May 20, 2020

CMS on Monday issued new guidance intended to help states form plans to ease restrictions aimed at curbing the new coronavirus' spread in nursing homes—and urged governors to use "extreme caution" in doing so.

How 5 hospitals are helping nursing homes control Covid-19

Nursing homes hit hard by new coronavirus

The new coronavirus has hit thousands of nursing homes throughout the United States. According to the Associated Press, the virus has been tied to more than 33,000 deaths among residents and staff at nursing homes and long-term care facilities in the country, representing more than one-third of all U.S. deaths linked to the new coronavirus so far. 

However, as states have begun reopening nonessential businesses and easing social distancing measures, some stakeholders have called for guidance on how to begin easing restrictions—such as bans on visitors—at nursing homes, as well.

For example, Toby Edelman of the Center for Medicare Advocacy said although prohibitions on visitors are intended to keep nursing home residents safe, they could have negative consequences if residents are socially isolated for too long. "It's been necessary but it takes its toll on residents and family members, psychologically, mentally, physically—in every conceivable way," he said.

CMS releases guidance for states to ease restrictions at nursing homes

As such, CMS on Monday issued new guidance detailing steps that nursing homes and their communities should take before relaxing restrictions aimed at curbing the new coronavirus' spread at the facilities. 

Notably, CMS said nursing homes should be the last businesses to ease such restrictions. The agency suggested that states should not consider relaxing restrictions aimed at curbing the new coronavirus' spread at nursing homes until they have evaluated the status the virus' transmission in both the community and in nursing homes, and until all staff and residents at nursing homes test negative for the virus.

In addition, CMS recommended that states evaluate staffing levels, access to testing for the new coronavirus, plans to perform baseline testing on all residents and staff and weekly retesting if needed, and plans to screen all staff and residents for potential symptoms of Covid-19, the disease caused by the virus. CMS also said states should check to ensure facilities have adequate access to personal protective equipment (PPE) for staff.

CMS also suggested that state survey agencies inspect nursing homes that had significant outbreaks of Covid-19 before easing restrictions at those facilities. Further, CMS said states should evaluate whether hospitals have enough capacity to accept transfers from nursing homes.

CMS in the guidance also recommended that nursing homes implement rigorous infection prevention and control strategies to prevent the new coronavirus' spread, such as requiring residents and visitors to wear face coverings or masks.

CMS recommended that, once states are ready to begin relaxing restrictions at nursing homes, they follow a three-phase plan outlined in the guidance. Each phase of the plan outlines the metrics states and nursing homes should meet before moving forward with the phase and the restrictions that should be lifted under the phase.

For instance, CMS suggested that states implement Phase 1 of the plan once most nursing home facilities are able to be at "their highest level of vigilance, regardless of transmission within their communities." Under Phase 1, visitors generally would not be permitted at the facilities.

In comparison, states could implement Phase 2 of the plan once transmission of the new coronavirus in the community and in nursing homes have hit certain metrics, such as seeing no newly reported cases for a period of 14 days. Under Phase 2, visitors still generally would not be permitted at the facilities.

Visitors would be permitted at nursing homes under Phase 3 with certain screening and other requirements in place. For example, CMS suggested that nursing homes require all visitors to wear face coverings or masks while inside the facility. If visitors are not able to wear face coverings or masks, nursing homes should consider limiting their ability to enter the facilities, CMS suggested. In addition, CMS recommended that all visitors maintain social distancing and wash or sanitize their hands upon entering the facilities.

CMS Administrator Seema Verma told the AP that CMS is "urging governors to proceed with extreme caution because these are the most vulnerable citizens." She said, "We know that nursing homes have struggled."

Industry groups say nursing homes need testing plan, support from CMS

Some industry groups and stakeholders said CMS' guidance does not help nursing homes implement adequate testing to safely ease restrictions at the facilities or implement evidence-based requirements for moving forward. 

Edelman said, "As usual throughout the [U.S. coronavirus epidemic], the federal government is once again putting responsibility on governors and others to make actual decisions. … We need national standards, based on science and expert advice, that everyone follows, not recommendations that can be ignored."

LeadingAge said the new guidance is "not grounded in [the] everyday realities" that nursing homes are facing and called on CMS to issue a plan for ensuring nursing homes can perform sufficient testing. "We need access to adequate testing supplies and PPE. And we need funding to make both of those possible for the brave people who care for vulnerable older adults day in and day out," the group said.

Similarly, the American Health Care Association said nursing homes need funding and support from state governments in order to expand their testing capacities.

Mike Dark, a lawyer with the nonprofit California Advocates for Nursing Home Reform, said, "The virus is already so widespread in facilities, and access to testing so limited, that asking for all residents and staff to test negative first means residents and families will lose hope of seeing one another again. … These are issues that CMS has already badly dropped the ball on, and now they're making families pay the price for it."

But Christopher Laxton—executive director of AMDA, the Society for Post-Acute and Long-Term Care Medicine—called CMS' guidelines "reasonable," saying they "allo[w] for flexibility based on the status of each facility" (Cirruzzo, Inside Health Policy, 5/18 [subscription required]; CMS release, 5/18; CMS guidance, 5/18; Choi, Associated Press, 5/18; Wilde Mathews, Wall Street Journal, 5/18; Goldstein et al., Washington Post, 5/18; Brady, Modern Healthcare, 5/18).

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