COVID-19 UPDATE #126
January 12, 2021
DEAR ADMINISTRATOR LETTERS EMPHASIZE LTC FACILITIES MUST OPERATE UNDER SAFE START FOR LTC
In Dear Administrator letters originally dated June 20, 2020, and amended January 11, 2021, to assisted living and skilled nursing providers, Residential Care Services reminds all long term care professionals that long term care settings must continue to operate under the Safe Start for Long Term Care plan under Governor’s Proclamation 20-66. RCS and the Department of Health (DOH) are finalizing revised Safe Start for Long Term Care Requirements and Recommendations documents with a planned release and effective date of January 13, 2021. Each letter reminds providers that if a resident plans to leave the facility for a medical appointment, a therapy appointment, an outing, or to work in the community, the facility should consider implementing certain infection control procedures. Both letters provide the following list of recommendations:
  • Assist the resident with acquiring any items needed to follow proper infection prevention practices, such as a mask and hand sanitizer;
  • Inform the resident about potential risks when going into the community, including the increased risk of exposure to COVID-19 and the increased risk of introducing COVID-19 to the facility upon return;
  • If someone is escorting the resident into the community, request they pick the resident up at the front door or curb;
  • Inform the person escorting the resident into the community about the potential risks, including the increased risk of exposure to COVID-19 for the resident as well as the increased risk of introducing COVID-19 to the facility upon return;
  • Request the person joining the resident in the community wear a mask at all times while with the resident;
  • Request the resident follow universal masking while in the community;
  • Request the resident adhere to social distancing practices while in the community;
  • Request the resident follow good hand hygiene procedures in the community, including frequent use of alcohol-based hand sanitizer when soap and water is not available;
  • With resident permission, keep a log of resident activities in the community to allow for contact tracing purposes if any community outbreaks occur in businesses or places the resident visited;
  • Continue to conduct daily symptom screenings with resident upon their return to the facility;
  • Request the resident practice social distancing when out of their room in the facility upon return from the outing;
  • Request the resident follow universal masking when outside of their room upon return from the outing;
  • If a facility is able, cohorting of residents who come and go from the facility would be recommended.

The letters each remind providers that additional resources on the Safe Start plan and other COVID-19 pandemic response can be found here. Providers are also encouraged to contact their local health jurisdiction for specific recommendations pertaining to virus activity in their area. Finally, each letter provides contact information if providers have questions. Assisted living professionals may reach out via email to Jeanette Childress or call her at (360) 764-9804. Skilled nursing providers may reach out via email to Lisa Herke or call her at (509) 209-3088.
COVID-19 PROACTIVE AND REACTIVE STEPS: BACK TO BASICS FOR ASSISTED LIVING
Since COVID-19 first entered long term care communities almost a year ago, we’ve learned much about the virus and how it behaves. Long term care facilities’ staff responded remarkably by quickly implementing new processes and changing course as new information developed, sometimes even daily. Assisted living communities quickly became lumped into “long term care facilities” and found themselves following CDC guidelines and OSHA laws.

DSHS investigators across the state are discovering basic infection control practices lacking and are citing these findings. In many cases, conditions are being placed on licenses, fines are levied, and stop placement orders are instituted.

Now is not the time to grow complacent. As the COVID-19 infections continue to surge through our settings, one must pause, reevaluate, and go back to the basics.

SYMPTOM CHECKS: STAFF AND VISITORS
Citations have occurred in this area for various reasons, including:
  • Staff and visitors (and residents, returning from outings) walking through the facility to reach the checkpoint area;
  • The facility staff relying on staff, visitors, and residents self-checking symptoms, rather than actively checking;
  • Partial documentation of symptoms, such as temperature only;
  • For residents, no oximetry readings along with other symptom checks;
  • No screening being conducted at all;
  • Inappropriate (or no) follow-up for those showing symptoms.

Visitors and staff must be actively checked for symptoms upon arrival at the facility. They cannot walk through the facility to reach the checkpoint area. Temperatures and other symptoms must be documented. Any hint of COVID-19 infection warrants no entry to the facility.

INFECTION CONTROL
Hand hygiene practices require frequent re-training, observation, and follow up with all staff, visitors, and residents. Ensure hand hygiene is being performed completely, and at the appropriate times.

Routine cleaning and disinfecting of common areas and high-touch surfaces are essential in mitigating infection spread.

PPE
There have been several reported citations surrounding appropriate use of PPE. Common themes include:
  • Staff not consistently wearing masks and eye protection;
  • Residents not wearing face coverings;
  • N95 masks not fitted, not available at all, or not used at the appropriate time/for the appropriate situation;
  • Staff observed donning and/or doffing PPE inappropriately and/or wearing PPE incorrectly;
  • Staff not changing PPE between residents.

COHORTING
There have been situations where residents who have symptoms of COVID-19, first move in and should be quarantined, or have tested positive, and are living/staying in areas of the facility where noninfected individuals live. It is imperative to have plans that can be carried out quickly to cohort like residents in the same area, or if not, have alternate locations to which they can be transferred.

ACTIVITIES AND DINING
There have been instances where DSHS staff have entered buildings where residents are dining and gathering together without social distancing standards in place. Following the Safe Start for Long Term Care guidelines outlines safe methods to promote resident connectedness and dining.
COVID-19 PROACTIVE AND REACTIVE STEPS: BACK TO BASICS FOR SKILLED NURSING
As we are quickly approaching a year of enduring and surviving the COVID-19 pandemic, it is necessary to remind all facilities to not lose sight of some of the initial and basic measures of infection control principles required to manage COVID-19. In recent weeks, several skilled nursing facilities have received citations under F880 at an immediate jeopardy level.

Keep in mind, for an immediate jeopardy to exist, three key components are required:
  • Non-Compliance - the facility has failed to meet one or more federal health, safety, and or quality regulations; AND
  • Serious Adverse Outcome or Likely Serious Adverse Outcome – must be present. As a result of the identified noncompliance, serious injury, serious harm, serious impairment, or death has occurred, is occurring, or is likely to occur to one or more identified residents at risk; AND
  • Need for Immediate Action – the noncompliance creates a need for immediate corrective action by the provider to prevent serious injury, serious harm, serious impairment, or death from occurring or recurring.

There are also some key definitions and clarifications made by CMS. Core Appendix Q makes it clear that to cite immediate jeopardy in situations where residents have not already suffered serious injury, harm, impairment, or death, the nature and/or extent of the identified noncompliance creates a likelihood (reasonable expectation) that such harm will occur if not corrected, not simply the potential for that level of harm to occur. It is very clear that COVID-19 is deadly to our LTC residents and, therefore, breaches in infection control standards will rise to the level of an immediate jeopardy very quickly. Also keep in mind that only one resident need be affected or potentially affected by the failed practice.

As the COVID-19 outbreaks continue in our long term care facilities across the state, it is necessary to evaluate the citations being issued and to address some common themes.
 
SYMPTOM CHECKS: STAFF AND VISITORS
F880 Citations have occurred in this area for various reasons, including:
  • Staff, visitors (and residents, returning from outings) walking through the facility to reach the checkpoint area.
  • The facility staff relying on staff, visitors, and residents self-checking symptoms, rather than actively checking.
  • Partial documentation of symptoms, such as temperature only.
  • For residents, no oximetry readings along with other symptom checks.
  • No screening being conducted at all.
  • Inappropriate (or no) follow-up for those showing symptoms. Staff have been allowed to work with symptoms of COVID-19 with lack of follow up to those symptoms.
 
INFECTION CONTROL
  • Staff have failed to remove gloves between resident contact.
  • Lack of hand hygiene/washing.
  • Biohazard waste and PPE have been improperly disposed of, overflowing, and not secured.
  • Lack of surface cleaning or failure to use proper disinfectants.
  • Lack of cleaning/sanitizing face shields.
 
PPE
There have been several reported citations surrounding the lack of or inappropriate use of PPE. Common themes include:
  • Staff not consistently wearing masks and eye protection.
  • Residents not wearing face coverings.
  • N95 masks not fitted, not available at all, or not used at the appropriate time/for the appropriate situation.
  • Staff have failed to remove PPE between residents when required and have gone between COVID positive, quarantine, and non-COVID units/rooms. Concerns have been identified with nursing staff, housekeeping, and maintenance staff.
 
COHORTING
There have been situations where residents who have symptoms of COVID-19, are admitted to the facility and should have been quarantined or have tested positive and are residing in areas of the facility where noninfected individuals live. 
  • Facilities have failed to cohort residents in a timely manner.
  • Facilities in an outbreak failed to have plans in place for cohorting and planned designated areas for outbreaks and quarantine when needed.

It is imperative to remain ever vigilant in your fight against this deadly virus, people are tired and may revert to their pre-COVID practices. Especially now as the COVID-19 vaccine is being rolled out, facilities must ensure that infection control practices are in place and consistently implemented. Facilities should continue to use the COVID-19 Focused Survey for Nursing Homes as a tool to ensure infection control practices are in place and that the facility is ready for the RCS IC survey as a result of a complaint or outbreak. Several resources are available on the following websites:
OSHA: A GUIDE TO MEETING REPORTING OBLIGATIONS
On September 30, 2020, the Occupational Safety and Health Administration (OSHA) released new FAQ’s regarding an employer’s obligation to report and record work-related COVID cases. They also offer a sample template to help facilities prepare their own Respiratory Protection Program. 

Reporting Obligations
In the released FAQ, OSHA defines the term “incident” that triggers the time period for calculating whether a case meets the reportability criteria. Incidents and timeframes include:
  • When an employee has an in-patient hospitalization which occurs within 24 hours of an exposure to COVID-19 at work. This must be reported within 24 hours of determination that the hospitalization was due to a work-related exposure to COVID-19. OSHA defines in-patient hospitalization as “a formal admission to the in-patient service of a hospital or clinic for care or treatment.” Providers do not have to report an in-patient hospitalization that involves only observation or diagnostic testing.
  • When there is an employee fatality within 30 days of exposure to COVID-19 at work. The employer must report the fatality within eight hours of knowing both that the employee has died and that the cause of death was due to a work-related case of COVID-19. 

Recording Obligations for OSHA 300 Logs
OSHA has further stated that COVID-19 is a recordable illness, and employers are responsible for recording cases of COVID-19 if:
  • The case is a tested-positive confirmed case of COVID-19, as defined by Centers for Disease Control and Prevention (CDC);
  • The case is "work-related," which is defined as an event or exposure that either caused or contributed to the resulting condition or significantly aggravated a preexisting injury or illness (this includes COVID-19 acquired from a co-worker or resident); and
  • The case involves one or more of the following: death, days away from work, restricted work or transfer to another job, medical treatment beyond first aid, loss of consciousness, or a significant injury or illness diagnosed by a physician or other licensed health care professional, even if it does not result in death, days away from work, restricted work or job transfer, medical treatment beyond first aid, or loss of consciousness.

The American Health Care Association has formatted a sample template letter that can be used in response to OSHA inquiries due to complaints received regarding PPE. This guidance is applicable to all long term care providers, including assisted living and skilled nursing providers.
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.