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Order of the Secretary of Health for Testing of Residents and Staff in Skilled Nursing Facilities Frequently Asked Questions

July 7, 2020

Question:  Why did the Secretary of Health issue this Order?
Answer:
 The Secretary of Health issued this Order to assist in protecting the safety of residents and staff in Skilled Nursing Facilities (SNFs) across the Commonwealth.  Many facilities across the Commonwealth are already conducting universal testing per the Department of Health (Department) plans published on May 12 and May 29, 2020. For facilities that have not begun testing already, this Order mandates testing because doing so protects vulnerable populations and frontline workers.

In addition, the Secretary of Health issued this Order to increase facility readiness.  Facilities need to prepare for a potential second surge in the future and developing capacity to do this in advance of a surge will help everyone to be better prepared. 

Question:  What is the timeline for testing? How long does a facility have to initiate or complete the tests?
Answer:  Facilities have until July 24, 2020 to complete the initial baseline testing, including testing of all staff and residents.  Facilities that have tested all staff and residents in the 14 days prior to the issuance of this Order (since May 24, 2020) may count that testing as meeting the initial baseline testing requirement, as long as the testing is appropriately captured in the data collection survey specified in the Requirements for Testing issued on June 8, 2020.  There is no requirement for when facilities must begin testing, but testing must be completed by July 24, 2020.

Question: Our facility completed a baseline test of all staff beginning May 20, 2020 and ending May 26, 2020. Is this close enough to meet the intent of the Order, or does another round of testing need to be done?
Answer:
To comply with the Order, all staff and residents must have a test completed since May 24, 2020. Any staff or resident that was tested prior to that date, will need a retest before July 24, 2020. The best practice would be to retest everyone. There are no exceptions or waivers. Please consult the Requirements for Testing for how to handle staff or residents who refuse testing.

Question:  Are staff who refuse testing allowed to work?
Answer
:  The facility's human resources department should develop a policy to address these staff based on their risk of exposure, community spread, and staffing needs. In facilities with residents who are exposed to or have COVID19 (Yellow and Red Zones per PA-HAN-509), staff persons refusing to be tested should not care for unexposed residents (Green Zones).

Question:  If a facility has completed universal testing, and it has been more than 14 days since the last case in staff or residents, does the facility need to continue testing?
Answer:
 The Order of the Secretary does not require continued testing.  However, continued testing is recommended contingent upon the availability of testing supplies and personal protective equipment (PPE).  SNFs should continue to test residents and staff if any staff or resident becomes symptomatic and follow guidelines in PA-HAN-509 for any new cases of COVID-19.

Question:  My facility administered the test and discovered some staff who are asymptomatic tested positive.  Are they allowed to work?
Answer:
  Asymptomatic staff who test positive but remain asymptomatic should be excluded from work and isolated for 10 days from the date of their first positive test.  

Question: How is "staff" defined in connection with the Order? Please provide clarification on what staff need to be tested and whether that includes such individuals as healthcare personnel not employed by the facility such as hospice and emergency medical services (EMS) personnel.
Answer:
Individuals employed by the facility or who work in the facility consistently three or more days per week (regardless of their role) are considered "staff" for purposes of the June 8th Order of the Secretary of Health. Therefore, direct care personnel and all others employed by the facility who work in the facility must be tested. This includes, but is not limited to, the Director of Nursing, Assistant Director of Nursing, administrative assistants, housekeeping, and dietary staff.

Contracted staff (such as therapists or PRN staff) who regularly enter the facility consistently three or more days per week are considered staff for purposes of the Order and must be tested.

Testing is not required for personnel who attend to healthcare needs of the residents but are not employed by the facility and do not enter the facility consistently three or more days per week. This includes, but is not limited to, EMS, phlebotomists, technicians, physicians, certified registered nurse practitioners, physician assistants, and hospice caregivers – if they are not employed by the facility. These individuals should, however, be screened each time before entering the facility. If they do not pass screening, they should not enter the facility.

Question: Does the facility have to test its own staff and send specimens to a commercial laboratory (like it would for patients), or can the facility either use an occupational testing vendor or require its staff to be tested?
Answer:
The facility can determine the most appropriate approach for testing all staff before July 24, 2020. However, the facility should impose a deadline for their staff to get tested and a range of dates that are acceptable, concurrent with testing occurring in the facility. The facility is responsible for compiling the results and taking appropriate action based on those results. Action is most effective when results are received at or around the same time.  An approach that tests a different subset of the staff or residents weekly until all have been tested does not align with the intention of the universal testing order.  Any laboratory the facility uses must have a current Pennsylvania laboratory permit and be approved to perform COVID-19 testing. A facility may verify licensure and approval by emailing RA-DHPACLIA@pa.gov.

Question: What arrangements can be made for the cost of the test for staff?
Answer:
The Department encourages each facility's staff to consult with their employer to determine how the test should be paid and whether there are any particular testing arrangements in place for that facility's staff.

Question: If there are staff without medical insurance, is there any payment mechanism for the test?
Answer:
The Health Resources and Services Administration (HRSA) will cover the cost for testing for uninsured. Information is available at https://www.hrsa.gov/coviduninsuredclaim/frequently-asked-questions.

Question: If there are residents or staff who have a prior positive test result, do they need to be re-tested?
Answer:
No, a resident or staff person with a history of a positive test for SARS-CoV-2 does not need to be re-tested to comply with the Order.

Question: If a resident was tested prior to discharge from the hospital (which occurred after May 24, 2020), does that resident need to be tested again?
Answer:
If the test result upon discharge was negative, the resident must be tested again to comply with the Order. If the test result upon discharge was positive, the resident does not need to be tested again to comply with the Order. 

Question: How should we report if the baseline results are not back within the 48 hours of completion of the baseline testing?
Answer:
Wait for test results to be returned before completing the survey and include a note that the test results were delayed.

Question: How do we report the testing results for different days but for the same facility?
Answer:
Facilities should complete the survey only once, so wait until all results are back. In the survey, for the field "On what date was Universal Testing completed in your facility?" enter the last date testing was done. Then enter a note in the survey with the range of dates used.

Question:  My facility is following PA-HAN 501, but now we cannot meet minimum staffing requirements.  What should we do?
Answer
: Facilities who are having difficulties with staffing should reference the April 19th Staffing Resources for Nursing Care Facilities During the COVID-19 Pandemic.  Facilities should consider a plan to augment staff, such as contacting staffing agencies, prior to receiving testing results.  The Commonwealth has worked to survey staffing agencies that may be able to aid. A facility may request that information by sending an email to ra-dhSNFquestion@pa.gov.  If facilities are unable to find additional staffing resources, the Commonwealth will provide emergency staffing as available.  Facilities are encouraged to work through their Regional Healthcare Coalition regional emergency manager and their county emergency management agency to access Commonwealth support.

Question:  If all my staff test positive and all my residents test negative, how do I have positive staff taking care of negative residents?
Answer
:  Staff who are symptomatic should be excluded from work and isolated until they meet return to work criteria.  Asymptomatic staff who test positive but remain asymptomatic should be excluded from work and isolated for 10 days from the date of their first positive test.  If there are no longer enough staff to provide safe patient care, and other contingency capacity strategies have been exhausted (see CDC strategies), facilities and employers may need to implement crisis capacity strategies to continue to provide patient care.  The decision to follow contingency or crisis standards rests with the facility, but these decisions and actions must be detailed in and consistent with their emergency preparedness plan.  Under crisis capacity standards, asymptomatic positive staff may be permitted to work in certain roles.  Please follow guidance in PA-HAN-501, and see the answer to the question above for additional information regarding staffing difficulties.

Question:  What if I am unable to cohort patients or create the red, yellow, green zones as outlined in in PA-HAN-509 due to lack of empty beds or space?
Answer
:  Please reference the section titled "Potential Cohorting Modifications for LTCFs" in PA-HAN-509 for recommendations on how facilities that cannot move patients around their facility can implement appropriate infection control measures.  For technical assistance with the implementation of infection prevention and control measures, please reach out to your local health department or call 1-877-PA-HEALTH.

Question:  What is the penalty if I do not follow the Secretary's Order?  Will I receive a deficiency or fine?
Answer
:  The Governor and the Secretary of Health believe that facilities intend and are attempting to care for their residents appropriately.  If, however, it appears that a facility willfully refuses to test as required in the Secretary's Order or is negligent in complying with the Order, the Department has the option to fine the facility under the Disease Prevention and Control Law or take other action under the Health Care Facilities Act.  Facilities are strongly urged to request help when necessary and take every step necessary to comply with the Secretary's Order.

Question:  Can we allow visitors if they have proof of a negative test?  Can we allow visitors/providers/care givers/clergy without proof of a negative test?
Answer:
  Please see COVID-19 Interim Nursing Facility Guidance for specific information about visitation at Steps 2 and 3 of reopening. All visitors to the facility will be screened, and must pass screening to gain admittance to the facility. Testing is not required for visitors.

Question:  How can facilities get assistance with swabbing residents and staff?
Answer
:  Facilities should rely primarily on in-house clinical expertise (e.g., the Medical Director, RNs, LPNs) to conduct testing.  For facilities that have those team members out sick or do not have these resources, the Department is currently bringing on additional resources to assist with swabbing.  Facilities in need of assistance should reach out to ra-dhCOVIDtesting@pa.gov for more information

Question:  Who will help facilities with follow-up testing?
Answer:  Facilities should have plans in place to implement follow-up testing if residents or staff within the facility test positive, as outlined in PA-HAN-509.  Facilities can coordinate with commercial vendors, including staffing support to conduct the tests, and commercial laboratories authorized by the Commonwealth to conduct SARS-CoV-2 testing.

Question:  How can facilities get assistance in obtaining supplies to conduct the swabbing?
Answer:  Facilities should first reach out to their laboratory or medical supply vendors to procure sufficient supplies to conduct specimen collection.  If normal supply chain procurements are unable to provide sufficient supplies, facilities lacking testing supplies can send an email to ra-dhCOVIDtesting@pa.gov.  The facility will receive an autoreply with a link to a form to request support, including supplies, from the Department of Health.  The form must be completed in its entirety.  Shipments will be based on the quantities available at the time the request is reviewed. 

Question: Is there a specific type of swab or test that facilities should be using?  Does one type of swab have a higher or lower error rate than the other?
Answer:  Viral testing (i.e. RT-PCR) should be used to inform additional actions necessary to keep SARS-CoV-2 out of facilities, detect COVID-19 cases quickly, and stop transmission. Facilities should consult with the laboratory that will be performing the testing as to the appropriate and approved specimen collection methods, such as (but not limited to) Nasal Pharyngeal (NP) or Anterior Nares (nostril) swab. Current CDC guidance does not prioritize one collection type over another. Testing practices should aim for rapid turn-around times (e.g., less than 48 hours) in order to facilitate effective action. At the current time, antibody test results should not be used to diagnose someone with an active SARS-CoV-2 infection and should not be used to inform infection prevention and control actions.