In a press release and memo to state officials on May 18, the Centers for Medicare & Medicaid Services (CMS) outlines critical steps that nursing homes and communities should take prior to relaxing protective restrictions currently in place and identifies factors state officials should consider in deciding when it is safe to re-open. While the guidance is specific to nursing homes, it may serve as a foundation for decisions affecting housing with services and assisted living communities as well.  

The memo arrives at a time when states across the country, including Minnesota, are beginning to loosen restrictions on businesses. CMS is sending a clear signal that states should proceed cautiously.

“While we are not at a point where nursing homes can safely open up,” says CMS, “we want to make sure communities have a plan in place when they are ready to re-open.”  

A key take-away from the memo is that CMS will not make a top-down decision about re-opening: “Given the critical importance in limiting COVID-19 exposure in nursing homes, decisions on relaxing restrictions should be made with careful review of a number of facility-level, community, and State factors/orders, and in collaboration with State and/or local health officials and nursing homes. Because the pandemic is affecting communities in different ways, State and local leaders should regularly monitor the factors for reopening and adjust their plans accordingly.”

A Phased Approach to Re-Opening

CMS is recommending a three-phased approach to re-opening:

• Phase 1 is where we are now, our current state, in which we maintain the highest level of vigilance and protection: screening, restrictions on visitation, limitations on communal activities, service delivery approaches to preventing transmission such as cohorting, heightened standards for utilization of PPE, limited MDH survey activity, and so forth. CMS calls this the “highest mitigation” phase.
• In Phase 2 operations and service delivery restrictions loosen slightly, such as allowing limited numbers of non-essential health care personnel and contractors, and limited group activities and outings.  MDH survey activities would also expand during this phase, such as complaints involving allegations below the IJ level.
• Phase 3 brings additional changes. Visitation resumes, though screening and other precautions remain in place. Non-essential personnel/contractors will be admitted as determined necessary by the nursing home, and group activities and outings are further relaxed, though numbers are limited by considerations such as the ability to maintain social distancing. Normal survey activity also resumes.

Notably, many of the restrictions and practices we are currently following (e.g. screening, cohorting) would remain in place in Phase 3, suggesting a “new normal” for care center operations.  Refer to the chart in QSO-20-30-NH for full information on each phase.

How do we move through these phases? 

The State will define criteria that must be met in order to lift restrictions, based on factors such as:

• Case status in community, such as a decline in the number of new cases, hospitalizations, or deaths;
• Case status in facilities, including no new nursing home onset of COVID-19 cases among residents or staff;
• Adequate staffing, meaning no staffing shortages and facilities not operating under a contingency staffing plan;
• Access to personal protective equipment (PPE); and
• Access to adequate testing.

In addition to identifying the key factors states should consider, CMS recommends specific measures, such as that facilities could not enter Phase 3 unless and until there have been no new nursing home onset cases in the facility for 28 days.  The recommendations include that nursing homes should have a testing plan in place that accounts for the following:

• Resident testing: All residents receive a single, baseline test for COVID-19. Residents are subsequently re-tested upon the identification of a single individual with symptoms consistent with COVID-19 or a staff member who tests positive for COVID-19. Residents will be re-tested until all residents test negative.
• Staff testing: All staff receive a single, baseline test for COVID-19. “Staff” includes any vendors or volunteers who are in the nursing home on a weekly basis. Staff are subsequently tested on a weekly basis thereafter. State or local officials may adjust the frequency of staff testing based on community data.
• Screening protocols: Nursing homes must have written protocols for screening all residents daily, all staff each shift, and all others upon entering the facility.
• Arrangements with labs: Nursing homes must have arrangements with labs to process tests. Tests must be able to detect the virus with greater than 95% sensitivity and 90% specificity. Results must be obtained within 48 hours and antibody tests should not be used for diagnostic purposes.
• Refusals: Nursing homes must have written procedures for residents or staff who decline or are unable to be tested.

Key Take-Aways and Next Steps

This framework will be valuable as we develop a plan for re-opening nursing homes, but the guidance has to be refined, customized, and adapted for implementation on a state-by-state basis.

Among the many complicated choices the State will have to make when developing our reopening plan is whether to require all facilities to go through each phase at the same time (i.e., waiting until all facilities have met criteria to advance to Phase 2 or 3), or will it follow a regional or local approach, such as allowing facilities in certain counties to enter each phase at the same time, or permit individual nursing homes to move through the phases based on each nursing home’s status for meeting the criteria.

Another key question is how the State may use these recommendations to be planful about re-opening of housing with services, assisted living, and adult day centers.

And certain recommendations, such as adequate staffing, adequate PPE, and a testing plan including baseline testing for all residents and staff, will prove insurmountable without significant support for providers, and we will continue our advocacy efforts for the tangible resources you need to protect the vulnerable populations in your care.

LeadingAge Minnesota has already reached out to the Minnesota Department of Health and other state officials to request a close and comprehensive collaboration on these issues, and we will work closely with our Long-Term Care Imperative partner through the process that lies ahead. 

We will provide more information on these vital issues in the coming days.