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Interim Guidance for Skilled Nursing Facilities During COVID-19

November 25, 2020

The Pennsylvania Department of Health (Department) is providing the below guidance as a replacement to the guidance issued on September 3, 2020, to all Skilled Nursing Facilities (SNF). This replaces the previous guidance in its entirety and brings the Department's guidance in alignment with the Centers for Medicare and Medicaid Services (CMS) Memorandums. The three-step process for lifting restrictions is no longer required, and facilities are no longer required to have implementation plans for lifting said restrictions. Facilities should continue to follow all relevant CMS guidance available now and in the future. If there is a conflict between Department and CMS guidance, follow the CMS guidance.

1. Terms and Acronyms Used in this Guidance

  • Terms
    Terms defined for the purposes of this guidance are as follows:
    • "Cross-over visitation" refers to visits to a SNF from an individual residing in a personal care home, continuing care retirement community, or assisted living facility that are not defined as compassionate care visitation by CMS.
    • "Outbreak" is defined by CMS QSO-20-38-NH as "a new COVID-19 infection in any staff member or any nursing home-onset COVID-19 infection in a resident. In an outbreak investigation, rapid identification and isolation of new cases is critical in stopping further viral transmission. A resident who is admitted to the facility with COVID-19 does not constitute a facility outbreak."
    • "Screening" includes identifying "all who enter the facility for signs and symptoms of COVID-19 (e.g., temperature checks, questions or observations about signs or symptoms), and denial of entry of those with signs or symptoms," per CMS QSO-20-39-NH.  Screening is one part of the Core Principles of COVID-19 Infection Prevention provided by CMS SNFs should use to protect residents, staff, visitors, and others.
    • "Social distancing (or physical 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).  Social distancing is one of the Core Principles of COVID-19 Infection Prevention provided by CMS. The more recent term “physical distancing” is used to stress the importance of maintaining physical space when in public areas.
    • "Staff" includes employees, consultants, contractors, volunteers, and caregivers who provide care and services to residents on behalf of the facility, and students in the facility's nurse aide training programs or from affiliated academic institutions. 
    • "Universal masking" means the protocols set forth in PA-HAN 492 and PA-HAN 524, with homemade cloth face covering being acceptable for visitors. Use of a face covering or mask is one of the Core Principles of COVID-19 Infection Prevention provided by CMS.
    • "Visitors" includes individuals from outside of the facility who will be interacting with residents. This includes cross-over visitors.
    • "Volunteer" is an individual who is a part of the facility's established volunteer program.
  • Acronyms
    Acronyms used in this guidance are defined as follows:
  • CMS – Centers for Medicare and Medicaid Services
  • PA-HAN – Pennsylvania Health Alert Network
  • PPE – Personal Protective Equipment
  • SNF – Skilled Nursing Facility

2. Relevant Directives and Information

This guidance is written in concert with applicable CMS Memorandums and PA-HANs.

  • CMS Memorandums and Alerts
    Facilities must adhere to all CMS Memorandums for nursing homes.  Two have been recently released that are of particular note for SNFs at this time:
    • Testing:  SNFs are to test residents and staff based on parameters and at the frequency set forth in the following CMS Memorandum – QSO-20-38-NH with the subject Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements and Revised COVID-19 Focused Survey Tool dated August 26, 20201.
    • Visitation:  SNFs are to follow the visitation guidance set forth in the following CMS Memorandum – QSO-20-39-NH with the subject Nursing Home Visitation – COVID-19 dated September 17, 2020.
    • Voting: SNFs are to follow the voting guidance set forth in the following CMS Memorandum – QSO-21-02-NH with the subject Compliance with Residents' Rights Requirement related to Nursing Home Residents' Right to Vote dated October 5, 2020.
    • Holidays: CMS issued an alert to reiterate the adherence to the Core Principles of COVID-19 Infection Prevention during the holiday season.

3. PPE and Infection Prevention

Appropriate use of PPE and infection prevention measures are critical in stopping the spread of COVID-19. The following guidance is provided for PPE and infection prevention2 in SNFs.

  • Each facility shall develop, implement, and adhere to policies and procedures that provide for the procurement and distribution of PPE to all staff.
  • The policies and procedures must, at a minimum, include distribution of respirators to staff providing direct patient care to COVID-19 positive and suspected cases and staff assigned to provide direct patient care in COVID-19 units. The respirators distributed by each facility must be National Institute for Occupational Safety and Health-approved particulate filtering facepiece respirators, or if those are not available, respirators approved by the Food and Drug Administration, including through an Emergency Use Authorization, as named in Appendix A. The respirator distribution must occur prior to the beginning of the staff member's shift, and the respirator must be replaced as soon as practical if the facility is notified by a staff member that their mask has become soiled, damaged, or otherwise ineffective.
  • CMS Core Principles of Infection Prevention
    In the CMS Memorandum (Ref QSO-20-39-NH), the following Core Principles of COVID-19 Infection Prevention are provided:
  • Screening of all who enter the facility for signs and symptoms of COVID-194 (e.g. temperature checks, questions or observations about signs or symptoms), and denial of entry of those with signs or symptoms;
  • Hand hygiene (use of alcohol-based hand rub is preferred);
  • Face covering or mask5 (covering mouth and nose);
  • Social distancing at least six feet between persons;
  • Instructional signage throughout the facility and proper visitor education on COVID-19 signs and symptoms, infection control precautions, other applicable facility practices (e.g., use of face covering or mask, specified entries, exits and routes to designated areas, hand hygiene);
  • Cleaning and disinfecting high frequency touched surfaces in the facility often, and designated visitation areas after each visit;
  • Appropriate staff use of PPE;
  • Effective cohorting of residents6 (e.g., separate areas dedicated COVID-19 care); and
  • Resident and staff testing conducted as required at 42 CFR 483.80(h) (See QSO-20-38-NH).
  • Communal Dining Precautions
    The following precautions are advised for communal dining in SNFs:
  • Stagger arrival times and maintain social distancing (also known as physical 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.
  • Cross-over Visitation Precautions
    Cross-over visitors must adhere to the same infection prevention precautions as other visitors. If there is an outbreak in the facility from which the cross-over visitor originates, cross-over visitation is permissible only if the cross-over visitor resides in a green zone (per PA-HAN 530).

4. COVID Alert PA App

The COVID Alert PA app is a critical tool in our fight against the spread of the COVID-19 virus. Residents and staff with a smartphone should be encouraged to download this free app. After downloading COVID Alert PA, users can opt-in to receive alerts if they have had a potential exposure to someone who tested positive for COVID-19. It can help reduce the risk of unknowingly spreading the virus to family, friends, coworkers, residents, and the larger community.

COVID Alert PA protects your privacy and personal information. It uses Bluetooth Low Energy (BLE) technology to detect if users are in close contact with another app user. (This is the same technology that smartphones use to connect to wireless headphones or a vehicle.) The app does not use GPS, location services, or any movement or geographical information, and it will never collect, transmit, or store your personal information and is completely anonymous.

5. Outings

  • Outings for Medical Appointments
    Residents should continue to receive necessary medical care that is needed outside of the SNF. Typically, transportation for these appointments is provided by the SNF. If the resident chooses to have a family member or friend transport them to the appointment, there should be no known risk of COVID-19 transmission in keeping with the facility's current screening and testing protocols. In all instances, the resident and those involved in the transportation should adhere to appropriate infection prevention and control protocols as outlined in PA-HAN 524 including universal masking. If a face covering or mask can be tolerated, the resident should wear one during transport and the driver should be wearing a face covering mask as well.  All should be screened upon return to the SNF as well.

    Staff should be cognizant of residents who go off-site for outpatient medical care, including dialysis, and remain alert for notification of any known exposures. Such exposure would require testing, case identification, contact tracing, quarantine, observation, and any other necessary medical care.
  • Outings for Non-Medical Reasons
    Each SNF should develop a policy to address outings for non-medical reasons, although there will be those scenarios that need assessed on a case-by-case basis. Considerations for development of those policies and making those assessments include:
  • The extent to which infection prevention and control precautions (including universal masking, hand hygiene, and physical distancing) are achieved based on the circumstances of the outing;
  • The resident's level of vulnerability due to any chronic or immunocompromised conditions; and
  • Duration of the outing, including whether it includes an overnight stay or vacation to another state (this could be informed by whether the vacation is to a state for which a 14-day quarantine is recommended upon return).

If the outing poses a high risk based on a number of factors (below), testing may be appropriate. Ideally, wait at least 2-3 days following the outing to perform testing. Residents with this type of high-risk outing do not need to be placed under transmission-based precautions unless exposure is known or highly suspected7. Factors of a high-risk outing include:

  • Substantial community spread in the area(s) visited or home county (≥10% county positivity rate or incident rate ≥100/100,000 incidence) AND
  • A gathering of more than 10 people AND
    • Failure of consistent universal masking for the duration of the outing OR
    • Failure of physical distancing from resident (for example, hugging or riding in a vehicle with persons not wearing face coverings or masks).

6. Cohorting (Expanding the Number of Beds or Converting Closed Wings or Entire Facilities)

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. 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.

7. 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.

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.

1 This updates the Interim Guidance for Skilled Nursing Facilities During COVID-19 issued on October 13, 2020. Revisions are displayed in red font.