INTRODUCTION

NRHP has put together this resource toolkit to assist Nevada Critical Access Hospitals (CAHs) during the coronavirus (COVID-19) emergency.

Guidance from the Centers for Disease Control and Prevention (CDC) and the state and local Departments of Public Health supersede the information in this toolkit. 

For the most up-to-date information and guidance, please visit the following websites as this is a rapidly evolving subject:

Click here to view a thank you message from Nevada Congressman Mark Amodei to the Humboldt County healthcare workers and first responders. 

Please contact Becky Bayley at (775) 830-7458 with any questions regarding this toolkit.

STATE AND LOCAL HEALTH AUTHORITY CONTACTS

Facilities should immediately call their local or state health authority if they have a suspected COVID-19 case. Contact numbers for all Nevada CAHs are listed below.

Health Authority Contact Information Facilities
Carson City Health and Human Services (775) 887-2190 Carson Valley Medical Center
South Lyon Medical Center
Southern Nevada Health District (702) 759-1300 Boulder City Hospital
Washoe County Health District (775) 328-2447 Incline Village Community Hospital
Nevada Division of Public and Behavioral Health (775) 684-5911
(M-F 8am-5pm)


(775) 400-0333
(after hours epi-on-call)

Banner Churchill Community Hospital
Battle Mountain General Hospital
Desert View Hospital
Grover C. Dils Medical Center
Humboldt General Hospital
Mt. Grant General Hospital
Pershing General Hospital
William Bee Ririe Hospital

TOOLKIT MENU

Identify – Isolate – Inform

Planning & Preparedness

Training & Education

Infection Control

Vaccines

Evaluation & Testing

PPE Supplies

Healthcare Personnel

Patient Communications

Visitor Restrictions

Finance & Operations

Funding Opportunities

Community Collaboration

Human Resources

Surge Capacity

Telemedicine

Long Term Care

EMS

Reporting Requirements

EMTALA

HIPAA / Privacy

Regulatory Environment

IDENTIFY-ISOLATE-INFORM

The Identify-Isolate-Inform (3I) Tool, originally conceived for the initial detection and management of Ebola virus. Although the progression of the COVID-19 pandemic has made some pieces of the tool, such as travel history, less relevant, it can still be adapted for any emerging infectious disease, including the 2019 coronavirus. View the original algorithm here: https://www.cdc.gov/vhf/ebola/pdf/ambulatory-care-evaluation-of-patients-with-possible-ebola.pdf


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PLANNING AND PREPAREDNESS

It is recommended that facilities review the Centers for Disease Control and Prevention (CDC) and Nevada Division of Public and Behavioral Health (DPBH) checklists and general guidance to ensure they are prepared for all aspects of the COVID-19 outbreak.

Facility Planning and Operations for COVID-19 | CDC

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TRAINING AND EDUCATION

Refer to the CDC for up-to-date training for Healthcare Professionals:

Training for Healthcare Professionals | CDC

Healthcare professionals (HCPs) should have job-specific training on all policies and procedures regarding COVID-19, including:

PROJECT FIRSTLINE

In October, the CDC launched Project Firstline, a comprehensive infection control program designed to help prevent the spread of infectious diseases in U.S. healthcare settings. The $180 million program features new training for staff in hospitals, outpatient clinics, dialysis centers, nursing homes, and other healthcare facilities to protect workers on the frontlines. CDC has teamed up with a coalition of more than a dozen healthcare, public health, and academic partners, as well as 64 state, territorial, and local health departments through the Epidemiology and Laboratory Capacity cooperative agreement to support development and dissemination of Project Firstline’s innovative, interactive infection control curriculum for healthcare and public health workforces across the United States.

Project Firstline | Infection Control | CDC

TRAINING FOR ENVIRONMENTAL SERVICES

Note: Environmental services personnel MUST have proper training, especially in regard to disinfection practices of high touch surfaces and observing dwell time!

TRAINING FOR NURSING HOMES

*Please see the Long Term Care section of this website for a list of training opportunities specific to nursing homes.

MISCELLANEOUS

The following materials are provided to assist CAHs with education of staff members on various aspects of COVID-19:

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INFECTION CONTROL

Clinicians should immediately implement recommended infection prevention and control practices if a patient is suspected of having COVID-19. Hospitals should refer to the following CDC website for the most current recommendations:

https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control.html

The following interim guidance has been updated based on currently available information about COVID-19 and the current situation in the United States. As healthcare facilities begin to relax restrictions on healthcare services provided to patients (e.g., restarting elective procedures), in accordance with guidance from local and state officials, there are precautions that should remain in place as a part of the ongoing response to the COVID-19 pandemic. CDC recommendations have been reorganized into the following sections:

  • Recommended infection prevention and control (IPC) practices for routine healthcare delivery during the pandemic
  • Recommended IPC practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection

https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html

INFECTION CONTROL PLANS

>>>UPDATE AS OF JULY 17, 2020:

Per Nevada DPBH, infection control plans that are specific to COVID-19 and specific to the facility must be in place and all staff trained to the policy and procedures. This plan should include the process of hiring and utilizing staff in a facility and a policy for staff who also work in other facilities. The COVID-19-specific infection control plan must include special circumstances and a policy for testing and quarantine if any staff member is exposed to the virus.

Items addressed in the plan should include, but are not limited to:

  • rapidly identifying staff with exposure, suspected or confirmed COVID-19;
  • appropriate placement within a unit based on COVID-19 status, including what to do if hospital is close to full capacity;
  • surge plan if large numbers of staff acquire disease;
  • environmental cleaning and disinfection;
  • individual hygiene;
  • facility entry, screening and related policies and procedures for visitors and staff;
  • social distancing and use of face masks/face coverings by staff, patients and visitors;
  • proper use of personal protective equipment (PPE); and
  • guidance to staff working in other facilities.

With the possibility of staffing shortages, all hospitals must have a staffing plan specific to COVID-19 — including a surge plan clearly delineating whether staff is to be shared between facilities and/or hospitals and the policies for infection control procedures.  It is recommended that the plan include designated staff for any COVID unit, as well as have clear policies and procedures to assure infection control safety for all staff and patients.

SCREENING AND TRIAGE OF ALL WHO ENTER FACILITY

In accordance with the Centers for Disease Control and Prevention’s (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, everyone entering a health care facility should be screened and triaged for signs and symptoms of COVID-19. This includes patients, health care professionals and employees of the facility and visitors.

To facilitate this process for employees, including contract staff, working in licensed health care facilities, facilities may develop an employee/contractor screening and triage policy and procedure that addresses the items noted in the document below, how the screening will be monitored and the actions to be taken based on the results of the screening.

All visitors, including inspectors, are to be screened and triaged upon entering a health care facility for signs and symptoms of COVID-19 in accordance with CDC guidelines.

RESOURCE: DPBH Memo 08/29/20 re: Screening & Triage Employees (of facility) Entering a Healthcare Facility for Signs and Symptoms of COVID-19

RESOURCE: COVID-19 Employee Screening Form

*Per the Nevada Hospital Association, through discussions with DHHS, it was determined that it would be acceptable to chart and maintain documentation of temperature by exception; however, facilities would still need to ask the questions on the screening form to screen everyone for symptoms.

Facility types subject to inspections by programs within the Division of Public and Behavioral Health (DPBH) have an obligation to admit inspectors or any authorized member or employee of the Division, without requiring them to sign any liability waiver, into buildings to inspect as required by statute or regulation.

RESOURCE: DPBH Memo 10/16/20 re: Health Facility Inspectors Must be Allowed to Enter

QUARANTINE FOR CONTACTS OF PERSONS WITH SARS-COV-2 INFECTION

CDC currently recommends a quarantine period of 14 days. However, based on local circumstances and resources, the following options to shorten quarantine are acceptable alternatives.

  • Quarantine can end after Day 10 without testing and if no symptoms have been reported during daily monitoring.
    • With this strategy, residual post-quarantine transmission risk is estimated to be about 1% with an upper limit of about 10%.
  • When diagnostic testing resources are sufficient and available (see bullet 3, below), then quarantine can end after Day 7 if a diagnostic specimen tests negative and if no symptoms were reported during daily monitoring. The specimen may be collected and tested within 48 hours before the time of planned quarantine discontinuation (e.g., in anticipation of testing delays), but quarantine cannot be discontinued earlier than after Day 7.
    • With this strategy, the residual post-quarantine transmission risk is estimated to be about 5% with an upper limit of about 12%.

In both cases, additional criteria (e.g., continued symptom monitoring and masking through Day 14) must be met and are outlined in full on the CDC website.

Options to Reduce Quarantine for Contacts of Persons with SARS-CoV-2 Infection Using Symptom Monitoring and Diagnostic Testing | CDC

RESOURCE: DPBH Technical Bulletin 12/2/20 re: CDC Updated Guidance for Reducing Quarantine Period for Contacts of Persons with COVID-19 Infection

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VACCINES

The first doses of COVID-19 vaccine arrived in Nevada on December 14, 2020. Doses were distributed to acute care hospitals statewide and Nevada’s pharmacy partners to vaccinate residents and staff at skilled nursing facilities. Hospitals and clinics have since moved on to vaccinating their communities according to the latest version of the Nevada “playbook” for vaccinations.

COVID-19 Vaccination | CDC

RESOURCE: COVID-19 Vaccination Program: Nevada’s Playbook for Statewide Operations v3

RESOURCE: NEVADA-COVID-19-VACCINE-PLAYBOOK-V3-BRIEF_011121.pdf (nv.gov)

RESOURCE: DPBH Technical Bulletin 03/10/21 re: CDC Interim Public Health Recommendations for Fully Vaccinated Individuals

RESOURCE: DPBH Technical Bulletin 03/03/21 re: Implementation Considerations for the Janssen COVID-19 Vaccine

RESOURCE: DPBH Technical Bulletin 03/03/21 re: Quarantine Guidance for Vaccinated Persons REVISED

RESOURCE: DPBH Technical Bulletin 03/03/21 re: Update to NSIP Guidance on Vaccine Access for Nevadans with Underlying Health Conditions

RESOURCE: DPBH Technical Bulletin 02/12/21 re: Quarantine Guidance for Vaccinated Persons

RESOURCE: DPBH Technical Bulletin 02/03/21 re: Placement of patients/residents who have been vaccinated against COVID-19 or who have had COVID-19 and have recovered (patient/resident no longer requires transmission-based precautions)

RESOURCE: DPBH Technical Bulletin 01/19/21 re: Moderna Vaccine Lot 41L20A and higher incidence of adverse reactions

RESOURCE: DPBH Technical Bulletin 01/19/21 re: Nevada’s COVID-19 Vaccine Prioritization and Eligibility Criteria

RESOURCE: NV Medicaid Web Announcement 01/15/21 re: Non-Emergency Transportation Available for Recipients to Receive COVID Vaccine

RESOURCE: DPBH Technical Bulletin 01/15/21 re: TB Testing Interim Recommendations Around COVID-19 Vaccinations

RESOURCE: Nevada’s COVID-19 Vaccination Prioritization and Eligibility of Behavioral Healthcare Providers 12/22/20

RESOURCE: HHS Press Release 09/16/20: Trump Administration Releases COVID-19 Vaccine Distribution Strategy 

RESOURCE: Governors Statement from Scientific Safety Review Workgroup 12/13/20

RESOURCE: COVID-19 Vaccine | Immunize Nevada

RESOURCE: COVID-19 Vaccine Planning | Immunize Nevada

RESOURCE: The Booster Bulletin: COVID-19 Vaccine Edition | Immunize Nevada

RESOURCE: Immunize Nevada COVID-19 What You Need to Know

RESOURCE: Vaccine Storage and Handling Toolkit-November 2020 (cdc.gov)

*Note: The Nevada State Immunization Program (NSIP) is hosting a videoconference every Friday at noon for Nevada’s COVID-19 vaccinating providers. Answers to questions on vaccine confidence, provider enrollment, storage and handling, logistics, and more will be provided at these meetings!

COVID-19 VACCINE CALL CENTER

The Nevada Department of Health and Human Services (DHHS) has launched a vaccination call center to answer questions and assist people who need help making an appointment. Through the call center Nevadans will be able to access county-specific updates and information as more Nevadans become eligible to receive the COVID-19 vaccine.

The call center is open 8 a.m. to 8 p.m. seven days a week and can be reached at 1-800-401-0946. 

For those with internet access, DHHS continues to encourage residents to go online to find the latest information on vaccinations through NVCOVIDFighter.org.

INFORMATION ON SECOND DOSES

The NV State Immunization Program has provided guidance on giving the second dose of COVID-19 vaccine to first dose recipients who developed COVID-19 disease after their first dose of COVID-19 vaccine:

The CDC states that the second dose may be deferred for 90 days if the patient has experienced COVID-19 disease after the first dose of COVID-19 vaccine.  Please have a discussion with each vaccine recipient who contracts COVID-19 disease after their first dose of COVID-19 vaccine.  Consider the following items in your discussion with the vaccine recipient.

  1. If the vaccine recipient wants the second dose of COVID-19 vaccine and has finished their isolation period, please administer the second dose.
  2. The second dose allocation sent to the facility is based on the number of dose #1’s administered. Another recipient will have to be found if the second dose is not administered to the intended recipient.
  3. Where will the vaccine recipient be able to find a second dose of the same COVID-19 vaccine product in 90 days?

If a COVID-19 vaccine recipient contracts COVID-19 disease and is hospitalized or dies, please remember that you are required to report that event to VAERS.

VACCINATION IN NURSING HOMES

Long-Term Care Facilities COVID-19 Vaccination | CDC

To meet the Trump Administration’s Operation Warp Speed (OWS) goals, the U.S. Department of Health and Human Services (HHS) and Department of Defense (DoD) announced on October 16, 2020 agreements with CVS and Walgreens to provide and administer COVID-19 vaccines to residents of long-term care facilities (LTCF) nationwide with no out-of-pocket costs. The Pharmacy Partnership for Long-Term Care Program provides complete management of the COVID-19 vaccination process. This means LTCF residents and staff across the country will be able to safely and efficiently get vaccinated once vaccines are available and recommended for them, if they have not been previously vaccinated.

Ensuring Access to Vaccines for Residents and Staff in LTCFs

Most clinics provided vaccination process management by the Pharmacy Partnership for Long-Term Care (LTC) Program will likely be completed by the end of March 2021. As the Pharmacy Partnership for LTC program comes to an end, it is important to ensure LTCFs have continued access to COVID-19 vaccine for new or unvaccinated residents and staff.

Learn more about ways for long-term care facilities to continue receiving COVID-19 vaccine, here: Ensuring Access to COVID-19 Vaccine in Long-Term Care Facilities  D-19 FAQ

Initial Vaccination of Residents and Staff in LTCFs

CVS and Walgreens will schedule and coordinate on-site clinic date(s) directly with each facility. It is anticipated that three total visits over approximately two months are likely to be needed to administer both doses of vaccine (if indicated) to residents and staff.  The pharmacies will also:

  • Receive and manage vaccines and associated supplies (e.g., syringes, needles, and personal protective equipment).
  • Ensure cold chain management for vaccine.
  • Provide on-site administration of vaccine.
  • Report required vaccination data (including who was vaccinated, with what vaccine, and where) to the state, local, or territorial, and federal public health authorities within 72 hours of administering each dose.
  • Adhere to all applicable Centers for Medicare & Medicaid Services (CMS) requirements for COVID-19 testing for LTCF staff.

RESOURCE: HHS Press Release 10/16/20: Trump Administration Partners with CVS and Walgreens to Provide COVID-19 Vaccine to Protect Vulnerable Americans in Long-Term Care Facilities Nationwide

RESOURCE: Pharmacy Partnership for Long-Term Care Program for COVID-19 Vaccination Overview

RESOURCE: Pharmacy Partnership for Long-Term Care Program for COVID-19 FAQ

VACCINATION TRAINING

VACCINATION RECIPIENT EDUCATION

MODERNA INFORMATION

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EVALUATION AND TESTING

POINT OF CARE TESTS

Point of care (POC) tests play an important role in the overall response against COVID-19. Various types of technologies exist in POC tests, such as, nucleic acid amplification (molecular), antigen and antibody testing. Currently, there are four (4) POC tests available under the Food and Drug Administration (FDA) Emergency Use Authorization (EUA).

1. Abbott IDNOW: nucleic acid amplification (molecular) test
2. Quidel Sofia: antigen test
3. Becton Dickinson Veritor: antigen test
4. Abbott BinaxNOW COVID-19: antigen test

*See more about reporting laboratory results of antigen tests in the Reporting section of this webpage.
*For facilities with distinct-part nursing homes, see more about mandatory routine testing of nursing home staff in the Long Term Care section of this webpage.

RESOURCE: DPBH Technical Bulletin 08/28/20 re: COVID-19 Point of Care Testing

RESOURCE: CDC Guidance for SARS-CoV-2 Point-of-Care Testing

RESOURCE: CDC Interim Guidance for Rapid Antigen Testing for SARS-CoV-2

Note that Nevada DHHS recommends using the Abbott IDNOW, Abbott BinaxNOW, or a PCR test for the purpose of removal from quarantine.

RESOURCE: DPBH Technical Bulletin 12/18/20 re: Update: COVID-19 Point of Care Antigen Testing

On November 3, 2020, the U.S. Food and Drug Administration (FDA) issued a Letter to Clinical Laboratory Staff and Health Care Providers to alert clinical laboratory staff and health care providers that false positive results can occur with antigen tests, including when users do not follow the instructions for use of antigen tests for the rapid detection of SARS-CoV-2.

This letter includes important information about potential false positive results with antigen tests for rapid detection of SARS-CoV-2:

  • Details on false positive results with antigen tests
  • Recommendations for health care providers and clinical laboratory staff
  • Actions FDA is taking
  • Instructions for reporting problems with a device

TEST RESULTS

>>>UPDATE AS OF JULY 20, 2020: Getting Delayed Test Results from DPBH

Due to overwhelming demand, delays in test results are becoming more frequent. Because test results must be reported to the State within 24 hours, it may be more expeditious to request the results directly from the Division of Public and Behavioral Health (DPBH) versus waiting for the lab to send the results. The Request for Information form attached below can be used to make such a request.

RESOURCE: DPBH Request for Information Form COVID-19 05/08/20

>>>UPDATE AS OF JULY 6, 2020: COVID-19 Test Reporting to US Health and Human Services

Results are reported through the state health department or local health authority’s existing process.

The Coronavirus Aid, Relief, and Economic Security (CARES) Act, requires “every laboratory that performs or analyzes a test that is intended to detect SARSCoV-2 or to diagnose a possible case of COVID-19” to report the results from each such test to the United States Secretary of the Department of Health and Human Services (HHS). In addition, the statute authorizes the Secretary to prescribe the form and manner, and timing and frequency, of such reporting.

The document below, titled, COVID-19 Pandemic Response, Laboratory Data Reporting in accordance with the CARES Act, Section 18115, provides information on the reporting requirements pursuant to the CARES act.

Test results are to be reported within 24 hours of analysis through established electronic lab reporting; or by faxing the lab report (positive or negative) to the local health authority, or for labs in rural areas fax reports to the Office of Public Health Investigations and Epidemiology at (775) 684-5999 . Last week, the Nevada Department of Health and Human Services informed all in-state and out-of-state laboratories that are processing and testing samples from Nevada residents that they are required under severe penalties to report all COVID-19 test results to the Division of Public and Behavioral Health.

RESOURCE: COVID-19 Pandemic Response, Laboratory Data Reporting in accordance with the CARES Act, Section 18115

RESOURCE: DPBH Technical Bulletin 06/25/20 re: Require Immediate Reporting of COVID-19 Test Results to DPBH

>>>UPDATE AS OF JULY 1, 2020: COVID-19 Tests for First Responders, Health Care Workers to Get Priority

Laboratories are strongly advised to expedite results for individuals with essential jobs. State agencies coordinating Nevada’s COVID-19 response have established a system to identify first responder COVID-19 test samples for priority sample processing.

This prioritization will ensure those individuals providing essential public safety and health care duties within Nevada have the ability to receive COVID-19 test results in an expeditious manner; allowing for early detection and rapid decision support regarding self-isolation or quarantine. This will support preventing the spread of infection from asymptomatic and pre-symptomatic individuals to other critical public safety responders and HCPs; and will conserve the capacity and capability of the public health/healthcare systems to serve the citizens and visitors to Nevada. It is therefore strongly advised for all laboratories processing COVID-19 samples to adopt this procedure immediately.

RESOURCE: DPBH Letter re: Prioritizing COVID-19 Specimen Collection and Testing for First Responders and Healthcare Providers

TESTING SUPPLIES/COLLECTION KITS

>>>UPDATE AS OF MAY 12, 2020: Requests for All COVID-19 Testing Supplies and PPE Must Go Through County Emergency Manager

To obtain test kits for collecting specimens going to the Nevada State Public Health Laboratory (NSPHL) or the Southern Nevada Public Health Laboratory (SNPHL), or to request additional personal protective equipment (PPE), it is recommended that you place your request for a one or two week supply through your local County Emergency Manager. Hospitals should be able to obtain as many collection kits as they are sending in on a “replacement basis”, as there is still a limited supply of collection kits and materials. NOTE: This directive is through December 31, 2020 ONLY.

RESOURCE: State of Nevada NDEM/SEOC Resource Request Form

RESOURCE: Resource Request Process

RESOURCE: Resource Request Flow

>>>UPDATE AS OF MARCH 27, 2020: COVID-19 Testing Supplies Available from the Nevada State Public Health Laboratory

The Nevada State Public Health Laboratory (NSPHL) is manufacturing collection kits which can be ordered via their External Supply Order Form. If facilities cannot pick up the collection kits, they may use the “ship to” section of the form.

RESOURCE: NSPHL Chain of Custody Document for Nasal Swab/Saline Kits

>>>UPDATE AS OF MARCH 12, 2020:

The FDA’s established 24/7 hotline may be used by laboratories that are in need of additional testing supplies. Facilities may call 1-888-INFO-FDA (1-888-463-6332). Hospitals should also notify their public health authority:

  • Carson City Health and Human Services: (775) 887-2190
  • Southern Nevada Health District: (702) 759-1300
  • Washoe County Health District: (775) 328-2447
  • Nevada Division of Public and Behavioral Health: (775) 684-5911 or (775) 400-0333 after hours

TESTING CRITERIA

>>>UPDATE AS OF 8/26/20: State health officials will continue to recommend COVID-19 testing for all close contacts, despite sudden change in CDC guidance 

In response to the Centers for Disease Control and Prevention (CDC) changing their COVID-19 testing guidance earlier this week to say that some individuals without symptoms may not need to be tested, State of Nevada health officials confirm that they will not be adopting the new guidance and will continue to strongly recommend testing for all individuals – symptomatic or asymptomatic – who have been in contact with a person who has been diagnosed with COVID-19.

Prior to the change made this week, the CDC guidelines recommended testing “close contacts of persons with SARS-CoV-2 infection” so that “contacts of individuals with SARS-CoV-2 infection be quickly identified and tested.” The State of Nevada will continue with this guidance.

If an individual has been in close contact, defined as within six feet, or a person with a confirmed or suspected COVID-19 infection for at least 15 minutes, Nevada Department of Health and Human Services officials recommend getting a test regardless of whether the individual is experiencing symptoms or not.

“We disagree with the change in CDC guidelines and will continue to strongly recommend and urge testing for all individuals – symptomatic or asymptomatic – who have been in close contact of persons with COVID-19,” said Dr. Ishan Azzam, Nevada’s Chief Medical Officer. “The continued testing of asymptomatic individuals is vital in helping state and local health officials determine the spread of COVID-19 in our communities, in addition to being a critical component of our contact tracing efforts, especially due to the fact that a significant number of transmissions can come from people not experiencing symptoms. Testing will help provide Nevadans with more information about their own health conditions and will help slow the spread of COVID-19 in our communities.”

>>>UPDATE AS OF 5/5/20: EXPANDED TESTING CRITERIA

Nevada health officials are advising the health care community that testing just symptomatic patients may not be sufficient to prevent further transmission of COVID-19. Testing expansion is urgently required to determine the impact of asymptomatic cases on viral spread.

Current symptom-based screening strategies seem to be inadequate to identify or early detect all COVID-19 cases to prevent viral spread in the community and the transmission of infection within skilled nursing homes and other residential facilities. Increasing testing availability will allow clinicians to consider testing for wider groups including mildly symptomatic, asymptomatic, and pre-symptomatic patients. To early identify more COVID-19 cases, testing should be extended to individuals with and without symptoms. Focused activities should be implemented to reduce and ultimately prevent further transmission, including testing of asymptomatic high-risk vulnerable individuals and those who could have been exposed to COVID-19 cases.

RESOURCE: DPBH Technical Bulletin 05/05/20: Expansion of COVID-19 Testing Criteria

>>>UPDATE AS OF APRIL 20: EXPANDED TESTING CRITERIA

DPBH has issued updated testing criteria for COVID-19 in order to expand laboratory testing to include all patients exhibiting symptoms consistent with COVID-19 infection and ensure a more robust approach to rapid infection control and containment within our state.

RESOURCE: DPBH Technical Bulletin – Updated Testing Criteria for COVID-19 04/20/20

Recommendations for testing prioritization from Nevada DHHS can be found in the information sheet below:

RESOURCE: NV Health Response COVID-19 Testing Information for Health Care Providers

>>>INITIAL TESTING CRITERIA GUIDANCE:

RESOURCE: DPBH Interim Testing Criteria Technical Bulletin 03-20-20

RESOURCE: DPBH Criteria for Testing (COVID-19) Form
*Note: This form is NOT mandated by DPBH. It is meant to assist in the clinician’s decision making process only. 

NOTIFICATION OF STATE

Health care providers should immediately notify their local/state health department in the event of a person under investigation (PUI) for COVID-19. This includes both suspected and confirmed cases.

*For rural hospitals under the jurisdiction of DPBH, PUI numbers are required regardless of laboratory being used, but the provider should not delay care or testing to obtain a PUI number. Facilities should have blocks of PUI numbers to assign to PUIs and should not need to contact DPBH to just to obtain PUI numbers at this time. 

Note: In order to allow for more accurate reporting of testing and results by county, facilities should include the patient’s physical address along with the county of residence on every lab requisition form for COVID-19 testing in addition to other demographic information required, regardless of which lab is utilized.

*Note: For more information on required notifications, see the Reporting Requirements section of this webpage. 

SPECIMEN COLLECTION

If it is determined that testing for COVID-19 should be done, providers must follow specific guidelines. Hospitals should refer to the following CDC website for the most current recommendations.

https://www.cdc.gov/coronavirus/2019-nCoV/lab/guidelines-clinical-specimens.html

RESOURCE: DPBH Laboratory Testing FAQs 05/05/20

RESOURCE: NV Health Response Press Release: Nevada one of three states allowed to develop, assess, and conduct COVID-19 testing on its own

RESOURCE: CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel Fact Sheet for Patients

*For more information on specimen collection kits/testing supplies, please visit the Inventory and Supplies section of this webpage. 
Laboratory Contact Information
Nevada State Public Health Laboratory https://med.unr.edu/nsphl/emergency/covid19
(775) 688-1335 (M-F 8:00am to 5:00pm)
(775) 823-1150 (after hours and weekends)
Southern Nevada Public Health Laboratory https://www.southernnevadahealthdistrict.org/programs/southern-nevada-public-health-laboratory/
(702) 759-1000
Quest Diagnostics https://www.questdiagnostics.com/home/Covid-19/
(866) 404-1550
LabCorp https://www.labcorp.com/information-labcorp-about-coronavirus-disease-2019-covid-19
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PERSONAL PROTECTIVE EQUIPMENT (PPE) SUPPLIES

>>>UPDATE AS OF JULY 20: Battelle N95 Decontamination

The Nevada Division of Emergency Management, Division of Public and Behavioral Health, and the Federal Emergency Management Agency have coordinated the use of a Battelle Sterilization System to sterilize N-95 masks for Nevada’s first responders and health care workers. Sterilized masks can be reused up to 20 times, and sterilization will be done at no charge to health facilities or the state. All shipping costs will be covered by Battelle with no cost to facilities.

As access to N95s may potentially become a challenge again, any agency that requests N95s from the State will be required to be a registered user of the Battelle CCDS or they will not be allocated additional N95s

https://www.battelle.org/decon

RESOURCE: Battelle CCDS Information Packet

RESOURCE: Battelle Decontamination System Fact Sheet for HCP

RESOURCE: FDA Investigating Decontamination and Reuse of Respirators in Public Health Emergencies

RESOURCE: Guide for Identifying FDA EUA Authorized N95 Respirators for Battelle CCDS™ Processing – April 24, 2020

>>>UPDATE AS OF MAY 12, 2020: Requests for All COVID-19 Testing Supplies and PPE Must Go Through County Emergency Manager

To obtain test kits for collecting specimens going to the Nevada State Public Health Laboratory (NSPHL) or the Southern Nevada Public Health Laboratory (SNPHL), or to request additional personal protective equipment (PPE), it is recommended that you place your request for a one or two week supply through your local County Emergency Manager. Hospitals should be able to obtain as many collection kits as they are sending in on a “replacement basis”, as there is still a limited supply of collection kits and materials. NOTE: This directive is through December 31, 2020 ONLY.

RESOURCE: State of Nevada NDEM/SEOC Resource Request Form

RESOURCE: Resource Request Process

RESOURCE: Resource Request Flow

3D Printed Protective Face Shields from UNR!

NRHP would like to thank the many people at the University of Nevada, Reno who came together to help identify solutions to the PPE shortage faced by many hospitals and healthcare workers in Nevada: Nick Crowl from the University Libraries’ DeLaMare Science and Engineering Library along with Daniel Smith from the Innevation Center, several faculty members from the Computer Science and Engineering Department and The Department of Art Fabrication Lab. The result was a 3D printed protective face shield which can be sanitized and reused. Many of these face shields have already been delivered to NRHP member hospitals across Nevada and put to use!

See more about the work that the University of Nevada, Reno is doing to meet PPE demands (and donate to the cause!) here: https://unr.scalefunder.com/cfund/project/20780.

MISCELLANEOUS RESOURCES

The following materials are provided to assist CAHs with ensuring they have the proper supplies to combat the current outbreak of COVID-19:

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HEALTHCARE PERSONNEL

Protecting healthcare personnel (HCP) should be a priority for every CAH. In addition to proper training and education and ensuring adequate supply of necessary PPE, facilities should actively monitor HCP caring for possible COVID-19 patients. Staff interacting with patients suspected of having COVID-19 should be required to document their daily interaction on a Room Entry Log or other tracking method.

RISK ASSESSMENT

Refer to the CDC guidance for exposures that might warrant restricting asymptomatic HCP from reporting to work:

Interim U.S. Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel with Potential Exposure to COVID-19 | CDC

Flowchart for management of HCWs with exposure to a person with COVID-19 | CDC

RESOURCE: DPBH Technical Bulletin 04/01/20 re: Guidance for Public Health Management of HCP with Potential Exposure to Patients with COVID-19 in Healthcare Settings

DPBH has provided a tracking form for asymptomatic HCP potentially exposed to COVID-19. Facilities should call their public health authority for guidance in completing this form and assessing the HCP; however, the form is not mandatory at this time.

RESOURCE: DPBH Interim Tracking Form for Asymptomatic HCP Potentially Exposed 01/31/20

RESOURCE: WHO Health Workers Exposure Risk Assessment and Management in the Context of COVID-19 Virus 03/04/20

RETURN TO WORK

Refer to the CDC guidance for return to work for HCP with suspected or confirmed COVID-19:

Return-to-Work Criteria for Healthcare Workers | CDC

Refer to the CDC guidance on the duration of isolation and precautions for adults with COVID-19:

Duration of Isolation and Precautions for Adults with COVID-19 | CDC

Refer to the CDC guidance for strategies to mitigate healthcare personnel staffing shortages here:

Strategies to Mitigate Healthcare Personnel Staffing Shortages | CDC

Refer to the OSHA guidance for return to work here:

Guidance on Returning to Work (osha.gov)

>>>UPDATE AS OF  JULY 17, 2020:

  • Except for rare situations, a test-based strategy is no longer recommended to determine when to allow HCP to return to work.
  • For HCP with severe to critical illness or who are severely immunocompromised, the recommended duration for work exclusion was extended to 20 days after symptom onset (or, for asymptomatic severely immunocompromised HCP, 20 days after their initial positive SARS-CoV-2 diagnostic test).

Other symptom-based criteria were modified as follows:

  • Changed from “at least 72 hours” to “at least 24 hours” have passed since last fever without the use of fever-reducing medications
  • Changed from “improvement in respiratory symptoms” to “improvement in symptoms” to address expanding list of symptoms associated with COVID-19

RESOURCE: (Prior Guidance) DPBH Criteria for Return to Work for Healthcare Personnel with COVID-19 05/03/20

Please note that insurers don’t have to cover COVID-19 tests for “return to work” programs.

RESOURCE: FAQs About FFCRA and CARES Act Implementation 06/23/20

PROTECTING HEALTHCARE WORKERS

VACCINES FOR HEALTHCARE PERSONNEL

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PATIENT COMMUNICATIONS

SIGNAGE AND PATIENT EDUCATION

Appropriate signage should be placed at all entrances instructing patients to clean their hands, put on a facemask, and contact a hospital representative (per hospital policy) if they have certain symptoms and exposure history (per current guidance).

In addition, hospitals should supply patients with relevant information regarding COVID-19, including how to prevent the spread of the disease at home and in the community. Consider posting information on websites, social media, in newspapers, etc. More information on this can be found here:

https://www.cdc.gov/coronavirus/2019-ncov/about/steps-when-sick.html

Note: If patients are showing symptoms of respiratory illness but do not require further care by the hospital, they should be encouraged to self-isolate until signs and symptoms subside. Should the patient become a person under investigation (PUI) as determined by the local health authority, it would then be the responsibility of the State to monitor the isolation of the patient.

Example facility posters and patient educational flyers are included in this Toolkit; however, facilities are encouraged to create their own posters and flyers based on the most recent guidelines and the facility’s location and capabilities.

RESOURCE: COVID-19 Symptoms

RESOURCE: Quarantine and Isolation

RESOURCE: Contact Tracing

PATIENT FINANCIAL ASSISTANCE

The PenFed Foundation COVID-19 Emergency Financial Relief Program was created to provide financial assistance to all Veterans, active military service members, and those currently serving in the Reserves and the National Guard who are experiencing a financial setback due to the negative economic effects of the COVID-19 pandemic.

Link to Apply:  https://penfedfoundation.org/apply-for-assistance/coronavirus-emergency-financial-assistance/

BEHAVIORAL HEALTH RESOURCES

RESOURCE: COVID-19 and Your Mental Health (English | Spanish)

RESOURCE: ASPR COVID-19 Behavioral Health Resources

RESOURCE: Crisis Call Lines in Nevada

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VISITOR RESTRICTIONS

Hospitals should have heightened policies regarding visitors during the COVID-19 outbreak, especially in regard to vulnerable Skilled Nursing Facility residents.

Considerations depending on hospital capabilities include:

  • Restricting visitation to all or certain areas of the acute hospital/SNF

  • Restricting visitation hours

  • Restricting family and friends that accompany patients to the ER

  • Restricting visitors of specific ages, e.g., those under the age of 12

  • Restricting visitors based on signs and symptoms of illness

Note: For more on allowing visitors in nursing homes, please see the Long Term Care section.

Note: Facilities should always indicate that anyone showing signs and symptoms of illness is entitled to a Medical Screening Examination and will not be turned away for medically necessary care.

Consider posting information on websites, social media, in newspapers, etc.

Finally, consider cancelling any events or activities that include members of the public and discontinuing volunteer services during the COVID-19 outbreak.

RESOURCE: Sample Visitor Screening Tool (Massachusetts General)

RESOURCE: DPBH Technical Bulletin 03/30/20 re: Limitations on Visitors

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FINANCE AND OPERATIONS

MEDICARE BILLING & PAYMENTS

Medicare Accelerated and Advanced Payments

As of April 26, CMS has announced that it is reevaluating the amounts that will be paid under its Accelerated Payment Program and suspending its Advance Payment Program to Part B suppliers effective immediately. Funding will continue to be available to hospitals and other healthcare providers on the front lines of the coronavirus response primarily from the Provider Relief Fund (see the Funding Opportunities section of this webpage for more information).

Repayment: Critical Access Hospitals (CAH) have up to one year from the date the accelerated payment was made to repay the balance.

Medicare Emergency Declaration Q&A for CAHs (Based on 1135 Waiver):

A: During the public health emergency period, and depending upon specific circumstances, CMS may waive both the limit of 25 inpatient beds and the 96-hour length of stay (LOS) limitation. If a waiver is made, then evacuees to a CAH operating under such waiver would not be counted toward the determination of the 25-bed limit or considered for the 96-hour average length of stay limit if this result is clearly identified as relating to the emergency. CAHs must clearly indicate in the medical record where an admission is made or length of stay extended to meet the demands of the emergency and must also annotate all Medicare fee-for-service claims for such admissions or length of-stay extensions with the “DR” condition code or the “CR” modifier, as applicable, for the period that the CAH remains affected by the emergency. 1135P-2

RESOURCE Medicare FFS Emergency Q&As with an 1135 Waiver

A: HHS is unable to implement specific 1135 waivers in anticipation of an actual need.  Rather, once the need arises, a waiver may be granted. The waiver can be retroactive to the date the need actually arose (i.e., back to the beginning of the waiver period).

RESOURCE Medicare FFS Emergency Q&As with an 1135 Waiver

A: CAHs already have the capability of having extra furniture as long as it is clearly in storage and is not staffed and ready for use. The CAH bed limit is statutory and would require either a statutory change or a section 1135(b) waiver to authorize any exceptions. However, under normal circumstances, CMS counts as part of the 25-bed limit any rooms/spaces that are equipped and clearly ready to be used by simply rolling a “stored” bed into that space. There is a difference between having warehoused beds that provide the ability to add surge capacity during a declared emergency and having beds that can be readily used whenever the CAH wishes to exceed the 25 bed limit. In a clear emergency situation, CMS would notify providers of the extent to which beds could be moved from storage and readied for use (and not counted). P-2

RESOURCE: Consolidated Medicare FFS Emergency Q&As without an 1135 Waiver

A: No. A CAH will receive 101 percent of reasonable costs for all inpatient services furnished by the CAH (other than services of distinct part units) irrespective of whether the patient was discharged from a hospital in an emergency area and then admitted to the CAH or transferred from that hospital.

RESOURCE: Consolidated Medicare FFS Emergency Q&As without an 1135 Waiver

MEDICAID BILLING & PAYMENTS

Medicaid Q&A for CAHs:

A: Yes, the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA) have created two new Healthcare Common Procedure Coding System (HCPCS) codes and one new Current Procedural Terminology (CPT) code for outpatient hospitals and laboratories to bill for testing. The new HCPCS codes are U0001 and U0002, and the CPT code is 87635. The ICD-10 diagnosis code for COVID-19 is U07.1.

Nevada Medicaid is currently in the process of completing system updates to allow for reimbursement of these tests. At this time there is no implementation date determined, however, any claims submitted with HCPCS/CPT codes U0001, U0002, or 87635 will be suspended until system configurations are completed, at which time claims will be released for reimbursement.

A: CMS has released reimbursement methodology for the COVID-19 laboratory tests. Nevada Medicaid reimburses laboratory procedures at 50% of the rate allowed by the 2014 Medicare Clinical Diagnostic Laboratory Fee Schedule.

MEDICARE PROVIDER ENROLLMENT

MEDICAID PROVIDER ENROLLMENT

  • Provider revalidations with due dates from March 16, 2020 through May 16, 2020 have been extended by 60 days.
  • Providers licensed in another state who are not licensed in NV must submit an enrollment application with NV Medicaid.
  • Fingerprint-based Criminal Background Checks (FCBC) are temporarily postponed.
  • Site visits are temporarily postponed.

RESOURCE: Medicaid Update on Provider Enrollment 03/25/20

CODING

For possible exposure to COVID-19 with the disease ruled out, report Z03.818 (Encounter for observation for suspected exposure to other biological agents ruled out). For actual exposure to COVID-19, report Z20.828 (Contact with and (suspected) exposure to other viral communicable diseases.)

RESOURCE: ArchProCoding COVID-19 Training


New Code: U07.1 COVID-19

RESOURCE: ICD-10-CM Tabular List of Diseases and Injuries April 1, 2020 Addenda


Note: For cases where there is a concern about a possible exposure to COVID-19, but this is ruled out after evaluation, it would be appropriate to assign the code Z03.818, Encounter for observation for suspected exposure to other biological agents ruled out. For cases where there is an actual exposure to someone who is confirmed to have COVID-19, it would be appropriate to assign the code Z20.828, Contact with and (suspected) exposure to other viral communicable diseases. 

RESOURCE: ICD-10-CM Official Coding Guidelines – Supplement Coding encounters related to COVID-19 Coronavirus Outbreak February 20, 2020 

RESOURCE: International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)


Medicare Administrative Contractor (MAC) COVID-19 Test Pricing March 12, 2020:

RESOURCE: MAC COVID-19 Test Pricing


CMS Develops Additional Code for Coronavirus Lab Tests

“CMS developed the first HCPCS code (U0001) to bill for tests and track new cases of the virus. This code is used specifically for CDC testing laboratories to test patients for SARS-CoV-2. The second HCPCS billing code (U0002) allows laboratories to bill for non-CDC laboratory tests for SARS-CoV-2/2019-nCoV (COVID-19). The Medicare claims processing systems will be able to accept these codes starting on April 1, 2020, for dates of service on or after February 4, 2020. Local Medicare Administrative Contractors (MACs) are responsible for developing the payment amount for claims they receive for these newly created HCPCS codes in their respective jurisdictions until Medicare establishes national payment rates.”

RESOURCE: CMS Develops Additional Code for Coronavirus Lab Tests


New CPT code announced to report novel coronavirus test

“For quick reference, the new Category I CPT code and long descriptor are: 87635 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique”

RESOURCE: AMA Press Release: New CPT code announced to report novel coronavirus test

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FUNDING OPPORTUNITIES

PROVIDER RELIEF FUNDS

The CARES Act, signed by President Trump on March 27, provided $100B in relief funds to hospitals and other healthcare providers and will be used to support expenses or lost revenue attributable to COVID-19.

CARES Act $50B General Allocation (“first tranche”)

The first $30B of the of the general allocation (first distribution of the “first tranche”) was distributed to hospitals on either April 10 or April 17 (depending on the hospital’s status with United Health Group) and was proportionate to their share of Medicare reimbursement. On April 24, the remaining $20B started to be distributed. Additional funds went out to reconcile inequities of the first $30B (i.e., higher Medicaid volumes, high Medicare Advantage patients) and this totaled $9.2B (second distribution of the “first tranche”).

This left $10.8B that still needed to go out (third distribution of the “first tranche”). HOSPITALS MUST APPLY FOR A PORTION OF THIS $10.8B. This is separate and distinct from the additional $10B designated for rural hospitals and rural health clinics (see below).

>>>Please read this FAQ carefully: https://www.hhs.gov/sites/default/files/20200425-general-distribution-portal-faqs.pdf

Hospitals must also go into the portal to attest for both amounts of stimulus that you have received. This is not the TeleTracking portal. This is not the CARES Act Provider Relief Fund Payment Attestation Portal. This is the Provider Relief Fund Application Portal (built by DocuSign): https://covid19.linkhealth.com/docusign/#/step/1.

CARES Act Provider Relief Fund Distribution Summary

CARES Act $50B Targeted Allocations (“second tranche”)

Rural Providers – Another $10B has been distributed to rural hospitals and rural health clinics. Each CAH will receive a base of $1M + 4% of operating expenses from the most recent cost report; each RHC will receive a base of $100K + 4% of operating expenses from the most recent cost report.

Skilled Nursing – HHS is making relief fund distributions to SNFs based on both a fixed basis and variable basis. The first distribution of $4.9B was made in May and was meant to to offset revenue losses and assist nursing homes with additional costs related to responding to the COVID-19 public health emergency and the shipments of personal protective equipment provided to nursing homes by the Federal Emergency Management Agency. Each SNF received a fixed distribution of $50,000, plus a variable distribution ranging between $2,000 per bed for the smallest SNFs (between 5 and 25 beds) and $1,800 per bed for the largest SNFs (more than 200 beds).

In August, another distribution was made of $2.5B, with a fixed distribution of $10K per facility plus $1,450 per bed. This funding could be used to address critical needs in nursing homes including hiring additional staff, implementing infection control “mentorship” programs with subject matter experts, increasing testing, and providing additional services, such as technology so residents can connect with their families if they are not able to visit. Nursing homes must participate in the Nursing Home COVID-19 Training to be qualified to receive this funding.

“Hot Spots” – $12B is allocated for targeted distribution to hospitals in areas that have been particularly impacted by COVID-19 (“hot spots”), but will also take into account Medicare Disproportionate Share Hospital (DHS) Adjustments. Hospitals must have entered data into the TeleTracking portal by noon on April 25 to be eligible for these funds. See the Reporting section of this webpage for more information.

Treatment of Uninsured – A portion of the Provider Relief Fund will be used to reimburse healthcare providers, at Medicare rates, for COVID-related treatment of the uninsured. See coviduninsuredclaim.hrsa.gov for more information.

Paycheck Protection Program and Health Care Enhancement Act

RHC Testing – HHS, through HRSA, provided $225 million to Rural Health Clinics (RHCs) for COVID-19 testing.  These investments will support over 4,500 RHCs across the country to support COVID-19 testing efforts and expand access to testing in rural communities. Rural Health Clinics are a special designation given to health care practices in underserved rural areas by the Centers for Medicare and Medicaid Services (CMS) that help ensure access to care for rural residents. This funding is through the Paycheck Protection Program and Health Care Enhancement Act that President Trump signed into law on Friday, April 24, 2020 which specifically directed these monies to be allocated to RHCs. HRSA funded RHC organizations based on the number of certified clinic sites they operate, providing nearly $50,000 per clinic site.

OIG Strategic Plan

The Office of Inspector General (OIG) released its strategic plan for oversight of COVID-19 response and recovery, with goals focused on protecting people, funds, and infrastructure, and promoting effectiveness. Read the OIG Strategic Plan here:

https://oig.hhs.gov/about-oig/strategic-plan/COVID-OIG-Strategic-Plan.pdf

PAYCHECK PROTECTION PROGRAM

CARES Act Paycheck Protection Program

The Paycheck Protection Program, part of the Coronavirus Aid, Relief and Economic Security (CARES) Act is a forgivable loan designed to provide a direct incentive for small businesses to keep their workers on the payroll. Small businesses and nonprofits with fewer than 500 employees can apply through any qualified lender. Loans will have a 1% fixed interest rate, require no collateral or guarantor, and will be due in two years with no prepayment penalties or fees. Loan payments will also be deferred for six months; during that time, interest will accrue. In addition to payroll, up to 25% of the loan may be spent on mortgage interest, rent and utility payments.

Loans granted under the Paycheck Protection Program will be forgiven in full if certain requirements are met. Companies must keep workers on their payrolls for an eight-week period after the loan is granted, and loan forgiveness will be reduced depending on how the money is used. Companies must keep workers on their payroll for an eight-week period after the loan is granted. If staff counts are reduced, or salaries for employees who earn less than $100,000 annually are reduced by more than 25%, then the loan must be repaid.

Paycheck Protection Program and Health Care Enhancement Act

The Paycheck Protection Program ran out of money on 4/16/200; however, President Trump signed the Paycheck Protection Program and Health Care Enhancement Act on April 24, a $470B “phase 3.5” coronavirus stimulus package, of which $310B is additional funding for the Paycheck Protection Program. This funding is being targeted toward different recipients than the first round of funding, and $75B is set aside for grants and other mechanisms for eligible healthcare providers. As of this writing, it is believed that the additional funding is being utilized on the backlog of applications from the first round, and the SBA website states that they are currently unable to accept new applications based on available appropriations funding. Please check the SBA site frequently for updates: SBA Paycheck Protection Program.

*Note: District hospitals were originally thought to be ineligible for the Paycheck Protection Program; however, guidance from the SBA released on April 24 has clarified that hospitals otherwise eligible to receive the loan would NOT be rendered ineligible due to ownership by a state or local government if the hospital receives less than 50% of its funding from state or local government sources, exclusive of Medicaid. 

RESOURCE: PPP Loan Forgiveness Application/Instructions
*This form provides step-by-step instructions on how to calculate the forgiveness amount and includes a new exception from the loan forgiveness reduction for borrowers that made a good-faith, written offer to rehire an employee during the covered period which was rejected by the employee, among other changes and clarifications. 

RESOURCE: SBA Interim Final Rule 05/19/20

RESOURCE: NRHA Blog Post on How to Apply for a Loan Under the PPP

RESOURCE: Eide Bailly PPP vs. Emergency Injury Disaster Loan Program 

RESOURCE: SBA Paycheck Protection Program Loans FAQs

CORONAVIRUS SMALL HOSPITAL IMPROVEMENT PROGRAM (C-SHIP) GRANT

The HRSA Federal Office of Rural Health Policy received $180 million in the Coronavirus Aid, Relief, and Economic Security (CARES) Act to support COVID-19 related activities, of which nearly $150 million will go to hospitals responding to this health crisis. Nevada Critical Access Hospitals will receive their funds from NRHP via the Small Rural Hospital Improvement Program (SHIP) grant mechanism.

MEDICARE ADVANCED AND ACCELERATED PAYMENT PROGRAM

See the Finance and Operations section of this webpage for detailed information on the Medicare Advanced and Accelerated Payment Program.

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COMMUNITY COLLABORATION

Hospitals should communicate with other entities in their community regarding their role during the COVID-19 outbreak. Entities that should be involved include the County Commission, EMS, County Health Officer (if applicable), Community Health Nurse, skilled nursing, law enforcement, schools, and the Emergency Manager.

The National Rural Health Association (NRHA), through donated services partner Legato Healthcare Marketing, is providing NRHA members free access to a communications toolkit — designed to allow customization and branding for your facility — with messaging focused on:

  • Calling first to determine if someone should be seen
  • Your rural hospital/clinic taking a leadership role to protect your community

RESOURCE: Free Rural Health COVID-19 “Call First” Communications Toolkit

Aging and Disability Services is leading a partnership with the University of Nevada, Reno School of Medicine (UNR Med) Sanford Center for Aging (SCA), UNR School of Community Health Sciences (CHS) Dementia Engagement, Education and Research (DEER) Program, Nevada Senior Services and Nevada 2-1-1, to plan and implement a comprehensive and coordinated approach to meet the needs of the potentially hundreds-of-thousands of newly-isolated elders. This new statewide, integrated aging services response to the COVID-19 crisis will carry the aspirational name of NV CAN, the Nevada COVID-19 Aging Network (CAN) Rapid Response.

RESOURCE: 3/26 Memo re: ADSD COVID-19 Crisis Update and Launch of NV COVID-19 Aging Network (NV CAN) Rapid Response

The American Hospital Association (AHA) in partnership with the Society for Health Care Strategy and Market Development (SHSMD) have identified tools and resources to help hospitals communicate effectively.

RESOURCE: AHA COVID-19 Communications Resources

RESOURCE: AHA Communications Checklist: Preparing for and Responding to COVID-19

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HUMAN RESOURCES

FAMILIES FIRST CORONAVIRUS RESPONSE ACT

The Families First Coronavirus Response Act (FFCRA), which went into law on April 1, 2020, gave all American businesses with fewer than 500 employees funds to provide employees with paid leave, either for the employee’s own health needs or to care for family members. The legislation was intended to ensure that workers are not forced to choose between their paychecks and the public health measures needed to combat the virus while at the same time reimbursing businesses.

However, under this new law, health care providers may be exempted from paid sick leave or expanded  family and medical leave by their employer. Per the Department of Labor (DOL):

[Updated to reflect the Department’s revised regulations which are effective as of the date of publication in the Federal Register.]

A: For the purposes of defining the set of employees who may be excluded from taking paid sick leave or expanded family and medical leave by their employer under the FFCRA, a health care provider includes two groups.

This first group is anyone who is a licensed doctor of medicine, nurse practitioner, or other health care provider permitted to issue a certification for purposes of the FMLA.

The second group is any other person who is employed to provide diagnostic services, preventive services, treatment services, or other services that are integrated with and necessary to the provision of patient care and, if not provided, would adversely impact patient care. This group includes employees who provide direct diagnostic, preventive, treatment, or other patient care services, such as nurses, nurse assistants, and medical technicians. It also includes employees who directly assist or are supervised by a direct provider of diagnostic, preventive, treatment, or other patient care services. Finally, employees who do not provide direct heath care services to a patient but are otherwise integrated into and necessary to the provision those services—for example, a laboratory technician who processes medical test results to aid in the diagnosis and treatment of a health condition—are health care providers.

A person is not a health care provider merely because his or her employer provides health care services or because he or she provides a service that affects the provision of health care services. For example, IT professionals, building maintenance staff, human resources personnel, cooks, food services workers, records managers, consultants, and billers are not health care providers, even if they work at a hospital of a similar health care facility.

To minimize the spread of the virus associated with COVID-19, the Department encourages employers to be judicious when using this definition to exempt health care providers from the provisions of the FFCRA. For example, an employer may decide to exempt these employees from leave for caring for a family member, but choose to provide them paid sick leave in the case of their own COVID-19 illness.

>>>UPDATE AS OF SEPTEMBER 16, 2020: 

The U.S. Department of Labor (DOL) issued revised regulations on the Families First Coronavirus Response Act’s (FFCRA’s) paid-sick-leave and paid-family-leave provisions, clarifying when leave is available and when employees must seek approval to take leave.

RESOURCE: DOL Paid Leave Under the Families First Coronavirus Response Act Temporary Rule 

IRS GUIDANCE: EMPLOYEE SOCIAL SECURITY DEFERRAL

On August 28th the IRS issued Notice 2020-65 providing guidance on implementation of the August 8th presidential executive order that allows the deferral of employee social security taxes for the period September 1, 2020 through December 31, 2020.

The deferral of the employee taxes is not mandatory and employers will need to decide whether they want to opt in. The potential to defer the withholding only applies with respect to employees whose gross pay for the pay period is less than $4,000 for a bi-weekly pay period (or equivalent for other payroll periods, e.g. $2,000 for weekly payroll). No deferral is available for any payment to an employee of taxable wages of $4,000 or above for a bi-weekly pay period.

See more at https://www.wipfli.com/insights/articles/tax-irs-guidance-employee-social-security-deferral

RESOURCE: IRS Notice 2020-65 Relief with Respect to Employment Tax Deadlines Applicable to Employers Affected by the Ongoing Coronavirus (COVID-19) Disease 2019 Pandemic

OSHA GUIDANCE

New guidance from the Occupational Safety and Health Administration (OSHA) relieves employers of some responsibility for investigating and recording cases of COVID-19 among employees; however, this new guidance does NOT apply to the health care sector. Health care employers must continue to investigate all COVID-19 cases among employees and record all of those acquired at work.

In addition, employers are required to record cases whenever:

  • There is objective evidence that a COVID-19 case may be work-related. This could include, for example, a number of cases developing among employees who work closely together without an alternative explanation.
  • The evidence was reasonably available to the employer. For purposes of this memorandum, examples of reasonably available evidence include information given to the employer by employees, as well as information that an employer learns regarding its employees’ health and safety in the ordinary course of managing its business and employees.

RESOURCE: OSHA Guidance on Return to Work

RESOURCE: OSHA Enforcement Guidance for Recording Cases of Coronavirus Disease 2019 (COVID-19) 04/10/20

RESOURCE: SCATS COVID-19 Resource Page

EEOC GUIDANCE

The Equal Employment Opportunity Commission (EEOC) has issued guidance to assist employers with the proper workplace conduct that must still be followed during the pandemic.

What You Should Know About COVID-19 and the ADA, the Rehabilitation Act, and Other EEO Laws | U.S. Equal Employment Opportunity Commission (eeoc.gov)

NV DIVISION OF PUBLIC AND BEHAVIORAL HEALTH (DPBH) COVID-19 MESSAGE TO EMPLOYERS

The Nevada Department of Public and Behavioral Health (DPBH) has put forth guidelines on handling employees with symptoms. Employers should not require a positive COVID-19 test result or a healthcare provider’s note for employees who are sick to validate their illness, qualify for sick leave, or to return to work.

RESOURCE: DPBH Technical Bulletin 03/27/20 re: COVID-19 Message to Employers

FRAUDULENT UNEMPLOYMENT CLAIMS

Nevada’s COVID-19 Task Force has recently received reports suggesting that personal identifying information of some present and past Nevada residents is being used to file fraudulent applications for unemployment benefits. Individuals who believe that someone is fraudulently using their identity to apply for unemployment benefits should file a complaint through the FBI’s Internet Crime Complaint Center (IC3), at www.ic3.gov and to DETR’s Fraud Report. Nevada’s COVID-19 Fraud Task Force is working with DETR to assess the problem.

RESOURCE: Nevada COVID-19 Fraud Task Force Provides Guidance for Victims of Unemployment Benefits Fraud 07/21/20

RESOURCE: Nevada Department of Employment, Training and Rehabilitation (DETR) Unemployment Fraud Guide 08/13/20

RESOURCE: FBI Sees Spike in Fraudulent Unemployment Insurance Claims Filed Using Stolen Identities — FBI

ADDITIONAL RESOURCES

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SURGE CAPACITY

Hospitals should have a plan in place to handle a potentially overwhelming influx of patients caused by the COVID-19 outbreak. Integral to addressing such a surge is the development of alternative strategies for triaging, caring for non-emergency cases, and transporting patients to tertiary facilities.

Refer to the following website for key considerations for transferring patients to relief healthcare facilities:

Key Considerations for Transferring Patients to Relief Healthcare Facilities when Responding to Community Transmission of COVID-19 in the United States | CDC

RESOURCE: Rural Healthcare Surge Readiness – Rural Health Information Hub

RESOURCE: AHRQ Optimizing Surge Capacity

RESOURCE: CDC COVID-19 Surge Tool

RESOURCE: Northeastern University Surge Capacity Tool

BATTLE BORN MEDICAL CORP

>>>UPDATE AS OF JUNE 23, 2020

Health facilities can now request volunteers by completing the forms available on the Battle Born Medical Corps page of the NV Health Response website. This includes the Resource Request Form and DEM request form (sections I and II only) detailing the volunteer request including how many and what types of volunteers are being requested, and answering the additional questions below using the BBMC Volunteer Request Form.

  • What is the contact information for who they need to reach if they wish to volunteer?
  • How long will you need volunteers for? Start Dates? End Dates?
  • Are you providing any meals, per diem, or lodging for those who are traveling from out of the area?
  • What is the address to where they will need to report?
  • What tasks are you searching for volunteers to complete?
  • Are specific skill sets or licensing requirements needed?

>>>UPDATE AS OF APRIL 1, 2020:

Governor Steve Sisolak announced that he signed the Battle Born Medical Corps emergency directive, aimed at expanding the healthcare workforce in Nevada to fight COVID-19. The Directive waives certain licensing requirements to allow Nevada to quickly bring additional health care workers into hospitals.

https://www.ServNV.org 

RESOURCE: BBMC – Press Release 04/04/20

RESOURCE: BBMC – How to Sign Up 04/03/20

RESOURCE: BBMC – Guidance 04/01/20

GOVERNOR’S DIRECTIVE RE: EXPANDING THE HEALTH CARE WORKFORCE

On April 1, 2020, the Governor’s Office issued a directive which included the following orders pertaining to HCP:

  • Waiver of certain licensing requirements to allow the practice of currently unlicensed skilled medical professionals during the declared emergency (a) who currently hold a valid license in good standing in another state, (b) whose license currently stands suspended for licensing fee delinquencies, (c) whose license currently stands suspended for failure to meet continuing medical education requirements; and who have retired from their practice in any state with their license in good standing;
  • Authorization of the Chief Medical Officer to approve waiver of professional licensing requirements for providers who received training in another country but are not currently licensed in the United States;
  • Medical facilities are responsible for ensuring that any provider employed or contracted with who is not licensed in Nevada during this declared emergency has notified the applicable Nevada license board or agency;
  • A provider of medical services during this emergency is authorized to supervise students in their profession to provide any emergency medical services as is appropriate to the student’s knowledge and skill level without further licensure or certification;
  • Providers of medical service are authorized to practice outside the scope of their specialization, within the limits of their competency;
  • Regulatory requirements for providers of medical services that are not compatible with the applicable Crisis Standards of Care as approved by the CMO will be suspended; and
  • Providers performing services for the COVID-19 emergency are afforded immunities and protections set forth in NRS 414.110.

RESOURCE: Crisis Standards of Care Plan for COVID-19 – Version 3.1 (nv.gov)

RESOURCE: State of Nevada Declaration of Emergency Directive re: Expansion of Healthcare Workforce 04/01/20

EXPANDING BED CAPACITY

If CAHs plan to expand their bed capacity, this must be done via the online licensing system: https://nvdpbh.aithent.com/Login.aspx. The fee should be waived; however, if hospitals see an issue with this they should contact the Division of Public and Behavioral Health (DPBH).

MEDICALLY NECESSARY PROCEDURES

In order to maintain capacity for treating emergency patients as COVID-19 cases surge, hospitals must make important decisions about continuing, postponing, or cancelling medically necessary surgeries and procedures. Nevada hospitals began to voluntarily cease such procedures in mid-March to ensure that they could safely and effectively respond to the emerging pandemic and provide health care to patients. It may be necessary to do so whenever COVID-19 cases are surging. At the same time, however, there is a need for patients to receive medically necessary procedures before their cases become emergent.

Per the Nevada Hospital Association, the following guidelines should be considered when resuming medically necessary procedures:

  • Adequate supply of PPE
  • Adequate availability of surgical equipment
  • Adequate ventilator capacity
  • Adequate staffing to care for surgical and post-operative patients, as well as other hospital volume
  • Available overall hospital licensed bed capacity

For more information on process guidelines hospitals should follow, please contact the Nevada Hospital Association: https://nvha.net/

RESOURCE: AHA Special Bulletin 04/17/20: AHA, Others Issue Roadmap for Safely Resuming Elective Surgery as COVID-19 Curve Flattens

COVID-19 RELATED HOSPITAL TRANSFERS

The Division of Health Care Financing and Policy (DHCFP) has been continuously monitoring the impact of COVID-19 on Nevada’s hospitals. Based on the upward trajectory of COVID-19 cases and Nevada hospitals’ high occupancy levels, the 75% capacity level requirement related to the consideration of Letter of Agreements (LOAs) is being suspended. LOAs will be evaluated as requested by Inpatient Rehabilitation, Long Term Acute Care (LTAC) Specialty Hospitals and Critical Access Hospitals (CAHs). LOA requests related to accepting a transferring patient from an acute care hospital to free up acute care beds will be evaluated on a case-by-case basis.

RESOURCE: DHCFP Web Announcement 12/16/20 re: COVID-19 Related Hospital Transfers

CMS HOSPITAL SURVEY PRIORITIES

To ensure quality of care oversight, while providing hospitals the ability to focus on serving their patients and communities, CMS has issued certain hospital survey limitations in effect for thirty (30) days from the date of issuance of a memo to state survey agency directors dated January 20, 2021, with potential for 30-day renewals following additional notice. View the memo below:

RESOURCE: CMS Memo 01/20/21 re: Hospital Survey Priorities

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TELEMEDICINE

MEDICARE

CMS has broadened access to Medicare telehealth services so that beneficiaries can receive a wider range of services from their doctors without having to travel to a healthcare facility under a temporary and emergency basis under the 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act.

There are three main types of virtual services physicians and other professionals can provide to Medicare beneficiaries summarized in the fact sheet shown below: Medicare telehealth visits, virtual check-ins, and e-visits.

Rural Health Clinics (RHCs) will be able to be the distant site during the emergency period.
*Note: H.R. 748 was signed into law by President Trump on Friday 3/27/2020*

For Medicare, RHCs must refer to G0071 for audio-only visits.

‘‘(8) ENHANCING TELEHEALTH SERVICES FOR FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS DURING EMERGENCY PERIOD.— ‘‘(A) IN GENERAL.—During the emergency period described in section 1135(g)(1)(B)— ‘‘(i) the Secretary shall pay for telehealth services that are furnished via a telecommunications system by a Federally qualified health center or a rural health clinic to an eligible telehealth individual enrolled under this part notwithstanding that the Federally qualified health center or rural clinic providing the telehealth service is not at the same location as the beneficiary;‘‘(ii) the amount of payment to a Federally qualified health center or rural health clinic that serves as a distant site for such a telehealth service shall be determined under subparagraph (B); and ‘‘(iii) for purposes of this subsection— ‘‘(I) the term ‘distant site’ includes a Federally qualified health center or rural health clinic that furnishes a telehealth service to an eligible telehealth individual; and ‘‘(II) the term ‘telehealth services’ includes a rural health clinic service or Federally qualified health center service that is furnished using telehealth to the extent that payment codes corresponding to services identified by the Secretary under clause (i) or (ii) of paragraph (4)(F) are listed on the corresponding claim for such rural health clinic service or Federally qualified health center service. ‘‘(B) SPECIAL PAYMENT RULE.— ‘‘(i) IN GENERAL.—The Secretary shall develop and implement payment methods that apply under this subsection to a Federally qualified health center or rural health clinic that serves as a distant site that furnishes a telehealth service to an eligible telehealth individual during such emergency period. Such payment methods shall be based on payment rates that are similar to the national average payment rates for comparable telehealth services under the physician fee schedule under section 1848. Notwithstanding any other provision of law, the Secretary may implement such payment methods through program instruction or otherwise. ‘‘(ii) EXCLUSION FROM FQHC PPS CALCULATION AND RHC AIR CALCULATION.—Costs associated with telehealth services shall not be used to determine the amount of payment for Federally qualified health center services under the prospective payment system under section 1834(o) or for rural health clinic services under the methodology for all-inclusive rates (established by the Secretary) under section 1833(a)(3).’’

MEDICAID

Nevada Medicaid has also announced expanded access to telehealth.

Providers are encouraged to monitor the Division of Health Care Financing and Policy’s COVID-19 webpage (http://dhcfp.nv.gov/covid19/) for additional resources and information regarding telehealth coverage during this crisis. For additional questions, please send an email to dhcfp@dhcfp.nv.gov.

RESOURCE: Nevada Medicaid Telehealth Announcement 03/27/20

RESOURCE: Web Announcement: Telehealth Billing Guidelines 03/26/20

RESOURCE: Nevada Medicaid Telehealth Announcement 03/20/20

RESOURCE: Nevada Medicaid Telehealth Memo 03/17/20

The rendering provider at the distant site must bill using the most appropriate CPT code and a 02 place of service code.

RESOURCE: DHCFP Telehealth Resource Guide

Nevada Department of Health and Human Services is filing an 1135 waiver with CMS. This will allow RHCs to be the distant site.
*Note: Nevada’s 1135 waiver has not yet been filed with or approved by CMS. NRHP expects the waiver to be approved by 3/31/2020 with a retroactive effective date of 3/1/2020.*

EQUIPMENT AND APPLICATIONS

Use of non-HIPAA compliant applications:

HIPAA rules have been relaxed to allow for increased use of telehealth, meaning providers may, in good faith, use non-HIPAA platforms.

“Under this Notice, covered health care providers may use popular applications that allow for video chats, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, or Skype, to provide telehealth without risk that OCR might seek to impose a penalty for noncompliance with the HIPAA Rules related to the good faith provision of telehealth during the COVID-19 nationwide public health emergency.  Providers are encouraged to notify patients that these third-party applications potentially introduce privacy risks, and providers should enable all available encryption and privacy modes when using such applications. “

RESOURCE: Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency

Use of telephone (audio only/no video):

VIRTUAL CHECK-INS: In all areas (not just rural), established Medicare patients in their home may have a brief communication service with practitioners via a number of communication technology modalities including synchronous discussion over a telephone or exchange of information through video or image.

Virtual check-ins can be conducted with a broader range of communication methods, unlike Medicare telehealth visits, which require audio and visual capabilities for real-time communication.

RESOURCE: Medicare Telemedicine Health Care Provider Fact Sheet

Q: Is any specialized equipment needed to furnish Medicare telehealth services under the new law?

A: Currently, CMS allows for use of telecommunications technology that have audio and video capabilities that are used for two-way, real-time interactive communication. For example, to the extent that many mobile computing devices have audio and video capabilities that may be used for two-way, real-time interactive communication they qualify as acceptable technology.

The new waiver in Section 1135(b) of the Social Security Act explicitly allows the Secretary to authorize use of telephones that have audio and video capabilities for the furnishing of Medicare telehealth services during the COVID-19 PHE. In addition, effective immediately, the HHS Office for Civil Rights (OCR) will exercise enforcement discretion and waive penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype, during the COVID-19 nationwide public health emergency.

RESOURCE: Medicare Telehealth Frequently Asked Questions (FAQs)

COMMERCIAL INSURERS

At this time, the Nevada Division of Insurance is not aware of any insurers requiring health care providers to use their own telemedicine portals to conduct telehealth visits. Additionally, the Nevada Division of Insurance recommends providers contact the insurers’ customer service representatives for questions/concerns with telehealth coverage.

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LONG TERM CARE

CAHs with distinct-part Skilled Nursing Facilities must take extra precautions with vulnerable long-term care residents. Long-term care facilities concerned that a resident, visitor, or employee may be a COVID-2019 patient under investigation should contact their local or state health department immediately for consultation and guidance.

Ill visitors and healthcare personnel (HCP) are the most likely sources of introduction of COVID-19 into a facility. CDC recommends appropriate visitor restrictions and enforcing sick leave policies for ill HCP, even before COVID-19 is identified in a community or facility. See below for guidance on reopening nursing homes to visitors. 

Specific guidance for long-term care facilities can be found here:

Nursing Homes and Long-Term Care Facilities | CDC

Nursing Home Resource Center | CMS

FOCUSED INFECTION CONTROL NURSING HOME SURVEYS

CMS has updated its COVID-19 Focused Survey for Nursing Homes. Click here to access the tool that updated 8/25/20.
CMS COVID-19 Focused Survey Protocol Training for Nursing Homes surveyor training materials can be found here (note these are for the 3/25/20 version of the tool).

CMS issued a revised memo to state survey agency directors, including FAQs, on January 4, 2021 regarding COVID-19 survey activities in Nursing Homes. Of note, nursing homes must grant access to surveyors performing onsite inspections, and may not require COVID-19 testing as a condition for entering the facility.

RESOURCE: CMS Memo 06/01/20 (Revised 01/04/21): COVID-19 Survey Activities, CARES Act Funding, Enhanced Enforcement for Infection Control Deficiencies, and Quality Improvement Activities in Nursing Homes

VACCINATION IN NURSING HOMES

UPDATE AS OF FEBRUARY 1, 2021: PLACEMENT OF RESIDENTS WHO HAVE BEEN VACCINATED

All patients/residents that are COVID-19 negative and have received their vaccination against COVID-19 should continue to be housed in the green zone (general population/COVID-19 negative unit). COVID-19 negative individuals who have been vaccinated for COVID-19 are not to be cohorted with suspected or COVID-19 positive patients/residents. These individuals should not share a room with suspected or COVID-19 positive patients/residents. See more in the Technical Bulletin below.

RESOURCE: DPBH Technical Bulletin 02/03/21 re: Placement of patients/residents who have been vaccinated against COVID-19 or who have had COVID-19 and have recovered (patient/resident no longer requires transmission-based precautions)

RESOURCE: Importance of COVID-19 Vaccination for Residents of Long-term Care Facilities | CDC

RESOURCE: Post Vaccine Considerations for Residents | CDC

*For information on vaccinations in nursing homes, see the Vaccines section of this webpage.

ROUTINE TESTING IN NURSING HOMES

Testing for SARS-CoV-2 infection among residents and healthcare personnel in nursing homes has become a priority to help inform prevention and control in the facility. Considerations for testing in LTC can be found here:

Testing Guidelines for Nursing Homes | CDC

Considerations for Use of SARS-CoV-2 Antigen Testing in Nursing Homes | CDC

>>>UPDATE AS OF DECEMBER 1, 2020:

The Division of Public and Behavioral Health (DPBH) issued further guidance on routine testing in nursing homes. Of note, facilities should not retest someone who has tested positive with a PCR test within three months provided they remain asymptomatic, and facilities should not continue to conduct serial PCR testing of staff and residents prior to receiving the results from the last round of testing.

RESOURCE: DPBH Memo re: COVID-19 Testing in Long Term Care Facilities, Skilled Nursing Facilities, and Residential Facilities for Groups

>>>UPDATE AS OF OCTOBER 9, 2020:

Effective immediately, the Nevada Department of Health and Human Service’s (DHHS) Chief Medical Officer’s (CMO) directive requiring skilled nursing facilities (SNFs) to immediately discontinue the use of all COVID-19 point of care (POC) antigen tests until the accuracy of the tests can be better evaluated, will be removed as directed by the United States Department of Health and Human Services (HHS), Office of the Secretary. This effectively allows the use of such tests in all SNFs.

RESOURCE: DPBH Technical Bulletin 10/9/20 re: REMOVAL OF DIRECTIVE to Discontinue the Use of Antigen Testing in Skilled Nursing Facilities Until Further Notice

ARCHIVED RESOURCE: DPBH Technical Bulletin 10/2/20 re: Discontinue the Use of Antigen Testing in Skilled Nursing Facilities Until Further Notice

Testing recommendations for LTC staff and residents has been outlined in an Interim Final Rule published 8/26/20. The new testing summary is as follows:

Testing Trigger Staff Residents
Symptomatic individual identified Staff with signs/symptoms must be tested Residents with signs/symptoms must be tested
Outbreak (any new case arises in facility) Test all staff that previously tested negative until no new cases Test all residents that previously tested negative until no new cases
Routine testing According to county positivity rate Not recommended unless resident leaves facility

Routine testing of staff should be based on the extent of the virus in the community and facilities should use their county positivity rate in the prior week as the trigger for staff testing frequency, as follows:

Community Activity County Positivity Rate in Past Week Test Positivity Classification Minimum Testing Frequency
Low <5%** GREEN Once a month
Medium 5% – 10%** YELLOW Once a week*
High >10%** RED Twice a week*
*This frequency presumes availability of Point of Care (POC) testing on-site at the nursing home or where off-site testing turnaround time is <48 hours.
**On 9/29/20, in response to concerns that the testing frequency guidelines did not work well for some rural areas, CMS announced an update to the methodology the agency employs to determine the rate of coronavirus disease 2019 (COVID-19) positivity in counties across the country. Counties with 20 or fewer tests over 14 days will now move to “green” in the color-coded system of assessing COVID-19 community prevalence. Counties with both fewer than 500 tests and fewer than 2,000 tests per 100,000 residents, and greater than 10 percent positivity over 14 days – which would have been “red” under the previous methodology – will move to “yellow.”

Reports of county positivity rates are available on the following website under “COVID-19 Testing” and should be checked regularly for updates (at least every other week): https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg*

*CMS county positivity rates may not match data received from the county or State. Of note, CMS positivity rates do NOT include antigen test results. In addition, there are other factors that may cause a discrepancy in the data, such as reporting processes or delays (see how CMS calculates positivity rates here). During a webinar on 9/3/20, HHS indicated that “county level data from the county or state agencies may be used provided that it is recent and that the nursing home documents the data and source of data they they are using for purposes of decisions”. View the HHS webinar here.
Noncompliance with this new requirement will be cited at tag F886, with fines starting at $400 per day, ranging up to $8,000, and with termination from the CMS program being the ultimate threat.

GUIDANCE ON REOPENING NURSING HOMES

>>>UPDATE AS OF SEPTEMBER 17, 2020:

CMS has issued new guidance recognizing that physical separation from family and other loved ones has taken a physical and emotional toll on residents, and outlines how visitation can be conducted while following certain core principles and best practices that reduce risk of COVID-19 transmission.

Of note, CMS has stated the following: “Except for on-going use of virtual visits, facilities may still restrict visitation due to the COVID-19 county positivity rate, the facility’s COVID-19 status, a resident’s COVID-19 status, visitor symptoms, lack of adherence to proper infection control practices, or other relevant factor related to the COVID-19 PHE. However, facilities may not restrict visitation without a reasonable clinical or safety cause, consistent with §483.10(f)(4)(v). For example, if a facility has had no COVID-19 cases in the last 14 days and its county positivity rate is low or medium, a nursing home must facilitate in-person visitation consistent with the regulations, which can be done by applying the guidance stated above. Failure to facilitate visitation, without adequate reason related to clinical necessity or resident safety, would constitute a potential violation of 42 CFR 483.10(f)(4), and the facility would be subject to citation and enforcement actions.

RESOURCE: CMS Memo re: Nursing Home Visitation – COVID-19 09/17/20

>>>UPDATE AS OF SEPTEMBER 2, 2020:

The Bureau of Health Care Quality and Compliance sent out an email asking long-term care facilities to consider what steps can be taken to safely continue providing services for asymptomatic or mildly symptomatic residents in the facility. In order to maintain capacity in the State’s spectrum of health care providers, it is important to transport to another facility only those residents requiring a higher level of care or those that the long-term care facility can no longer safely keep due to staffing or resource shortages. If a change in a resident’s status requires the need for a higher level of care, a hospital would be appropriate. However, if the resident does not require a higher level of care, a transfer to another skilled nursing facility that can safely accept the resident may be more appropriate.

As such, here are some recommendations:

  1. Monitor residents with signs and symptoms of COVID-19, or who have COVID-19, three time a day and staff at the beginning of each shift.
  2. Ensure the facility has a screening process for staff as they arrive at work in accordance with CDC guidelines. (See the Infection Control section of this webpage)
  3. Request facility-wide testing through local emergency managers as needed.
  4. Ensure the facility has infection prevention plans in place.

If possible, long-term care facilities are asked to include processes and procedures to keep residents at “home” as part of the facility’s staffing and infection control and prevention plan.

On June 19, a questionnaire was sent to all Nevada Skilled Nursing Facilities so that the Division of Public and Behavioral Health can work with the facilities to assess their readiness to receive visitors based on the phases identified in the 5/18 CMS Memo below.

RESOURCE: DPBH Plan for Determining Phases to Allow Visitors in Nursing Facilities 06/19/20

CMS announced new guidance for state and local officials to ensure the safe reopening of nursing homes across the country. The guidance released on May 18 is part of President Trump’s Guidelines for Opening Up America Again. It details critical steps nursing homes and communities should take prior to relaxing restrictions implemented to prevent the spread of COVID-19, including rigorous infection prevention and control, adequate testing, and surveillance. The recommendations allow states to make sure nursing homes are continuing to take the appropriate and necessary steps to ensure resident safety and are opening their doors when the time is right.

RESOURCE: CMS Memo: Nursing Home Reopening Recommendations for State and Local Officials 05/18/20
*Note: Nevada facilities were notified on 5/19/20 that the state’s Chief Medical Officer is requiring COVID-19 testing for all skilled nursing facility residents and staff by Friday, May 29. 

RESOURCE: CMS Frequently Asked Questions (FAQs) on Nursing Home Visitation 06/23/20

TRAINING FOR NURSING HOMES

In partnership with the University of New Mexico’s ECHO Institute and the Institute for Healthcare Improvement (IHI), AHRQ has established a National Nursing Home COVID Action Network to prevent infections among nursing home residents and staff. The new network is being created under an AHRQ contract worth up to $237 million that is part of the nearly $5 billion Provider Relief Fund authorized earlier this year under the Coronavirus Aid, Relief, and Economic Security (CARES) Act. Over 15,000 nursing homes that are certified to participate in the Medicare and Medicaid programs will be able to participate in a 16-week training program using a standardized curriculum developed by the IHI. The training program will include best practices for using personal protective equipment, COVID-19 testing, clinical management of asymptomatic and mild cases, and other topics. Nursing home teams seeking to participate may sign up on the Project ECHO website.

The Network will provide free training and mentorship to U.S. nursing homes to enhance evidence-based safety practices to protect residents and staff. Goals include:

  • Prevent SARS-COV-2 from entering nursing homes where it has not been detected.
  • Identify residents and staff who have been infected with SARS-COV-2.
  • Prevent the spread of SARS-COV-2 between staff, residents, and visitors.
  • Provide safe and appropriate care to residents with mild and asymptomatic cases of COVID-19.
  • Ensure staff members have the knowledge, skills, and confidence to implement best-practice safety measures to protect residents and themselves.
  • Reduce social isolation for residents, families, and staff during these difficult times.

CMS Targeted COVID-19 Training for Frontline Nursing Home Staff and Management: On 8/25/20, CMS implemented this first-of-its kind scenario-based training designed specifically with COVID-19 in mind.

The course for frontline staff covers the following five topics:

  • Module 1: Hand Hygiene and PPE
  • Module 2: Screening and Surveillance
  • Module 3: Cleaning the Nursing Home
  • Module 4: Cohorting
  • Module 5: Caring for Residents with Dementia in a Pandemic

The course for management covers the following 10 topics:

  • Module 1: Hand Hygiene and PPE
  • Module 2: Screening and Surveillance
  • Module 3: Cleaning the Nursing Home
  • Module 4: Cohorting
  • Module 5: Caring for Residents with Dementia in a Pandemic
  • Module 6: Basic Infection Control
  • Module 7: Emergency Preparedness and Surge Capacity
  • Module 8: Addressing Emotional Health of Residents and Staff
  • Module 9: Telehealth for Nursing Homes
  • Module 10: Getting Your Vaccine Delivery System Ready

The course is available here: https://qsep.cms.gov/welcome.aspx

Nursing Home Infection Preventionist Training: This course is designed for individuals responsible for infection prevention and control (IPC) programs in nursing homes, and was produced by CDC in collaboration with the Centers for Medicare & Medicaid Services (CMS).

This specialized nursing home training covers:

  • Core activities of effective IPC programs,
  • Recommended IPC practices to reduce:
    • Pathogen transmission
    • Healthcare-associated infections
    • Antibiotic resistance

Start the training here: https://www.train.org/cdctrain/training_plan/3814

National CMS/CDC Nursing Home COVID-19 Training: Through the Quality Improvement Organization (QIO) Program, the Centers for Medicare & Medicaid Services (CMS) hosts a weekly webinar series (every Thursday, 4-5 pm ET) to provide training for infection control processes in nursing homes.

The Centers for Medicare & Medicaid Services (CMS) is airing a series of short podcasts for frontline nursing home staff. The series, “CMS Beyond the Policy: Nursing Home Series for Frontline Clinicians and Staff,” is designed to reinforce training and infection control practices in nursing homes to help combat the spread of coronavirus disease 2019 (COVID-19).

To listen to the podcast, please click here: https://www.cms.gov/podcast/nursing-home-series-front-line-clinicians-and-staff

ADDITIONAL RESOURCES

RESOURCE: Infection Prevention and Control Assessment Tool for Nursing Homes Preparing for COVID-19 | CDC

RESOURCE: ASPR TRACIE LTC COVID-19 Toolkit

RESOURCE: Attorney General Ford Warns Against Stimulus Checks Being Taken From Nursing Home Residents 05/26/20

RESOURCE: CMS Memo: COVID-19 Survey Activities, CARES Act Funding, Enhanced Enforcement for Infection Control deficiencies, and Quality Improvement Activities in Nursing Homes 06/01/20

RESOURCE: CDC Infection Prevention and Control Assessment Tool for Nursing Homes Preparing for COVID-19

RESOURCE: CMS Toolkit on State Actions to Mitigate COVID-19 Prevalence in Nursing Homes May 2020

RESOURCE: CMS Letter to Nursing Home Facility Management and Staff 05/11/20

RESOURCE: CMS Memo: Interim Final Rule Updating Requirements for Notification of Confirmed and Suspected COVID-19 Cases Among Residents and Staff in Nursing Homes 05/06/20

RESOURCE: CMS Coronavirus Commission for Safety and Quality in Nursing Homes 04/30/20

RESOURCE: CMS Memo: Nursing Home Five Star Quality Rating System updates, Nursing Home Staff Counts, and Frequently Asked Questions 04/24/20

RESOURCE: CMS Memo: Long-Term Care Facility Transfer Scenarios 04/13/20

RESOURCE: Nursing Home Infection Prevention Assessment Tool for COVID-19

RESOURCE: Long-Term Care Facility Guidance 04/02/20

RESOURCE: CDC Long-Term Care Respiratory Surveillance Line List

RESOURCE: Kirkland, Washington Update and Survey Prioritization Face Sheet

RESOURCE:  CDC Nursing Homes Preparedness Checklist

RESOURCE: CMS Memo: Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes 03/13/20 

RESOURCE: Long Term Care Resources from APIC

RESOURCE: Long-Term Care Nursing Homes Telehealth and Telemedicine Tool Kit

Key Strategies to Prepare for COVID-19 in Long-Term Care Facilities (LTCF)

>> Keep COVID-19 from entering your facility.

>> Identify infections early.

>> Prevent spread of COVID-19.

>> Assess supply of PPE and initiate measures to optimize current supply.

>> Identify and manage severe illness.

See the Reporting section of this webpage for reporting mandates specific to long-term care facilities.

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EMERGENCY MEDICAL SERVICES (EMS)

Facilities should have a plan in place with their local EMS for communication prior to the arrival of a suspected COVID-19 patient.

Facilities with their own EMS services should refer to the following websites for EMS-specific guidance:

Interim Recommendations for Emergency Medical Services (EMS) Systems and 911 Public Safety Answering Points/Emergency Communication Centers (PSAP/ECCs) in the United States During the Coronavirus Disease (COVID-19) Pandemic | CDC

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REPORTING REQUIREMENTS

CAPACITY & UTILIZATION

>>>UPDATE AS OF OCTOBER 6, 2020

On 9/2/20, The Federal Register published CMS’s interim final rule (IFC), “Medicare and Medicaid Programs, Clinical Laboratory Improvement Amendments (CLIA), and Patient Protection and Affordable Care Act; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency,” CMS-3401-IFC, which included new requirements for hospitals and CAHs to report data in accordance with a frequency and in a standardized format as specified by the Secretary during the PHE for COVID-19.

hospital COVID-19 capacity data at the facility level can be found here: Search | HealthData.gov

RESOURCE: CMS Memo re: Interim Final Rule (IFC), CMS-3401-IFC; Requirements and Enforcement Process for Reporting of COVID-19 Data Elements for Hospitals and Critical Access Hospitals

RESOURCE: COVID-19 Guidance for Hospital Reporting and FAQs for Hospitals, Hospital Laboratory, and Acute Care Facility Data Reporting 10/6/20

>>>UPDATE AS OF JULY 15, 2020

Hospitals should no longer report capacity and utilization data via the National Healthcare Safety Network (NHSN) website. Note that this directive does NOT apply to LTC reporting, which should still be done via NHSN.

RESOURCE: COVID-19 Guidance for Hospital Reporting and FAQs for Hospitals, Hospital Laboratory, and Acute Care Facility Data Reporting 07/10/20

>>>UPDATE AS OF MAY 11, 2020

On May 11, facilities were asked for information about the number of patients currently being treated for the coronavirus on an inpatient basis in order to inform current and future distributions of remdesivir to areas of greatest need. While the initial data are due by 8:00pm on May 12, facilities will be asked to provide this information on a weekly basis so the government can adjust to the changing national need for remdesivir. This information may be entered via the TeleTracking portal; however, NHA has verified that their daily survey is an approved method for submitting this information as well.

RESOURCE: AHA Special Bulletin: HHS Requests Weekly Data from Hospitals to Inform Remdesivir Distribution

>>>UPDATE AS OF APRIL 10, 2020

On March 29, 2020, Vice President Pence sent a letter to hospital administrators across the country requesting daily data reports on testing, capacity and utilization, and patient flows to facilitate the public health response to the 2019 Novel Coronavirus (COVID-19).

It was requested that capacity and utilization data be reported into the CDC National Safety Healthcare Network (NHSN) in order to assist the White House Coronavirus Task Force in tracking the movement of the virus, and to facilitate planning, monitoring, and resource allocation during the COVID-19 Public Health Emergency (NOTE: see update above!). Members may have also received information from TeleTracking Technologies, Inc., which has been commissioned by Health and Human Services (HHS) to create a COVID-19 Portal to capture this same information. These and other reporting options can be found under the FAQ section of the HHS letter sent out on April 10th.

RESOURCE: FEMA Coronavirus (COVID-19) Pandemic: HHS Letter to Hospital Administrators 04/10/20

However, hospitals may instead report capacity and utilization data to the State “if they have received a written release from the State and the State has received written certification from their FEMA Regional Administrator to take over Federal reporting requirements.” As of April 13th, the Nevada Hospital Association (NHA) has verified that they have been in touch with the White House COVID-19 Task Force and NHA’s daily survey is now an approved method for submitting information. This data is reported to the Governor’s Office and the results can be found here: https://nvhealthresponse.nv.gov/news-resources/daily-situation-reports/.

RESOURCE: Nevada Hospital Association COVID-19 State Reporting Certification from HHS 083120

Information on the reporting of COVID-19 tests conducted within the hospitals’ laboratories can be found here: https://www.cdc.gov/coronavirus/2019-ncov/lab/reporting-lab-data.html.

CASE REPORTING

Hospitals MUST report all COVID-19 confirmed and suspect cases still awaiting laboratory confirmation to the Division of Public and Behavioral Health (DPBH) per the communicable disease reporting regulations (NRS 441A.120 and NAC 441A.085).

RESOURCE: DPBH Technical Bulletin re: COVID-19 Laboratory Reporting Requirements 09/04/20

RESOURCE: DPBH Technical Bulletin re: Reporting of Extraordinary Occurrence of Illness 03/05/20

MIS-C (CHILDREN) REPORTING

Effective May 21, immediate reporting of suspected or confirmed Multisystem Inflammatory Syndrome in Children (MIS-C) is mandatory in Nevada.

RESOURCE: DPBH Technical Bulletin 06/11/20 re: MIS-C and Required Reporting for MIS-C

RESOURCE: How to Report a Case of MIS-C Associated with COVID-19 in Washoe County

PATIENTS WAITING FOR DISCHARGE REPORTING

Nevada DHHS is collecting information on patients awaiting hospital discharge in an effort to assist hospitals in transferring patients needing a lower level of care so they have the resources available for those patients needing a higher level of care. Hospitals are to report details on patients that are waiting for discharge via a spreadsheet that is uploaded weekly to a secure SFTP site requiring a login. Please contact NRHP for more information on how to access this information.

DEATH REPORTING

All health care facilities MUST report immediately to their local and state health department each death that is caused by, associated with or related to COVID-19 infection consistent with CDC criteria.

RESOURCE: DPBH Technical Bulletin re: Mandatory Reporting of All COVID-19 Mortality 04/08/20

CANCELLATION/POSTPONEMENT OF MEDICALLY NECESSARY PROCEDURES REPORTING

All NV hospitals must report to the Division of Public and Behavioral Health (DPBH) within 24 hours of any decision or intent to stop medically necessary procedures and provide the dates that the stoppage will remain in effect.

RESOURCE: DPBH Technical Bulletin 12/14/20 re: Requirement for Hospitals to Report Ban on Medically Necessary Procedures

TEST RESULT REPORTING

>>>UPDATE AS OF SEPTEMBER 4, 2020: Healthcare Providers Must Collect Demographic Information

Effective August 1, healthcare providers should work with the laboratories to provide the required data elements upon initial order of the test by completing all the demographic information on the laboratory requisition form or the equivalent electronic laboratory order. Once laboratories have completed the testing, the below required data elements must be submitted with the laboratory result:

  • Test ordered – use harmonized LOINC codes provided by CDC
  • Device Identifier (Point of Care Device Type)
  • Test result – use appropriate LOINC and SNOMED codes, as defined by the Laboratory In Vitro Diagnostics (LIVD) Test Code Mapping for SARS-CoV-2 Tests provided by CDC
  • Test result date
  • Accession number/Specimen ID
  • Patient age
  • Patient race
  • Patient ethnicity
  • Patient sex
  • Patient residence zip code
  • Patient residence county
  • Ordering provider name and NPI (as applicable)
  • Ordering provider zip code
  • Performing facility name and/or CLIA number, if known
  • Performing facility zip code
  • Specimen source — use appropriate LOINC, SNOMED-CT, or SPM4 codes, or equivalently detailed alternative codes
  • Date test ordered
  • Date specimen collected

Laboratories and healthcare providers must submit ALL COVID-19 results (positive, negative and indeterminant) within 24 hours of analysis through the electronic laboratory reporting (ELR) system.

RESOURCE: DPBH Technical Bulletin 090420 re: COVID-19 Laboratory Reporting Requirements

RESOURCE: CDC How to Report COVID-19 Laboratory Data

Effective June 24, all in-state and out-of-state laboratories that are processing and testing samples from Nevada residents are required under severe penalties to report all COVID-19 test results to the Division of Public and Behavioral Health within 24 hours by fully completing the Nevada Confidential Morbidity Report Form.

RESOURCE: DPBH Technical Bulletin re: COVID-19 Laboratory Testing 06/24/20

>>>UPDATE AS OF JULY 6, 2020: COVID-19 Test Reporting to US Health and Human Services

Results are reported through the state health department or local health authority’s existing process.

The Coronavirus Aid, Relief, and Economic Security (CARES) Act, requires “every laboratory that performs or analyzes a test that is intended to detect SARSCoV-2 or to diagnose a possible case of COVID-19” to report the results from each such test to the United States Secretary of the Department of Health and Human Services (HHS). In addition, the statute authorizes the Secretary to prescribe the form and manner, and timing and frequency, of such reporting.

The document below, titled, COVID-19 Pandemic Response, Laboratory Data Reporting in accordance with the CARES Act, Section 18115, provides information on the reporting requirements pursuant to the CARES act.

Test results are to be reported within 24 hours of analysis through established electronic lab reporting; or by faxing the lab report (positive or negative) to the local health authority, or for labs in rural areas fax reports to the Office of Public Health Investigations and Epidemiology at (775) 684-5999 . Last week, the Nevada Department of Health and Human Services informed all in-state and out-of-state laboratories that are processing and testing samples from Nevada residents that they are required under severe penalties to report all COVID-19 test results to the Division of Public and Behavioral Health.

RESOURCE: COVID-19 Pandemic Response, Laboratory Data Reporting in accordance with the CARES Act, Section 18115

RESOURCE: DPBH Technical Bulletin 06/25/20 re: Require Immediate Reporting of COVID-19 Test Results to DPBH

NURSING HOME NHSN REPORTING 

Under the new §483.80(g), CMS is requiring facilities to report COVID-19 cases in their facility to the CDC National Health Safety Network (NHSN) on a weekly basis. CDC and CMS will use information collected through the new NHSN Long-term Care COVID-19 Module to strengthen COVID-19 surveillance locally and nationally; monitor trends in infection rates; and help local, state, and federal health authorities get help to nursing homes faster. Nursing home reporting to the CDC is a critical component of the national COVID-19 surveillance system and to efforts to reopen America. The information will also be posted online for the public to be aware of how the COVID-19 pandemic is affecting nursing homes.

NHSN data on nursing homes is publicly reporting at: https://data.cms.gov/stories/s/bkwz-xpvg

Facilities are also required to notify residents, their representatives, and families of residents in facilities of the status of COVID-19 in the facility, which includes any new cases of COVID-19 as they are identified. This action supports CMS’ commitment to transparency so that individuals know important information about their environment, or the environment of a loved one.

RESOURCE: CMS Memo: Interim Final Rule Updating Requirements for Notification of Confirmed and Suspected COVID-19 Cases Among Residents and Staff in Nursing Homes 05/06/20

RESOURCE: Long Term Care Facilities (Skilled Nursing Facilities and/or Nursing Facilities): CMS Flexibilities to Fight COVID-19

RESOURCE: CMS Memo re: Upcoming Requirements for Notification of Confirmed COVID-19 (or COVID-19 Persons under Investigation) Among Residents and Staff in Nursing Homes 04/19/20

RESOURCE: Trump Administration Announces New Nursing Homes COVID-19 Transparency Effort – Press Release 04/19/20

NURSING HOME DAILY STATUS SURVEY 

Skilled Nursing Facilities must complete a COVID-19 Daily Symptomatic Surveillance/Status Survey via a link sent from the Office of Analytics when there is no current outbreak situation at the facility. If a facility is not receiving this email and think they should be, they should contact their local health authority.

NURSING HOME OUTBREAK REPORTING

Skilled Nursing Facilities must report all outbreaks (any new occurrence in resident or staff member) via submission of daily reports into the REDCap reporting system until they receive written notification from DPBH to discontinue reporting once there are no new cases. Outbreak reporting into REDCap is activated when a positive resident or staff member is indicated in the SNF Daily Status Survey. If a facility has not been receiving the daily survey, they should contact DPBH. Facilities must also complete a CDC PUI Form for each positive resident or staff member during an outbreak in addition to entering information into REDCap as this goes directly to the CDC.

NURSING HOME HEALTH ADVISORY NETWORK REPORTING

Effective 7/15/20, Nevada’s Chief Medical Officer, Dr. Ihsan Azzam, is requesting all skilled nursing facilities to participate in the Nevada Health Alert Network (NVHAN).

NVHAN is administered through a program called EMResource. In addition to delivering NVHAN messages, EMResource is a statewide bed tracking, availability and alerting system used in each hospital and will also begin including skilled nursing facilities throughout the state. NVHAN relays important health care information received from the Centers for Disease Control and Prevention (CDC) and state and local agencies via Technical Bulletins.

It is understood during this time of crisis that skilled nursing facilities are extremely busy taking care of residents; therefore, in addition to general demographics the only information being requested is:

  1. The skilled nursing facility census reported daily; and
  2. Whether the facility can safely accept new residents, including recovering COVID-19 residents that are within the scope of care provided by skilled nursing facilities.

RESOURCE: HAVBed Chief Medical Officer Directive 07/15/20

NURSING HOME DAILY CENSUS

Skilled Nursing Facilities should complete a daily census via REDCap per an email directive sent on 12/18/20.

INDIVIDUAL VACCINATION REPORTING

All individual vaccinations must be reported to WebIZ via an HL7 connection or manual entry within 24 hours.

AGGREGATE VACCINATION REPORTING

Additional vaccination information must be reported via REDCap on a weekly basis.

VACCINE INVENTORY REPORTING

Vaccine inventory information must be reported to Vaccine Finder.

VACCINE ADVERSE EVENT REPORTING

Any adverse events involving vaccine administration must be reported to the Vaccine Adverse Event Reporting System (VAERS).

COVID-19 POSITIVE TEST AFTER VACCINATION REPORTING

You should inform DPBH staff immediately if a resident or staff tests positive two weeks or more following their second dose of the COVID-19 vaccine. Contact your hospital acquired infection (HAI) lead or email dpbhepi@health.nv.gov within 24 hours of receiving the positive test. Your HAI Lead will work with you to send a test sample to the Nevada State Public Health Lab for further analysis and your disease investigator might request additional case investigation information.

RESOURCE: DPBH Technical Bulletin 02/03/21: Placement of patients/residents who have been vaccinated against COVID-19 or who have had COVID-19 and have recovered (patient/resident no longer requires transmission-based precautions)

MBQIP REPORTING CHANGES FOR CAHS

Medicare Beneficiary Quality Improvement Program (MBQIP) data submission will be optional over the coming months based on Critical Access Hospitals’ ability to report. This exception is based on HHS Secretary Azar’s authority to declare a public health emergency in the entire United States through the Public Health Service Act, and in alignment with the Trump Administration’s regulatory flexibilities enacted in response of these extreme and uncontrollable circumstances.

The current MBQIP policy change applies to data due for the upcoming reporting periods: Quarter 4, 2019 (Oct 1-Dec 31, 2019), Quarter 1, 2020 (Jan 1-Mar 31, 2020), Quarter 2, 2020 (Apr 1-Jun 30). Details on each MBQIP measure and impacted submission periods are available in an updated submission deadline schedule. FORHP will continue to monitor the developing COVID-19 situation and re-assess reporting requirements as needed.

Hospitals that are able to report MBQIP measures are encouraged to continue reporting, as measures will be used to inform FORHP about making improvements in care for rural populations. While hospitals direct their resources toward caring for ill patents and ensuring the health and safety of their staff, FORHP recognizes that any quality measure reporting during this national emergency may not be reflective of actual performance. Of note, the updates for MBQIP data submission align with the CMS reporting updates.

RESOURCE: MBQIP Updated Submission Deadline Schedule

OSHA REPORTING GUIDANCE

Per DHHS, all employers in Nevada are required to report to the state Occupational Safety and Health Administration (OSHA) when an employee is killed on the job, or suffers a work-related hospitalization, amputation or loss of an eye.  Requirements for reporting work-related deaths extend to deaths caused by illnesses – including COVID-19 – associated with the worker’s job, even if the worker does not die at the workplace.

Employers are required to report work-related fatalities to OSHA within eight hours of the employer learning of the death. Hospitalizations, amputations and loss of eye incidents must be reported to OSHA within 24 hours of the incident. Reports can be made by calling the nearest OSHA district office at 702-486-9020 (Southern Nevada) or 775-688-3700 (Northern Nevada), by the national incident reporting hotline at 1-800-321-6742, or online via the serious event reporting form linked here. Employers should be prepared to provide:

  • business name;
  • names of employees affected;
  • location and time of the incident;
  • date that the Nevada Department of Health and Human Services was notified of the death (if applicable);
  • a brief description of the incident; and
  • contact person and phone number for the employer.

NRS 618.378 and 29 CFR 1904 require all employers to report workplace fatalities and serious injuries or illnesses, regardless of whether the employer is exempt from other OSHA recordkeeping requirements due to their industry or company size.  Additional guidance can be found online here.

RESOURCE: OSHA Enforcement Guidance for Recording Cases of Coronavirus Disease 2019 (COVID-19) 04/10/20

RESOURCE: Alliant Factsheet on OSHA’s Recordkeeping and Reporting Requirements–COVID-19 

PROVIDER RELIEF FUND 

Provider Relief Fund (PRF) recipients that received one or more payments exceeding $10,000 in the aggregate from the PRF will be required to report to HHS demonstrating their compliance with the terms and conditions which they agreed to. The reporting system will become available for reporting on January 15, 2021.

RESOURCE: Post Payment Notice of Reporting Requirements 091920

RESOURCE: General and Targeted Distribution Post-Payment Notice of Reporting Requirements 07/20/20

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EMTALA

One March 9, 2020, CMS issued a memorandum which addresses implications of COVID-19 in compliance with EMTALA. More information can be found in the attached memo.

CMS 1135 Waiver re: EMTALA

CMS is waiving the enforcement of section 1867(a) of the Social Security Act (the Emergency Medical Treatment and Active Labor Act, or EMTALA). This will allow hospitals, psychiatric hospitals, and CAHs to screen patients at a location offsite from the hospital’s campus to prevent the spread of COVID-19, in accordance with the state emergency preparedness or pandemic plan.  (Source: CMS COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, page 40)

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HIPAA/PRIVACY

PROTECTED HEALTH INFORMATION

It is especially important during extraordinary circumstances such as the current COVID-19 pandemic that healthcare providers understand the rules that apply to the privacy and confidentiality of patients’ health information. LiCON’s Risk Manager, Linda Garrett, has put together a memorandum addressing HIPAA regulations which apply to protected health information.

RESOURCE: Memo re: Coronavirus Risk Management Concerns/HIPAA

RESOURCE: Confidentiality Rules:  Uses and Disclosures of PHI Related to Coronavirus (COVID-19) Exposures and Infections For Nevada Heath Care Entities and Providers

There is a limited waiver of HIPAA sanctions and penalties during the current public health emergency which applies to hospitals only (not clinics). The hospital must have enacted their emergency plan in order for the waiver to apply, and there is a 72-hour time limit. The waiver affects the following provisions:

  • Patient authorization to speak with family members or friends involved in their care;
  • Honoring a request to opt out of the facility directory;
  • Distribution of the Notice of Privacy Practices;
  • Patient’s right to request privacy restrictions; and
  • Patient’s right to request confidential communications

*Note: Failure to follow STATE LAWS could still result in a breach!

RESOURCE: HHS COVID-19 & HIPAA Bulletin – Limited Waiver of HIPAA Sanctions and Penalties During a Nationwide Public Health Emergency

The HIPAA Privacy Rule permits a Covered Entity to disclose the protected health information (PHI) of an individual who has been infected with, or exposed to, COVID-19, with law enforcement, paramedics, other first responders, and public health authorities without the individual’s HIPAA authorization, in certain circumstances, as outlined in the resource below.

RESOURCE: OCR COVID-19 and HIPAA: Disclosures to law enforcement, paramedics, other first responders and public health authorities

USE OF NON-HIPAA COMPLIANT APPLICATIONS

HIPAA rules have been relaxed to allow for increased use of telehealth, meaning providers may, in good faith, use non-HIPAA platforms.

“Under this Notice, covered health care providers may use popular applications that allow for video chats, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, or Skype, to provide telehealth without risk that OCR might seek to impose a penalty for noncompliance with the HIPAA Rules related to the good faith provision of telehealth during the COVID-19 nationwide public health emergency.  Providers are encouraged to notify patients that these third-party applications potentially introduce privacy risks, and providers should enable all available encryption and privacy modes when using such applications. “

RESOURCE: Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency

RESOURCE: OCR FAQs on Telehealth and HIPAA during the COVID-19 nationwide public health emergency

SECURITY AND REMOTE WORK

If any employees are working from home, it will be very important to ensure the security of the home setup in order to protect the hospital’s system and patients’ PHI. NRHP’s CIO has provided some guiding principles for working remotely, which can be found below.

RESOURCE: NRHP Guiding Principles for Working Remotely

RESOURCE: Free Webinar from ArchProCoding: Facilitating HIPAA Compliance During the COVID 19 Pandemic

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REGULATORY ENVIRONMENT

State of Nevada

All Directives and Declarations from Governor Sisolak and State of Nevada Executive Department can be found here:

Paycheck Protection Program Flexibility Act – 6/5/20 (H.R.7010)

The Paycheck Protection Program Flexibility Act of 2020 (H.R. 7010) amended the Paycheck Protection Program. Loan forgiveness was expanded from eight weeks of eligible costs to the 24 weeks or December 31, 2020, whichever is earlier; alternatively, a business whose PPP loan was made before June 5 may opt to use the eight-week period instead. PPP loans made on or after June 5 must have a minimum term of five years, rather than two years. At least 60% of the loan forgiveness amount must be for payroll costs, rather than 75%. The safe harbor provision that loan forgiveness will not decrease if the business rehires employees and restores wage reductions by June 30 is extended to December 31. Loan forgiveness will not decrease if the business was unable to rehire its employees on February 15 and is unable to hire similarly qualified employees by December 31. Loan forgiveness will not decrease if the business is unable to return to its previous level of business activity due to compliance with requirements or guidance from the Department of Health and Human Services, the Centers for Disease Control, or the Occupational Safety and Health Administration between March 1 and December 31, involving COVID-19-related standards for worker safety or customer safety. The deferral of principal and interest payments was extended to the date that loan forgiveness is remitted to the lender or, if the borrower does not apply for loan forgiveness, ten months after the end of the covered period. Employer payroll tax deferral is allowed even after loan forgiveness is approved. PPP loan proceeds are required to be spent only on allowable costs during the eight- or 24-week covered period.

PHASE 3.5: Paycheck Protection Program and Health Care Enhancement Act – 4/24/20 (H.R.266)

Paycheck Protection Program and Health Care Enhancement Act (H.R. 266) is a $484 billion law that increases funding to the Paycheck Protection Program and also provide more funding for hospitals and testing for COVID-19.

This Act is referred to as “Phase 3.5” as it includes “interim” funding that replenishes one of the programs established by the CARES Act (Phase 3). The CARES Act created the $349-billion Paycheck Protection Program, which provided low-interest loans to small businesses that were forgivable if they maintained their employees and payroll. The $349 billion was fully allocated within 13 days. During those 13 days, 1.6 million loans were approved by nearly 5,000 banks and other lenders.

Provisions of the Paycheck Protection Program and Health Care Enhancement Act include the following.

  • Appropriates an additional $320 billion of funding for the Paycheck Protection Program, which provides low-interest loans for payroll costs and other expenses to small businesses that are forgivable under certain circumstances. Of that amount, $60 billion is for PPP loans made by small banks, small credit unions, and community financial institutions
  • Appropriates an additional $10 billion for emergency Economic Injury Disaster Loans
  • Expands eligibility for emergency Economic Injury Disaster Loans to farms and agricultural-related businesses.
  • Appropriates $50 billion for Small Business Administration disaster loans.
  • Appropriates an additional $75 billion to the Public Health and Social Services Emergency Fund for health care providers’ expenses or lost revenues related to coronavirus.
  • Appropriates $25 billion to the Public Health and Social Services Emergency Fund for researching, developing, validating, manufacturing, purchasing, administering, and expanding capacity for COVID-19 testing.
  • Appropriates $2.1 billion for salaries for the Small Business Administration.

PHASE 3: The Coronavirus Aid, Relief, and Economic Security Act (CARES Act) – 3/27/20 (H.R.748)

The Coronavirus Aid, Relief, and Economic Security Act (the CARES Act) was signed into law on March 27, 2020 and provides resources and flexibility for rural hospitals, such as:

New Access to Capital

  • New funding for health care providers, including $150M that will go directly to CAHs via the Small Hospital Improvement Program (SHIP)
  • Small business loans via the “Paycheck Protection Program”

Medicare/Medicaid Payment Improvements and Flexibilities

  • Temporary elimination of Medicare sequestration
  • Expanded option for accelerated payments
  • Medicaid DSH cut reduction and delay

Telehealth Access and Flexibilities

  • Additional funding for telehealth
  • Improved Medicare beneficiary access to telehealth
  • RHCs as distant sites

RESOURCE: AHA CARES Act: Provisions to Help Rural Hospitals

RESOURCE: H.R. 748 The Coronavirus Aid, Relief, and Economic Security Act 

RESOURCE: The Small Business Owner’s Guide to the CARES Act

PHASE 2: The Families First Coronavirus Response Act (FFCRA) – 3/18/20 (H.R.6201)

The Families First Coronavirus Response Act (FFCRA) was signed into law on March 18, 2020 and per a statement, the White House, “provides paid leave, establishes free coronavirus testing, supports strong unemployment benefits, expands food assistance for vulnerable children and families, protects front-line health workers, and provides additional funding to states for the ongoing economic consequences of the pandemic, among other provisions.” Among other things, this new law includes:

  • The Emergency Family and Medical Leave Expansion Act (EFMLA), which amends the Family and Medical Leave Act of 1993 (FMLA) to provide up to 10 weeks of protected paid leave to eligible employees for a coronavirus related reason
  • The Emergency Paid Sick Leave Act (EPSLA) provides full time employees up to a two-week period of paid sick leave for coronavirus related reasons

*Note: Health care providers may be exempted from Paid Sick Leave or Expanded Family and Medical Leave by their employer under the FFCRA. Per the Department of Labor, a health care provider is defined anyone employed at any doctor’s office, hospital, health care center, clinic, post-secondary educational institution offering health care instruction, medical school, local health department or agency, nursing facility, retirement facility, nursing home, home health care provider, any facility that performs laboratory or medical testing, pharmacy, or any similar institution, Employer, or entity. This includes any permanent or temporary institution, facility, location, or site where medical services are provided that are similar to such institutions. 

RESOURCE: Department of Labor: COVID-19 and the American Workplace

RESOURCE: H.R.6201 – Families First Coronavirus Response Act

PHASE 1: Coronavirus Preparedness and Response Supplemental Appropriations Act – 3/6/20 (H.R.6074)

The Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 (H.R. 6074) is an act of Congress enacted on March 6, 2020. The legislation provided emergency supplemental appropriations of $8.3 billion in fiscal year 2020 to combat the spread of coronavirus disease 2019 (COVID-19) and counter the COVID-19 pandemic.

Broken down by category, the bill provides funding for the following purposes:

  • More than $3 billion for “research and development of vaccines, as well as therapeutics and diagnostics”
  • $2.2 billion “in public health funding to aid in prevention, preparedness and response efforts — including $950 million to support state and local agencies”
  • Almost $1 billion for “medical supplies, health-care preparedness, Community Health Centers and medical surge capacity”
  • $1.25 billion to fight COVID-19 internationally.[9]

Emergency Declaration 1135 Waivers

On March 13, 2020, the President declared the ongoing Coronavirus Disease 2019 (COVID-19) pandemic of sufficient severity and magnitude to warrant an emergency declaration for all states, tribes, territories, and the District of Columbia pursuant to section 501 (b) of the Robert T. Stafford Disaster Relief and Emergency Assistance Act, 42 U.S.C. 5121-5207 (the “Stafford Act”).

The Trump Administration has issued an array of temporary regulatory waivers and new rules, which apply for the duration of the emergency declaration, to equip the healthcare system with the flexibility it needs to respond to the COVID-19 pandemic.

The goals of these temporary waivers are as follows:

  1. To ensure that local hospitals and health systems have the capacity to handle a potential surge of COVID-19 patients through temporary expansion sites (aka CMS Hospital Without Walls);
  2. To remove barriers for physicians, nurses, and other clinicians to be readily hired from the community or from other states so the healthcare system can rapidly expand its workforce;
  3. To increase access to telehealth in Medicare to ensure patients have access to physicians and other clinicians while keeping patients safe at home;
  4. To expand in-place testing to allow for more testing at home or in community based settings; and
  5. To put Patients Over Paperwork to give temporary relief from many paperwork, reporting and audit requirements so providers, health care facilities, and States can focus on providing needed care to beneficiaries affected by COVID-19.

RESOURCE: Summary of COVID-19 Emergency Declaration Waivers & Flexibilities for Health Care Providers

RESOURCE: Hospitals: CMS Flexibilities to Fight COVID-19

RESOURCE: Long Term Care Facilities (Skilled Nursing Facilities and/or Nursing Facilities): CMS Flexibilities to Fight COVID-19 

RESOURCE: Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs): CMS Flexibilities to Fight COVID-19 

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