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Interim Guidance for Skilled Nursing Facilities During COVID-19

Frequently Asked Questions

October 14, 2020; updated February 11, 2021

The Department of Health (Department) is providing this document to address questions from skilled nursing facilities regarding the Guidance on COVID-19 for Skilled Nursing Facilities in Pennsylvania, as updated on September 3, 2020 (September guidance). These frequently asked questions relate to testing in particular, but address other miscellaneous questions. Please note that the Department is reviewing the recent CMS Memorandums [Ref. QSO-20-38-NH (Long-Term Care Testing Requirements) dated August 26, 2020 and Ref. QSO-20-39-NH (Nursing Home Visitation – COVID-19) dated September 17, 2020] to determine whether updates to existing guidance are needed. If there is conflict between one of these CMS Memorandums and the guidance, follow the CMS Memorandum.

Testing

Q: Our skilled nursing facility has created a plan for screening (aka surveillance testing). Does the Department of Health need to approve that plan?
A: No, the Department does not need to approve that plan. However, the plan should have been created in accordance with guidance from CMS and the September guidance from the Department.

Q: Our facility conducted screening testing and is still waiting for results more than 48 hours later. Do we need to notify anyone that the results are not back yet?
A: There is no need to notify the Department, but the facility needs to document the challenges relating to testing and be prepared to share them during their survey.

Q: A resident was admitted to our skilled nursing facility with a test pending from the hospital and the facility subsequently received the result as a positive. Is this to be reported to Survey 123 as a positive case for our facility?
A: Yes, it is to be reported to Survey 123 as a positive case for the facility.

Q: If a new resident tests positive in the facility during the 14-day incubation period after a hospital stay, is this to be reported to Survey 123?
A: Yes, it is to be reported to Survey 123 as a positive case for the facility.

Q: An agency nurse who worked at our facility a week ago called off this week because she was sick. She had symptoms of COVID-19 so she went on her own for a test. She reported to the facility today that the test was positive. How do we report this in Survey 123? She is not our employee, we did not test her, and (since she is an agency nurse) she may have worked in other facilities recently as well.
A: In this instance, there is no need to make this report to Survey 123. However, ensure that testing and appropriate transmission-based precautions are in place in the facility.

Q: The current Department of Health guidance refers skilled nursing facilities to the Centers for Medicare and Medicaid Services (CMS) data site to determine the positivity rate in their county (which determines their testing intervals). Can we use state data instead?
A: CMS has clarified that a facility may choose the data source for their county's positivity rate. A facility may choose the CMS data, Department data, or another published source such as county data. Once the facility has chosen their data source, they must continue to use that same source. If the facility chooses a source other than the CMS data, they must document that the selected source provides more current data.

Q: Is the county positivity rate the infection rate in our county or the percentage of positive tests?
A: The county positivity rate is the percentage of tests in the county that were positive for the virus that causes COVID-19. Facilities should note that CMS and the Department calculate the percentage of tests differently, which is why there is sometimes a discrepancy between the CMS and the Department's data.  The calculations are different because CMS uses a 14-day time period with additional criteria, while the Department uses a 7-day time period and no additional criteria.  This is why once a facility picks a data source to use for testing frequency, they must continue to use that data source moving forward.

Q: Please explain when and how often we should be checking the county positivity rate for our county to determine our testing frequency.
A: The following steps may be helpful in clarifying the requirements to get started:

  1. Determine which day of the week the facility will check the county positivity rate on alternating weeks. For example, the facility might pick Tuesday.
  2. Determine the source the facility will consistently use for their county positivity rate (e.g., CMS or Department).
  3. On the day of the week previously selected (e.g., Tuesday), check the county positivity rate from the selected data source. Compare it to Table 2 in CMS Memorandum (QSO-20-38-NH) to determine whether the county's positivity rate falls within the Low, Medium, or High level of community COVID-19 activity. Administer testing at the frequency outlined in the third column of the Table.
  4. In two weeks, on the day of the week previously selected (e.g., Tuesday), check the county positivity rate for the county from the source previously selected. Compare it to Table 2 in CMS Memorandum (QSO-20-38-NH) to determine whether the county's rate falls within the Low, Medium, or High level of community COVID-19 activity.
    • If the county positivity rate is at the same level as the last time it was checked, continue the frequency of testing currently being performed.
    • If the county positivity rate is at a higher level than the last time it was checked, the testing frequency must change in accordance with Table 2.
    • If the county positivity rate decreases to a lower level of activity from the previous time it was checked, testing should continue at the current frequency level for at least two weeks before reducing testing frequency.

Q: There appears to be a discrepancy between CMS Memorandum (Ref. QSO-20-38-NH) and the Department's Interim Guidance for Skilled Nursing Facilities During COVID-19 regarding the county positivity rate for the level of community COVID-19 activity. Specifically, the point at which a facility should test staff twice a week in the CMS Memorandum is different from the Department's guidance (>10% in the CMS Memorandum opposed to ≥10% in the Department's guidance). Which should we follow?
A: As noted above, follow the CMS Memorandum (Ref. QSO-20-38-NH) on this issue and any other issue on which the two documents conflict.

Q: Does CMS red classification for county positivity rate change anything other than increasing frequency of routine testing (e.g., does it change the Step in the lifting of restrictions)?
A: The county positivity rate doestrigger appropriate testing based on the level of community COVID-19 activity (i.e., Low, Medium, High). In addition, when the level of community COVID-19 activity is at High, visitation should only occur for compassionate care situations according to the core principles of COVID-19 infection prevention and facility policies, per CMS Memorandum (Ref. QSO-20-39-NH). Finally, CMS also encourages facilities in Medium or High-positivity counties to test visitors, if feasible.

Q: Since the point of care testing is antigen testing, when (if at all) will it need to be confirmed by a PCR test?
A: The Centers for Disease Control and Prevention (CDC) has published Considerations for Interpreting Antigen Test Results in Nursing Homes and the Department has issued HAN 526, Point-of-Care Antigen Testing for SARS-CoV-2 in Long-term Care Facilities.  Facilities should consult these resources for further guidance.

Q: Do we need to enter all the positive antigen test results in NEDSS?
A: Yes, and negative test results must be entered as well. View more information about Point of Care Testing and reporting of test results.

Q: Does this mean we will have to do monthly testing always, at least once per month?
A: If the level of community COVID-19 activity is Low (according to Table 2 in the CMS Memorandum QSO-20-38-NH), then routine testing of asymptomatic staff should occur every four weeks, and routine testing of asymptomatic residents is not recommended. Follow the testing frequency in Table 2 for initial testing and when the level of community COVID-19 activity changes.

Q: Please clarify the definition of staff. Does this include individuals coming into the facility infrequently such as x-ray technicians or imaging?
A: For purposes of testing, use the definition of facility staff in CMS Memorandum QSO-20-38-NH. If those coming in are contractors of the facility, they fall under this definition so their contracts should include provisions for testing requirements. This documentation will be included in the Department's surveyor review.

Q: The first paragraph on page 5 of the CMS Memoradum (QSO-20-38-NH) refers to "contact" with the local or state health department. For Pennsylvania, what does that mean? And what is an acceptable form of documentation? For example, we have an unmet needs assessment form. Is completion of that form sufficient?
A: "Contact" in the CMS memorandum means the facility would reach out to their local health department (i.e., county/municipal health department if one exists or the local office or the Department). Any form of documentation is acceptable such as copies of emails, internal facility forms, and phone notes with dates and times. The unmet needs assessment form is sufficient with proof of submission.

Q: It appears there are inconsistencies in the definitions between CMS and the PA Department of Health for the terms outbreak and staff. Should we go with the stricter interpretation?
A: As noted above, follow the CMS Memorandum (Ref. QSO-20-38-NH) for these definitions as they relate to testing.

Q: Will the state be providing a training webinar on entering the point of care testing data into NEDSS?
A: The Department recently released a PA-NEDSS Manual Test Reporting Instructions and Reporting FAQ which explains how to enter cases manually into PA-NEDSS. This includes step-by-step instructions with screen shots. Other mechanisms to allow for upload of data via an Excel worksheet are being explored.  Facilities should first consult these thorough resources, and if additional questions remain, the Department will consider a webinar.

Q: Our facility has an adjoining personal care home and CCRC. May we use the POC antigen testing machine for all our facilities?
A: The facility may use the instrument and test for whomever they choose, as long as sufficient supplies and equipment remain available to meet the testing requirements per CMS for skilled nursing facility staff.  After a facility uses the kits and the machines provided by the federal government, the facility will be responsible for continuing to procure needed machines and kits through their normal supply chain/vendors to meet the CMS regulatory requirements. Keep in mind that the BD Veritor Plus System has a lifespan of approximately 3,500 tests. Replacement of the machine and testing kits are the responsibility of the facility.

Q: What training is available for individuals operating the antigen machines?
A: Many of the manufacturers of antigen machines make online training available and it is suggested that anyone performing these types of tests review instructions for use (IFUs) and review any materials or training provided by the manufacturer. There is also a booklet and training that is provided by CDC. While training is not required it is certainly recommended:

Other

Q: Are skilled nursing facilities with active outbreaks permitted to send non-positive residents on green zones out for non-urgent/elective medical appointments?
A: Yes, residents should continue to receive necessary medical care.

Q: May family members transport residents from the facility to their medical appointments?
A: Yes, that is the resident's choice if there is no known risk of COVID-19 transmission based on the facility's current screening and testing protocols. The family member and the resident should adhere to appropriate infection control protocols including masking, hand sanitation, and social distancing.

Q: When implementing extended use, is there a recommended way to protect respirators from surface contamination in order to prolong their use?
A: During extended use of respirators, PADOH and the CDC recommends wearing a reusable face shield over a respirator to help protect these devices from potential surface contamination.  Do not wear a surgical or cloth mask over a respirator. NIOSH has not approved nor recommends wearing a surgical or cloth mask over an N95 is because it is inconsistent with the conditions of approval and voids their certification. Furthermore, double-masking may cause the worker to more frequently touch the face to make adjustments, putting them at risk for self-contamination.

Q: Where should I direct a question that is not covered in this document?
A: Questions may be directed to ra-dhSNFquestion@pa.gov.

Q: If I am in the Federal Pharmacy Partnership and have already had my first and second clinic, will first doses be provided at the third clinic?
A: The state's Federal Pharmacy Partners, CVS and Walgreens, are working to vaccinate all those in long-term care facilities that are part of the program. For facilities that have three clinics, first doses may be provided at the first and second clinics. At the third clinic, only second doses will be provided.

After the completion of the two-dose COVID-19 vaccine series, facilities will return to working with the vaccination provider it uses for routine vaccines.