary rate increase will be retrospective to March 1, 2020, and continue to be available through June 30, 2020. The retrospective portion can be claimed as soon as it invoices in ProviderOne. The temporary rate increase is an additional rate of $9.31/day, including Specialized Dementia Care. For ESFs, an additional rate of $64.87/day is provided. The additional rate will be available until the end of the fiscal year, June 30, 2020. You will find billing instructions here .

MANAGEMENT BULLETIN TO CASE MANAGERS

DENIED CLAIMS – INSTRUCTIONS TO RESUBMIT
If you have attempted to submit claims for the new “Pandemic-related Extraordinary Services” service codes SA020 (with modifier U1, U2, U3, U4, U5, or UD) or SA031, U1 prior to 11:00 AM on May 5, 2020, you may have encountered an error and denied claim. These errors occurred because the claim was not split into individual dates of service. 

This issue has since been resolved and you should be able to resume submitting batch claims for a date range and ProviderOne will break up that range into individual days. 
 
Please resubmit claims that are in denied status for this reason and you should not have any issues. Claims submitted by 5 PM today, May 5, 2020, will be reflected on the RA that will be generated this Friday, May 8, 2020. If you are unfamiliar with how to resubmit claims, please refer to the ProviderOne Billing and Resource Guide .
CMS ISSUES CLAIMS PROCESSING GUIDANCE RELATED TO NEW COVID-19 ICD-10 CODE
AHCA reported to CMS an apparent glitch with implementing the U07.1 - 2019-nCoV acute respiratory disease ICD-10 CM code when the five-day assessment window overlaps March into April dates of service.

For example, when the MDS assessment reference date (ARD) is in April [4/1/20], but the date of service (DOS) is in March [3/25-3/31]. This is creating a problem given the U07.1 code is valid as primary in the MDS grouper April 1 but not on the UB-04 for DOS prior to April 1. Specifically, this is creating a primary diagnosis conflict whereby providers cannot match the primary diagnosis on the UB-04 in form locator 67 with the primary reason for skilled care in item I0020B of the MDS.

CMS has provided the following standardized guidance to the MACs:

“Based on the following guidance from the CMS PDPM FAQs  question 1.8 is to tell providers with a five-day PPS MDS with an April 2020 ARD, but a lookback period that extends into March 2020 that, when applicable, they can use the COVID 19 ICD-10 code U07.1 in MDS item I0020B to obtain the appropriate PDPM case-mix classification, but that the claim associated with March DOS must contain a different ICD-10 code that applies to the beneficiary and that was valid in March.

“We understand that this is a one-time event that only impacts a relatively small number of admissions related to COVID-19 that spanned the March-April implementation of the new U07.1 diagnosis code.  The claim will need to contain a different diagnosis other than U07.1 but the assessment may contain U07.1 code in these instances .”

AHCA recommends providers share the above with billing staff.
VISITATIONS, GROUP ACTIVITIES, AND COMMUNAL DINING STILL ON HOLD
Governor Inslee’s proclamations, in addition to the CDC guidelines, are still in effect. These efforts are designed to protect the most vulnerable in our state. While Governor Inslee’s proclamations, and extensions granted by the Legislature, are due to expire on May 9, it is anticipated that they will be extended through May, as are the ‘stay at home, stay healthy’ orders for the state.

As the weather warms and holidays like Mother’s Day and Memorial Day approach, residents and their families are likely anxious and looking forward to spending time together. At this point, however, only essential travel is allowed in the state; visiting loved ones outside the household is not yet deemed safe. Residents in long term care facilities remain at high risk for COVID-19. Residents leaving to visit loved ones in their homes may only prompt additional risk of exposure and subsequent spread of the virus throughout long term care communities.

WHCA is working with the Governor’s leadership team to develop a safe way to reopen long term care buildings to visitors, as well as opening dining rooms and group activities once the spread of COVID-19 has decreased. We are hopeful a process is developed soon, and will share that process with members once it is published.
IRS ISSUES NEW FAQs FOR EMPLOYEE RETENTION CREDIT, THE CARES ACT RELIEF PROVISION FOR EMPLOYERS TOO BIG, TOO LATE, OR TOO WORRIED ABOUT PPP LOANS
Paycheck Protection Program (PPP) loans have received the most attention–both positive about the benefits they provide and negative about borrowers now fearing that they are no longer considered eligible. The employee retention credit (ER Credit) has receive far less attention but for many it will prove more valuable than the PPP. On April 29, the IRS updated its FAQs about the ER Credit to add dozens more. There are a total of 94 FAQs, proving nothing involving tax is ever clear from the face of the statute. The most significant FAQs appear to effectively eviscerate one of the two ways by which an employer can be eligible for the ER Credit. Read more . Many thanks to Lane Powell for this article.
WA-PALTC TO HOST WEBINAR FOR ASSISTED LIVING PROVIDERS
Assisted living facilities are an essential part of the long term care continuum. Assisted living residents are indeed at high risk for COVID-19 infections and poor outcomes, and the state of Washington has seen many COVID-19 cases in assisted living facilities. Yet these congregate living facilities often follow a social model, making effective infection control all the more difficult. Join us for COVID in Assisted Living: Infection Control Interventions in a Non-medical Setting – Challenges and Opportunities, a discussion with assisted living experts on the specific challenges and opportunities to keep residents and staff in assisted living centers safe. This webinar will be hosed on Wednesday, May 6, at 6 PM. Register here .
PPE UPDATE
Personal Protective Equipment (PPE) such as masks, gloves, and gowns are essential for mitigating the spread of COVID-19 in long term care facilities. Due to the unprecedented national shortage of PPE, it has been difficult for LTCFs to secure the PPE they need. However, while gowns remain in short supply, the supply line for masks is opening up with increased availability.

The State Department of Health released new guidelines for PPE allocation . These guidelines, dated April 13, 2020, elevate long term care facilities without a case to the Tier One category and define long term care facilities as including nursing facilities, assisted living facilities, adult family homes, and supportive living providers. Previously, only long term care facilities with a case were in Tier One, and the types of facilities included were not defined. 

To request PPE from the King County Office of Emergency Management , please fill out this form and send your request to rcecc.logs@kingcounty.gov . The deadline for weekly submission is Wednesday at 12:00 p.m.
 
Cloth masks should not be worn for patient care, unless you are in a crisis standards of care situation. At this time King County is able to provide more PPE and all facilities who do not have enough should request weekly supplies through the King County website under PPE guidance.

For any facility outside of King County, the State Emergency Operations Center (SEOC) will survey each long term care facility once per week for PPE needs, and forward that information to the local Emergency Management Agency (EMA). The EMA will set up routine PPE delivery based on survey responses. To find out where your EMA is, contact your local health jurisdiction .
DEAR ADMINISTRATOR LETTER EXPLAINS PROCESS FOR DEDICATED COVID-19 UNITS
In a Dear Administrator letter dated May 4, 2020, the Department of Social and Health Services explains the work being done to contract with several nursing facilities and assisted living centers to establish dedicated units to care for residents with a confirmed COVID-10 positive diagnosis. The intent of establishing these units is to allow COVID-19 positive residents from other residential care or acute care settings to move to a setting where they can receive appropriate care in an environment where there will be less risk of COVID -19 virus transmission to other residents and staff. The letter explains the process by which facilities can apply to have a dedicated unit and refers to the contract amendment . Facilities interested in potentially providing a dedicated COVID-19 unit can reach out to Dennis Elonka via email at dennis.elonka@dshs.wa.gov .
DSHS TO HOST WEBINAR ON ALTSA RESPONSE TO COVID-19
On April 16, the Department of Social and Health Service (DSHS) hosted a webinar to discuss what Aging and Long Term Support Administration (ALTSA) has done in response to COVID-19. The questions and responding information from that webinar can be found here .
 
On May 14, DSHS is hosting a second webinar at 11:00 AM. During that webinar, they will continue discussion on ALTSA’s further efforts in response to COVID-19. Bill Moss, Assistant Secretary, ALTSA, will be joined by Bea Rector to discuss the status action items by Home and Community Services, Director Candace Goehring will provide updates on actions taken by Residential Care Services (RCS), and Director Deborah O’Willow will provide information related to the Office of Deaf and Hard of Hearing. The webinar will provide a time for Q&A. In order to provide for proper time for that, instructions will be provided in the confirmation email that will be sent when individuals register .
DSHS ONLINE REPORTING TOOL - NUMBER OF LTC FACILITIES REPORTING IS INCREASING, BUT WE ARE NOT THERE YET!
On April 20, 2020, the Aging and Long-Term Support Administration (ALTSA) announced the launch of an online tool  for providers to update COVID-19 information. DSHS/RCS is asking each facility to visit the website twice weekly—on Monday and Thursday by midnight—to update the COVID-19 status of residents, staff numbers, census, and COVID-19 test kit training needs. The numbers of facilities reporting are increasing; however, there are facilities (both AL and SNF) not utilizing the system pursuant to DSHS request. Instructions for using this tool are available here . More information can be found in the Dear Administrator letter  dated April 20, 2020. According to RCS Director, Candace Goehring , if you have questions, please contact your local field manager . 
PLAN FOR TESTING AND POSITIVE COVID-19 RESULTS
As point prevalence testing and test kits become more widely available, all facilities should prepare for facility wide testing of residents and staff. Now is the time to plan, do drills, and make sure staff are prepared when/if you get your first COVID positive result of residents/staff.

What to do When Residents Test Positive
Residents who test positive for COVID-19 must be isolated and wear a source control mask until placed in isolation. Providers should explore cohorting with other positive residents, if possible. Caution needs to be applied to actions after a new confirmed test in a resident, so it does not trigger unnecessary moving of the resident out of their existing room where exposure has already occurred. AHCA/NCAL has also updated this resource as COVID-19 is increasingly impacting nursing homes and assisted living communities.

Due to the rapid progression of this virus, centers should assume it is already in their surrounding community and may be in their facility. This resource outlines four action steps.

What to do When Staff Test Positive
Per CDC Return to Work Criteria guidance , health care facilities must be prepared for potential staffing shortages and have plans and processes in place to mitigate them, including considerations for permitting health care providers to return to work without meeting all return-to-work criteria outlined.

CDC refers to the Strategies to Mitigate Healthcare Personnel Staffing Shortages for information which provides both contingency and crisis strategies. Contingency strategies apply when staffing shortages are anticipated and crisis strategies apply when staffing shortages are happening. Facilities can activate these strategies based on their staffing situation and should document when they are activating these strategies with the reason why they were activated. Also, notify the local or state health departments of these actions. AHCA/NCAL summarized this guidance in more detail in a recent member update .
FEMA PLANNING TO DISTRIBUTE PPE TO LTC CENTERS
The Federal Emergency Management Agency (FEMA) will coordinate two shipments totaling a 14-day supply of personal protective equipment (PPE) to nursing homes across the nation. By the beginning of July, each center will receive two separate packages containing a seven-day supply of eye protection, surgical masks, gowns, and gloves. Each center will receive an allotment of all four items based on the size of the facility.

The Level 1 medical gowns included in the shipments are intended for use in basic care settings for minimal risk situations. The gowns are durable and can be washed 30-50 times.

Distribution of a one-week supply will start this week. It is likely that nursing homes will receive little or no notice of the arrival of this PPE. Plans are to have FEMA distribute an additional one week supply to skilled nursing facilities next month. In addition, FEMA is currently determining how it can also distribute PPE to assisted living facilities. Unfortunately, while welcomed, this effort comes more than two months into the pandemic as the death toll climbs.
WHO CARES ABOUT MY PPP LOAN? EVERYONE.
In recent weeks, a number of businesses have been thrust in the media spotlight for accepting PPP loans made available through the CARES Act. Certain number of these businesses are now seeking to return the borrowed funds, including Ruth’s Chris, Shake Shack, Potbelly Corp, and the Los Angeles Lakers. Whether these companies elected to return their respective loans as a result of the public relations pressure or the ever-changing guidance issued by the administration is unclear. On April 27, President Trump told reporters that he would be interested in having a list of names of PPP loan recipients made publicly available, but that he would have to give thought to the legal implications of such disclosure. Read more . Many thanks to Lane Powell for providing this article.
DOH TO HOST WEBINAR FOR HEALTHCARE PROVIDERS
The Department of Health (DOH) will host its weekly webinar on Thursday, May 7, at 11:00 AM. This weekly call is designed for healthcare providers enabling them access to DOH officials and experts so they can get answers to questions and additional information to help them respond to the COVID-19 public health emergency. Register in advance , and once you register, you can save the link to join each week through May 28 as an appointment on your calendar so you will not need to search for the link each week. The password will be provided upon registration.
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.