MDS Alert

Accessing and affording testing is the next major hurdle before normalcy.

As nursing homes try to find some semblance of normalcy during a pandemic that strikes residents particularly hard, the Centers for Disease Control and Prevention (CDC) has put forth new guidelines on the testing protocols facilities should have in place.

The CDC is careful to note that testing should be one part of a two-pronged approach to managing disease exposure and risk — testing should be methodical and frequent but should not supersede regular infection control and prevention (IPC).

“In order for our industry to truly get ahead of the COVID-19 outbreak, expanding the availability of rapid testing remains a top priority,” said Mark Parkinson, president and CEO of the American Health Care Association and National Center for Assisted Living (AHCA/NCAL), in a May 2020 letter to the Department of Human Services Health Secretary Alex Azar, Centers for Medicare and Medicaid Services Administrator Seema Verma, and CDC Director Robert Redfield, MD.

Navigate Reopening Criteria

As states move to reopen economies and return to some semblance of what we all used to consider “normal,” the significance of testing has only increased.

“Given the critical importance in limiting COVID-19 exposure in nursing homes, decisions on relaxing restrictions should be made with careful review of a number of facility-level, community, and State factors/orders, and in collaboration with State and/or local health officials and nursing homes,” says David R. Wright, director of quality, safety, & oversight group at CMS in Baltimore, in a recent memorandum.

Screening will be an important tool. The White House guidelines for Opening Up America Again include three phases, including the current mitigation-focused pause for most places. All three phases list screening of all people entering the facility, including staff, at the beginning of each shift, via temperature checks; the use of face covering or facemask; questionnaires about symptoms and exposure; and observation of signs and symptoms, as recommended “considerations” for long-term care facilities to implement. All residents should receive temperature checks and be questioned and observed for signs and symptoms daily, as well.

But the most important strategy may be testing. Wright notes that case status in the community and within the facility and access to “adequate” testing are necessary for mitigating infection and moving forward with reopening.

Understand Why Your Facility Must Test

Testing is perhaps the most crucial aspect of getting the virus under control in long-term care facilities, but the logistics and costs are formidable.

Wright describes adequate testing as the capacity for all residents and staff to receive a baseline COVID-19 test, and the capacity to retest if a resident or staff tests positive and/or weekly testing until everyone tests negative.

Testing is a much more important tool for infection mitigation than symptom screening, and your facility cannot rely on screening alone.

“Many residents and caregivers of nursing homes and assisted living communities across the country could be a carrier of the virus without symptoms, but contagious and at risk to spread the virus. The only way for our health care sector to get ahead of the outbreak of this deadly virus is for priority testing and availability of both collection and testing kits to be expanded to ALL our residents and caregivers, as well as assuring expedited test results,” Parkinson said.

Wright recommends that all staff, volunteers, and vendors receive a baseline test and be retested weekly — with the option for state and local officials to reevaluate the weekly requirement depending on how infection seems to be spreading within the community at large.

With federal agencies making recommendations and considerations, states, organizations, and individual facilities are bearing the brunt of figuring out the logistics. The cost of testing every U.S. nursing home resident and staff member for SARS-CoV-2, the virus that causes COVID-19, just once would be $440 million, according to AHCA/NCAL data. The organization has also published recommendations on the types of tests facilities should pursue and which specific labs/vendors may be good to work with.

You can read the vendor list here: www.ahcancal.org/facility_operations/disaster_planning/Documents/COVID Testing Vendors 4 9 20.pdf.

Know Who to Bill

“To aid in this effort and rapidly expand COVID-19 testing, CMS recently issued a ruling that Medicare will pay a rate of $100 for certain laboratory tests that use high-throughput technologies to rapidly process large numbers of specimens for COVID-19 testing per day,” CMS says.

The requirements for testing staff vary from state to state, and as such, so does the guidance. The AHCA says employers are generally responsible for covering the costs of the tests. For residents, testing costs vary with beneficiary status, the AHCA says:

• Medicare FFS and Medicare Advantage plans will cover COVID-19 polymerase chain reaction (PCR) tests.
• Medicare Part B will only provide partial reimbursement for the tests.
• State Medicaid plans will generally cover the cost of testing, but providers need to confirm with their individual states.
• The CARES Act provides grant funds that can be used for covering the cost of resident testing that is not otherwise reimbursable.
• The CARES Act requires that COVID-19 testing for beneficiaries is covered without cost to that person.

“AHCA states that if the State mandated testing for employees, then the employer may not be held accountable for the cost of the test, but they have not confirmed this yet,” says Linda Elizaitis, RN, RAC-CT, BS, president and founder of CMS Compliance Group in Melville, New York.

“What we are seeing in New York, where an Executive Order was put into place mandating that nursing homes test employees twice a week is that, due to pushback from providers about costs and access to adequate testing, these tests were deemed ‘medically necessary’ by the State,” she says. See the directive at https://coronavirus.health.ny.gov/system/files/documents/2020/05/medicalnecessitydirective.pdf.

“Per the CARES Act, these medically necessary tests are payable for both in-network and out-of-network providers without any cost-sharing. This means that facilities can submit claims for insurance coverage per the CARES Act, and if the insurance carrier denies coverage, then the facility must pay; New York State may ‘facilitate’ trying to get federal reimbursement or FEMA funding for the testing,” Elizaitis explains. Read about the New York-specific guidance here: www.dfs.ny.gov/industry_ guidance/circular_letters/cl2020_11.

Do This if Staff Get Sick or Test Positive

You already know that residents should be isolated (or cohorted, if that makes sense within your facility) upon testing positive or showing symptoms consistent with COVID-19.

Having a plan for staffing shortages is crucial; know how your facility can mitigate a shortage without sacrificing care or relying on staff to work while sick or to work so frequently that they are burnt out. The CDC has made recommendations for facility staff who get sick, including sending any staff with a positive test or symptoms home immediately, reinforcing sick leave policies, and encouraging healthcare personnel to not work when ill.

Long-term care facilities can make COVID-19 testing a condition of employment, says AHCA/NCAL. “This includes terminating or not hiring a person who refuses a COVID-19 test. However, employers must make this a condition of employment and follow state requirements for making such a policy, which may include modifying employment contracts where applicable,” AHCA/NCAL says in an organizational resource on testing.