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Interim Guidance for Skilled Nursing Facilities During COVID-19

June 26, 2020

The Department of Health (Department) is providing the below guidance as an update to guidance issued on May 12, 2020 and in light of the statement issued on June 2, 2020 "Restrictions to Protect Residents in Skilled Nursing Care (SNF) Facilities Temporarily Remain in Place in Counties in the Green Phase of the Governor's Process to Reopen Pennsylvania."  To protect the residents and staff of SNFs during the COVID-19 pandemic, restrictions were put in place. To safely lift those restrictions, the Commonwealth has developed this reopening guidance (beginning in Section 6) that will occur in a three-step process.  Facilities licensed by the Centers for Medicare and Medicaid Services (CMS) should also continue to follow all relevant CMS guidelines available now and in the future.

1. Cohorting Residents

If a SNF wishes to expand the number of beds or convert closed wings or entire facilities to support COVID-19 patients or residents, first review PA-HAN 496, Universal Message Regarding Cohorting of Residents in SNF. If the facility's planned strategy appears to conform with PA-HAN 496, submit a request to the Department's appropriate field office for approval. Each request will be considered on a case-by-case basis, and dialogue with the facility will occur to acquire all details needed for the Department to render a decision. To ensure the Department has the necessary information to enter that dialogue, include at a minimum the following information for the new or expanded space (if applicable) with the request:

  • Number of beds and/or residents impacted, including whether residents will be moved initially.
  • Whether the beds are Medicare or Medicaid (including proof of approval from the Department of Human Services to expand the number of Medical Assistance beds, if applicable).
  • Location and square footage (with floor plan and pictures, if appropriate).
  • Available equipment in the room.
  • Staffing levels and plan for having adequate staffing for the duration of the cohorting.
  • Plan for locating displaced residents including care of vulnerable residents (such as dementia residents) either in the same facility or sister facility.
  • Description of how residents with COVID-19 or unknown COVID-19 status will be handled (e.g., moving within the facility, admitted from other facilities, admitted from the hospital).
  • Plan for discontinuing use of any new, altered or renovated space upon the expiration of the Governor's Proclamation of Disaster Emergency issued on March 6, 2020.
  • Contact information for person responsible for the request.

Upon submission of the request, a representative from the Department will reach out to the facility's contact person to discuss next steps. Questions regarding this process can be directed to the appropriate field office.

2. Mandatory Reporting through Corvena (previously known as Knowledge Center) and Survey123

In accordance with the Order of the Secretary of Health issued on April 21, 2020, all SNFs licensed in the Commonwealth must complete the SNF Capacity Survey in Corvena (formerly Knowledge Center) at 0800 daily. All fields indicated as mandatory must be completed. If any non-mandatory field has changed from the initial submission, the facility must update that field on the next calendar day's submission.

Additionally, in accordance with the Order of the Secretary of Health issued on May 14, 2020, all SNFs licensed in the Commonwealth must complete the survey data collection tool daily. All facilities must update all data fields each day, including cumulative case counts (total counts identified in the facility since the beginning of the outbreak) where indicated.

3.  Infection Control and Personal Protective Equipment (PPE)

a.     The infection control specialists designated by the facility must review PPE guidelines with all staff.

b.     Screen residents and staff for fever and respiratory symptoms (using a checklist for employees such as the one developed by the American Health Care Association and the National Center for Assisted Living). Staff should be screened at the beginning of every shift, and residents should be screened daily. All other personnel who enter the facility should be screened.

c.     Staff with even mild symptoms of COVID-19 should consult with occupational health before reporting to work. If symptoms develop while working, staff must cease resident care activities and leave the work site immediately after notifying their supervisor or occupational health services, in accordance with facility policy. 

d.     Minimize resident interactions with other personnel and contractors performing essential services (e.g., plumbers, electricians, etc.)

e.     Arrange for deliveries to areas where there is limited person-to-person interaction.

f.     Ensure cleaning practices comport with CDC guidance.

g.     Refer to the following for guidance on infection control and PPE use, including universal masking for all persons entering the facility:

4.     Visitor Policies When Not In the Reopening Process

SNFs or residents not part of reopening as defined in Section 6 must follow the guidance in this section for visitors.  If facilities encounter regression criteria outlined in Section 6c, they must resume the visitation policies described in this section.

a.     To limit exposure to residents, restrict visitation as follows:

    • Restrict all visitors, except those listed in Section 4b below.
    • Restrict all volunteers, non-essential health care personnel and other non-essential personnel and contractors (e.g., barbers).
    • Restrict cross-over visitation from personal care home (PCH), Assisted Living Facility, and Continuing Care Community residents to the SNF. Ensure cross-over staff adhere to the facility's Infection Control Plan.

b.     The following personnel are permitted to access SNFs and must adhere to universal masking protocols in accordance with HAN 492 and HAN 497:

    • Physicians, nurse practitioners, physician assistants, and other clinicians;
    • Home health and dialysis services;
    • The Department of Aging/Area Agency on Aging including the Ombudsman and the Department of Human Services where there is concern for serious bodily injury, sexual abuse, or serious physical injury;
    • Visitors to include but not be limited to family, friends, clergy, and others during end of life situations;
    • Hospice services, clergy and bereavement counselors, who are offered by licensed providers within the SNF; and
    • Department of Health or agents working on behalf of the Department, such as Long-Term Care Ombudsman, or local public health officials.

5.     Dining Services When Not In the Reopening Process

SNFs or residents not part of reopening as defined in Section 6 must follow the guidance in this section for dining.  If facilities encounter regression criteria outlined in Section 6c, they must resume the dining policies described in this section.

a.     Provide in-room meal service for residents who are assessed to be capable of feeding themselves without supervision or assistance.

b.     Identify residents at-risk for choking or aspiration who may cough, creating droplets. Meals for these residents should be provided in their rooms with assistance. If meals cannot be provided in their rooms, the precautions outlined below must be taken for eating in a common area in addition to ensuring the residents remain at least six feet or more from each other.

c.     Residents who need assistance with feeding and eat in a common area should be spaced apart as much as possible, ideally six feet or more. Where it is not possible to have these residents six feet apart, then no more than one resident who needs assistance with feeding may be seated at a table.

Precautions When Meals Are Served in a Common Area
  • Stagger arrival times and maintain social distancing;
  • Increase the number of meal services or offer meals in shifts to allow fewer residents in common areas at one time;
  • Take appropriate precautions with eye protection and gowns for staff feeding the resident population at high-risk for choking, given the risk to cough while eating; and
  • Staff members who are assisting more than one resident at the same time must perform hand hygiene with at least hand sanitizer each time when switching assistance between residents.

6.     Reopening of SNFs

To safely lift restrictions, the reopening has two primary components:

  • Reopening prerequisites, requirements, and criteria (sections 6b-c); and
  • Reopening "Steps" (section 6d).
    These components were developed in consultation with the Centers for Medicare and Medicaid Services guidelines on reopening nursing homes.  The prerequisites and requirements define the capability and capacity an individual facility must have to enter reopening. The criteria for moving forward and backwards among the "Steps" is defined, and the requirements associated with visitation are specified.

The word "Step" was intentionally chosen to differentiate it from the White House's "Opening Up America Again" Phases to reopening, as well as Governor Wolf's Phased Reopening Plan.  If a county is in Governor Wolf's Yellow or Green phase, it is considered part of the White House's Phase 3.  The "Steps" were developed to carefully allow SNFs to resume communal dining, activities, volunteers, non-essential personnel, visitors and outings in a measured approach.  The Steps strike a balance between protecting residents' physical health (through incrementally reopening when it is safe) with their mental health (that necessitates visitation and communal activites).

Terms used in explaining reopening are defined in section 6a. Given the interrelated nature of these sections, it is recommended that each is read in close consultation with each other.

a.    Terms Used in this Section

Terms used in section 6 are defined below:

    • "Cross-over visitation" refers to visits from an individual residing in a personal care home, continuing care retirement community, or assisted living facility.
    • "Exposed residents" refers to those residents with a known recent exposure to the virus that causes COVID-19 or have had a positive test result for the virus that causes COVID-19 in the past 14 days.
    • "Neutral zone" means a pass-through area (such as a lobby or hallway not in a red, yellow, or green zone per HAN 509) and/or an area of the facility and facility grounds not typically occupied or frequented by residents with COVID-19 or exposed to COVID-19 (such as an outside patio area or a dining or activity room).
    • "New facility onset of COVID-19 cases" refers to COVID-19 cases that originated in the facility, and not cases where the nursing home admitted individuals from a hospital with a known COVID-19 positive status, or unknown COVID-19 status but became COVID-19 positive within 14 days after admission. In other words, if the number of COVID-19 cases increases because a facility is admitting residents from the hospital AND they are practicing effective Transmission-Based Precautions to prevent the transmission of COVID-19 to other residents, that facility may still advance through the steps of reopening. However, if a resident contracts COVID-19 within the facilty without a prior hospitalization within the last 14 days, the facility will be deemed to have new facility onset of COVID-19.
    • "Non-essential personnel" includes contractors and other non-essential personnel.
    • "Screening" includes checking for fever and symptoms of COVID-19 and asking questions about possible exposure.
    • "Social distancing" is the practice of increasing the physical space between individuals and decreasing the frequency of contact to reduce the risk of spreading COVID-19 (ideally to maintain at least 6 feet between all individuals, even those who are asymptomatic).
    • "Unexposed to COVID-19" refers to an individual who has no known recent exposure to the virus that causes COVID-19 or has not had a positive test result for the virus that causes COVID-19 in the past 14 days.
    • "Universal masking" means the protocols set forth in PA-HANs 492 and 497, with homemade cloth masks being acceptable for visitors.
    • "Visitors" includes individuals from outside of the facility as well as cross-over visitors.
    • "Volunteer" is an individual who is a part of the facility's established volunteer program.

b.    Reopening Prerequisites and Requirements

Following CMS guidelines, the Department will survey those nursing homes that experienced a significant COVID-19 outbreak prior to reopening to ensure the facility is adequately preventing transmission of COVID-19.  In order to enter reopening, the facility must meet the following prerequisites and the requirements for entering either Step 1 or Step 2.

1)    Prerequisites:
All the following prerequisites must be met before entering Step 1, advancing to each new Step, or in order to remain in each Step:

    • Develop a Reopening Implementation Plan.  The Plan must be posted on the facility's website, if they have an existing website, or available to all residents, families, advocates such as the Ombudsman and the Department upon request.  The Implementation Plan shall include, at a minimum, the following components:
        • A testing plan that, at minimum:
        • Identifies how the facility has fully complied with the Order dated June 8, 2020. Completion of baseline testing must be accomplished prior to reopening;
        • Includes the capacity to administer COVID-19 diagnostic tests to all residents showing symptoms of COVID-19 and do so within 24 hours;
        • Includes the capacity to administer COVID-19 diagnostic test to all residents and staff if the facility experiences an outbreak;
        • Includes the capacity to administer COVID-19 diagnostic tests to all staff, including asymptomatic staff;
        • Includes a procedure for addressing needed testing of non-essential staff and volunteers; and
        • Includes a procedure for addressing residents or staff that decline or are unable to be tested.
      • A plan to cohort or isolate residents diagnosed with COVID-19 in accordance with PA-HAN 509 pursuant to Section 1 of this guidance.
      • A written screening protocol for all staff during each shift, each resident  on a daily basis, and all persons (visitors, volunteers, non-essential personnel, and essential personnel) entering the facility or facilty grounds.
      • A plan to ensure and a current cache of an adequate supply of personal protective equipment for staff.
      • A plan to ensure and a current status of adequate staffing – no staffing shortages and the facility is not under a contingency staffing plan.
      • A plan to allow for communal dining and activities to resume pursuant to the guidance provided in Section 6d "Step to Reopen."
      • A plan to allow for visitation pursuant to the guidance provided in Section 6e "Visitation Requirements."
      • A plan to halt all reopening facilities if the county in which the facility is located is reverted to a Red Phase of the Governor's Reopening Plan.
        • To begin reopening, a facility must be in a Yellow or Green county per the Governor's Reopening Plan.

2)    Requirements for Initial SNF Reopening:

  • To enter reopening at Step 1, the facility must meet all the Prerequisites.
    • To enter reopening at Step 2 (that is, the SNF skips Step 1 and moves immediately into Step 2), the facility must meet all the Prerequisites AND have the absence of any new facility onset of COVID-19 cases  for 14 consecutive days since baseline COVID-19 testing

c.    Criteria for Advancing to and Regressing from Next Step

The following criteria will be applied to determine movement among steps of reopening.

    1. To enter Step 1, the facility must meet all Prerequisites.

      If at any point during Step 1 (14 consecutive days) there is a new facility onset of COVID-19 cases, the facility must cease Step 1 reopening and return to the guidance described in Sections 4 and 5 relating to visitors and dining, respectively. Moving back to the guidance described in Sections 4 and 5 restarts the 14-day period count.  After the new 14-day period, if there is no new facility onset of COVID-19 cases the facility may reinitiate Step 1.
       
    2. From the date the facility enters Step 1, if there is no new facility onset of COVID-19 cases for 14 consecutive days the facility may move to Step 2.

      If at any point during Step 2 (14 consecutive days) there is a new facility onset of COVID-19 cases, the facility must cease Step 2 reopening and return to the guidance described in Sections 4 and 5 relating to visitors and dining, respectively. Moving back to the guidance described in Sections 4 and 5 restarts the 14-day period count.  After the new 14-day period, if there is no new facility onset of COVID-19 cases the facility may reinitiate Step 1.
       
    3. From the date the facility enters Step 2, if there is no new facility onset of COVID-19 cases for 14 consecutive days the facility may move to Step 3.

      If at any point during Step 3 there is a new facility onset of COVID-19 cases, the facility must cease Step 1, 2, and 3 reopening and return to the guidance described in Section 4 and 5 relating to visitors and dining, respectively. Moving back to the guidance described in Sections 4 and 5 restarts the 14-day period count.  After the new 14-day period, if there is no new facility onset of COVID-19 cases the facility may reinitiate Step 1.

    4. If a county in which a facility is located moves into the Red Phase, the SNF must return to the guidance described in Section 4 and 5 relating to visitors and dining, respectively. When the county moves back to the Yellow Phase, the facility may enter reopening again only when the prerequisites and requirements in Section 6b are also met.

d.     Steps to Reopen

The following Steps provide an incremental lifting of restrictions. The prerequisites and requirements to enter reopening are detailed in Section 6b, and the criteria for advancing (or retreating) a Step are detailed in Section 6c. Further detail on visitation requirements is listed in Section 6e.

  Step 1 Step 2 Step 3
Dining[1]Communal dining is limited to residents unexposed to COVID-19. Those residents may eat in the same room with social distancing (limited number of people at tables and spaced by at least six feet). Adhere to the Precautions When Meals Are Served in a Common Area in Section 5 of this guidance. All other residents must adhere to the restrictions in Section 5, Dining Services When Not In the Reopening Process.
ActivitiesLimited activities may be conducted with five or less residents unexposed to COVID-19. Social distancing, hand hygiene, and universal masking are required. Limited activities may be conducted with ten or less residents unexposed to COVID-19. Social distancing, hand hygiene, and universal masking are required.Activities may be conducted with residents unexposed to COVID-19. Social distancing, hand hygiene, and universal masking are required.
Non-Essential PersonnelAdhere to restrictions in Section 4, Visitor Policies When not In the Reopening Process.Non-essential personnel are allowed as determined necessary by the facility, with screening and additional precautions including social distancing, hand hygiene, and universal masking.   Services for exposed residents adhere to the restrictions in Section 4, Visitor Policies When Not In the Reopening Process. Non-essential personnel are allowed with screening and additional precautions including social distancing, hand hygiene, and universal masking. Services for exposed residents adhere to the restrictions in Section 4, Visitor Policies When Not In the Reopening Process.
VolunteersAdhere to restrictions in Section 4, Visitor Policies When not In the Reopening. Process.Volunteers are allowed only for the purpose of assisting with visitation protocols[2] and may only conduct volunteer duties with residents unexposed to COVID-19. Screening, social distancing, and additional precautions including hand hygiene and universal masking are required.  Volunteers are allowed but may only conduct volunteer activities with residents unexposed to COVID-19. Screening, social distancing, and additional precautions including hand hygiene and universal masking are required.
VisitorsAdhere to restrictions in Section 4, Visitor Policies When not In the Reopening Process.Outdoor visitation (weather permitting) is allowed in neutral zones to be designated by the facility. If weather does not permit outdoor visitation, indoor visitation is allowed in neutral zones to be designated by the facility and defined in their Implementation Plan.  Visitation is limited to residents unexposed to COVID-19. Review Section 6e for additional requirements.  Visitation for exposed residents adhere to the restrictions in Section 4, Visitor Policies Not Impacted by the Reopening Process.Indoor visitation is allowed in neutral zones to be designated by the facility. Visitation is limited to residents unexposed to COVID-19. Visiting in a resident's room (within facility's established protocols) is permitted only if the resident is unable to be transported to designated area. Cross-over visitation is only permitted if there is no new facility onset of COIVD-19 in the facility in which the cross-over visitor resides. Review Section 6e for additional requirements.  Visitation for exposed residents adhere to the restrictions in Section 4, Visitor Policies Not Impacted by the Reopening Process.
OutingsAdhere to restrictions in Section 4, Visitor Policies Not Impacted by the Reopening.Adhere to restrictions in Section 4, Visitor Policies Not Impacted by the Reopening.Outings are allowed only for residents unexposed to COVID-19. Outings limited to no more than the number of people where social distancing between residents can be maintained. Appropriate hand hygiene, and universal masking are required. Outings for all exposed residents adhere to the restrictions in Section 4, Visitor Policies Not Impacted by the Reopening Process.

 

e.     Visitation Requirements

For visitation to be permitted under Steps 2 and 3 (as described in Section 6d), a facility must establish and enforce a visitation plan within their Implementation Plan that meets the following requirements while ensuring the safety of visitation and the facility's operations:

1)    Establish a schedule of visitation hours.

2)    Designate a specific visitation space in a neutral zone, ensuring that visitors can access that area passing only through other neutral zones. Where possible, use a specified entrance and route for visitors.

  • Outdoor visitation is strongly preferred when weather and resident appropriate.  Facilities should have a plan for how visitation will safely occur in neutral zones in the event of severe weather (e.g. rain, excessive heat or humidity, etc.).

3)    For the outdoor visitation area, ensure coverage from inclement weather or excessive sun, such as a tent, canopy, or other shade or coverage.

4)    Ensure adequate staff or volunteers to schedule and screen visitors, assist with transportation and transition of residents, monitor visitation, and wipe down visitation areas after each visit. Facilities may leverage technology to use volunteers to perform scheduling activities remotely.

5)    Establish and maintain visitation spaces that provide a clearly defined six-foot distance between the resident and the visitor(s).

6)    Determine the allowable number of visitors per resident based on the facility's capability to maintain social distancing and infection control protocols.

7)    Use an EPA-registered disinfectant to wipe down visitation area between visits.

8)    Determine those residents who can safely accept visitors at Steps 2 and 3.

9)    Prioritize scheduled visitation for residents with diseases that cause progressive cognitive decline (e.g., Alzheimer's disease) and residents expressing feelings of loneliness.

10)   Provide a facemask to each resident (if they can comply) to wear during the visit.

11)  Children are permitted to visit when accompanied by an adult visitor, within the number of allowable visitors as determined by the facility. Adult visitors must be able to manage children, and children older than 2 years of age must wear a facemask during the entire visit. Children must also maintain strict social distancing.

12)   Ensure compliance with the following requirements for visitors:

    • Establish and implement protocols for screening visitors for signs and symptoms of COVID-19. Do not permit visitors to access facility or facility grounds if they do not pass screening.
    • Provide alcohol-based hand rub to each visitor and demonstrate how to use it appropriately, if necessary.
    • Visitors must:
      • Wear a face covering or facemask during the entire visit;
      • Use alcohol-based hand rub before and after visit;
      • Stay in designated facility locations;
      • Sign in and provide contact information;
      • Sign out upon departure; and
      • Adhere to screening protocols.

This updated guidance will be in effect immediately and through the duration of the Governor's COVID-19 Disaster Declaration. The Department may update or supplement this guidance as needed.

RESOURCES

Department's Guidance, FAQs, and Orders for SNFs: https://www.health.pa.gov/topics/disease/coronavirus/Pages/Nursing-Homes.aspx

Department's Health Alerts, Advisories, and Updates: https://www.health.pa.gov/topics/prep/PA-HAN/Pages/2020-HAN.aspx

CMS Reopening FAQ: https://www.cms.gov/files/document/covid-nursing-home-reopening-recommendation-faqs.pdf

CMS Reopening Memo: https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and-memos-states-and/nursing-home-reopening-recommendations-state-and-local-officials

[1] Communal dining is the same for all steps of reopening.

[2] Outdoor visitation protocols could include scheduling of visits, transporting (but not lifting) residents and monitoring visitation.