COVID-19 Frequently Asked Questions

7/10/2020

Please define “quarantine” and “isolation” status.  Are the two terms interchangeable?

The two terms indicate two different types of segregation of residents. The recent IDPH DIA guidance states, “Isolation refers to keeping persons who are sick away from others until they recover. Quarantine refers to keeping persons who had an exposure but are not yet sick away from others so that if they were to become sick, they could not infect anyone else. Both isolated and quarantined residents should be placed in a private room and cohorted with dedicated staff.”  See the FAQ’s found in the June 30 IDPH guidance.

 

When does IDPH recommend that N95 (or equivalent) respirators should be worn?

IDPH recommends that N-95 respirators are needed only for aerosol generating procedures in isolation or quarantine units.

 

Please define “conventional” use of PPE, including gowns, masks, gloves, and eye protection. 

Conventional, contingency and crisis capacity use of PPE is described in CDC in Strategies to Optimize the Supply of PPE and Equipment.  Conventional use of PPE does not allow for extended use of PPE between resident contacts.  IDPH has indicated that this would include mask, glove, and gown changes between each resident contact.  If face shields or googles use for eye protection, have a manufacturer’s recommendation for sanitizing, IDPH is allowing these to be used for multiple patient contacts with appropriate sanitizing between each contact.

 

When is the “conventional” use of PPE required?

IDPH has indicated in webinars presented for LTC providers on June 30 and again on July 5 that “conventional” use of PPE is expected in quarantine and isolation units.  “Contingency” use of PPE is reserved for use outside of quarantine and isolation units and does allow the extended use of PPE through-out a shift.  IPDH states that employees should be issued a new medical grade or disposable mask or a freshly laundered cloth mask each day or when they become contaminate or soiled during the work shift.

 

How do you determine if PPE is designated as medical grade?

You should ask suppliers when ordering if the equipment is approved as medical grade by the FDA.  More information about the determination of medical grade PPE can be found on the FDA’s website.  IDPH recognizes that finding medical grade PPE may be difficult, but it is the recommended type of PPE when available.

 

Please provide guidance on the use of KN95 vs. N95 masks?

IDPH is allowing the use of KN-95 masks if no N-95 approved masks are available.  Please see the CDC guidance Strategies for Optimizing the Supply of N95 Respirators.

 

Are residents who are in “quarantine” or “isolation” status allowed to participate in outdoors visits?

No.  The IDPH DIA Reopening Guidance issued on June 30 states, “Outdoor visits, open-window visits, and dedicated chat box visits are allowed only at facilities that are not in an outbreak status, and only for residents that are asymptomatic and not confirmed COVID-19 positive.”  Residents in “quarantine” or “isolation” status would not fit that criteria.

 

7/20/2020

Do “open window” visits require the same screening as do “outdoor” visits that allowed in Phase 1 reopening?

Yes.  Open window visits would require the same screening, mask use and appropriate social distancing that applies to outdoor visits.

 

Would a LTC resident be allowed to attend the funeral of a family member or leave the facility for other special family functions?

Each of these occasions should be assessed on their own merits.  Generally, visits such as these should be discouraged.  However, attending a funeral for a spouse or a child, for instance, would certainly create more reason for a resident to leave a facility currently under visitation restrictions than would attending some other type of celebration or family function.  Preparation for such an absence should include extensive resident and family counseling about the risks of this outing and exploration of other options that might negate the need for an absence.  If the resident chooses to leave for an event, every attempt should be made with the family to minimize the risk of exposure for the resident during their absence from the facility.  The resident and family should also be advised during preparation for the leave that a 14-day quarantine will be required after the resident absence from the facility.  Facilities should carefully document all counseling, resident and family responses, and risk management measures taken.

 

8/4/2020

The ICAL Reopening Plan Phase 2 guidance states that non medically necessary trips should be avoided and that residents should be quarantined for 14 days upon return? 

IDPH and DIA has not provided official guidance on the reopening of AL programs.  The ICAL Reopening Template that members may choose to use states the following regarding non-medically necessary trips outside the program:

• Non-medically necessary trips outside the building should be limited and discouraged but allowed. It is recommended tenants with high-risk co-morbidities continue to avoid non-medically necessary trips outside the building. It is encouraged that these decisions be made collaboratively by the tenant, and their representative in consultation with the tenant’s physician.
• Any tenant living in the program should wear a cloth face mask while out of the building as should anyone accompanying them. To prevent potential harm to others in the program, tenant must also agree to current tenant screening policies practiced by the AL and restrictions to their unit if there are any signs or symptoms of COVID identified.
• Tenants leaving the building for any reason should be observed for 14 days upon return. Depending upon the level of potential exposure encountered during on outing, a tenant may need to refrain from communal dining and group activities for a period of time as determined by the program.

8/11/2020

We have an employee (aide) on vacation in another state.  Does she need a 14-day quarantine upon her return as she is an essential healthcare worker? 

According to the 2019 Novel Coronavirus Resources for Local Public Health Partners , page 3, found on the IDPH website “there is no longer a recommendation to self-isolate for 14 days after returning home from travel outside of Iowa and within the United States (as long as the traveler remains well and has not been identified as a close contact of an ill individual).”   (Guidance updated 8-6-2020)

 

Has a date been set for when the 3-night acute qualifying stay for skilled coverage will end?

The federal waiver that applies to the Medicare Part A requirement has been extended until at least January 2, 2020.

 

How do I report COVID positive admissions from the hospital to the NHSN?

Under current IDPH guidance this resident would require 14 days of quarantine, regardless of testing status.  The Table of Instructions for completing the NHSN Resident Impact and Facility Capacity Form states you should report resident in the data field labeled “Admissions: Residents admitted or readmitted from another facility who were previously diagnosed with COVID-19 and continue to require transmission-base precautions.   

 

We have a home care patient who has a live-in family member who is COVID positive.   Staff wear full PPE during the visit and require the family member to be in another room when home care is provided.  Is there anything else we should be doing in that home or other patient homes after that visit?

The precautions you are taking are appropriate.  We add that best practice would be to make this the final visit of the day for any workers going into the home, thus decrease the risk of spreading the virus to other home care clients.

 

8/27/2020 

When will the re-certification surveys for AL’s resume?

The Department of Inspections and Appeals have not said yet when re-certification surveys will resume.

 

When emergency personnel enter facilities to transport patients to other levels of care, is there a requirement to screen these individuals?

Yes, you should be following your building protocols for screening of all entering your facility.  However, if it is an emergent situation such a code or other like situations, you should consider the consequences of delaying treatment of the patient.  Always ensure that anyone entering has on proper PPE.

 

After exposure to COVID do you have to isolate as an essential Employee?

An exposure is defined as close contact (within 6 feet) of a confirmed infected person for at least 15 minutes when not wearing PPE.  In most cases, contact with a confirmed COVID positive person in the health care workplace is not considered an exposure warranting 14 self-quarantine.  Exposure, wherever it occurs, does require a quarantine.

 

Are nursing students allowed to enter LTC facilities for clinical experience?

DIA has advised IHCA during a recent phone conference that nursing students are considered essential workers and thus allowed them as well as CNA students to re-enter nursing facilities for clinical experience at the discretion of the facility.  According to QSO 20-38-NH, any students entering your facility will be subject to staff testing as required by the recent Interim Final Rule.

 

9/11/2020

Are facilities required to keep documentation of the tests of staff “under arrangement” such as hospice, therapy, etc.?

Yes, the facility under QSO 20-38-NH,  and the interim final rule facilities are required to keep documentation of all staff which must be tested including those outside vendors such as hospice etc. and ensure it meets the facility’s required testing time frame requirements.

 

9/18/2020

Who will be receiving Abbott testing supplies from CMS?

CMS has communicated Abbott testing supplies will be delivered nursing facilities and assisted living facilities in COVID-19 hotspot areas.  The CMS distribution list for this distribution is now on IHCA’s COVID-19 webpage.

 

If a staff member is off 14 days due to a COVID exposure, should they still be tested with the facility routine testing or wait until returning to work to test?

Any staff member who is currently quarantined at home related to a COVID should not be reporting to the facility for testing during that 14-day period.  If the employee develops symptoms, they should seek medical evaluation.  If remaining asymptomatic during the quarantine period, the employee should report to duty and resume the facility’s current testing frequency at the end of the 14 days.

 

How would a facility obtain a “critical staffing shortage” designation from the Iowa Department of Public Health to allow a facility to deploy the CDC guidance “Strategies to Mitigate Healthcare Personnel Staffing Shortages” in contingency or crisis situations?

If a facility finds themselves in outbreak status and unable to fill crucial employee positions due to the outbreak, they should contact IDPH to ask for assistance with this designation.  In most nursing facility outbreaks where significant numbers of staff are unable to report, IDPH is already working collaboratively with the facility.

 

When can we move an asymptomatic resident who tests positive for COVID while in a 14-day quarantine back into general population? 

If a resident is in quarantine due to a recent admission, they must complete 14 days regardless of testing status.  If a resident, regardless of admission status, tests positive during a 14 day quarantine period, they should be moved to isolation and remain for at least 10 days after the positive test, and have been fever free without medications for at least 24 hours and symptoms, and have improved or resolved symptoms as recommended in CDC guidance regarding the discontinuation of transmission based precautions.

 

When conducting antigen testing for outside contractors, agency staff, and vendors are we required to report those results to IDPH?

All antigen testing conducted under a CLIA waiver must be reported to IDPH.  Providers who are testing these individuals should make attempts to collect the necessary demographic data to submit testing results through the IDPH reporting REDCap portal just as they would employees.  IDPH needs this information for contact tracing.

 

When are N95 masks required for administering nebulizer treatments in nursing facilities?

QSO 20-38-NH contains the revised Infection Control Survey Protocol that asks this question, “When COVID is present in the facility, are staff wearing an N95 or equivalent or higher-level respirator, instead of a facemask, for aerosol generating procedures?”   If a facility has any identified cases of COVID, all treatments of this nature would require a mask even when the resident is not quarantined or isolated until outbreak status is cleared for at least 14 days.

 

9/25/2020

What is the source document that provides guidance for the CMS designated testing categories and where can we find it?

The source document for the CMS designated testing frequencies categories, i.e. red, yellow and green, are found on the CMS COVID-19 Nursing Home Data page.  This page has links to the weekly updates of the county positivity rates and all archived versions of earlier releases of positivity data.

 

Which antigen tests meet the CMS requirements for routine staff testing in nursing facilities?

There are four antigen tests currently approved by FDA and CMS for use in nursing facilities:  

• Abbott BinaxNOW COVID-19 Ag Card
• LumiraDX SARS-CoV-2 Ag Test
• BD Veritor System for Rapid Detection of SARS-CoV-2
• Sofia SARS Antigen FIA

 

Does the 48-hour turnaround time apply only to the procurement of routine testing supplies or does it also apply to the turnaround time for “outbreak” testing?

The 48-hour turnaround time listed in QSO 20-38-NH certainly applies to the routine testing requirement for staff.  The inability to acquire tests with this turnaround time after considerable effort is made to find test sources, is considered by CMS to be meeting the intent of the regulation.  However, if a facility finds themselves in outbreak status and unable to test, the provider should make every effort possible to get assistance from the SHL for outbreak testing assistance.

 

Does a positive antigen test require a confirmatory PCR test?

Not in all cases.  Providers should refer to the CDC Guidance Considerations for Use of SARS-CoV-2 Testing in Nursing Homes.

 

Do we need to buy the separate printer for our BD machine to print results?

We have been advised that printers for BD Veritors are not included in the HHS distributions.  It is up to the facility on how to record testing data.  The State Hygienic Lab has provided many resources for providers to utilize to meet CLIA Waiver requirements for each of 3 testing systems that can be found here.

 

How often and for how long with providers be receiving HHS shipments of Abbott testing kits?

CMS and AHCA sources indicate that providers will be receiving weekly shipments of these test kits through the end of 2020.

 

How many confirmed cases of COVID in a nursing facility triggers an Infection Control Survey?

Three new cases of residents with COVID, or 1 new resident case in a building that was previously without any COVID cases.

 

For the purposes of the nursing facility COVID Value Based Purchasing program, how will the facility’s infection rate be calculated?

At this point, IHCA believes the rate will be calculated based upon the facility’s specific number of in- house acquired COVID cases (does not include admissions diagnosed with COVID) as compared to total resident census.  It is thought that the payment will be based upon a weighted average of the facility’s infection (80%) and mortality (20%) rates.  As more specific information is released, it will be shared.

 

QSO 20-39-NH outlines several classes of individuals, such as hospice workers, that must be allowed entrance to nursing facilities.  What should nursing facilities do prior to admitting these workers to the building?

These essential workers should be screened and then tested prior to entry to your facility.  The testing may be done outside of your facility but must match closely to your testing time frames and the worker should provide proof of test results.

 

If we have no way to have a dedicated area for indoor visits, what do we do?

Consider how you can create a visitation booth in one of your larger congregate areas by using plexiglass barriers, etc.  It should be located as close to the entrance as possible to prevent visitor traffic.  Visits would need to be scheduled around any resident activities such as dining that would cause larger number of residents to be using this common space.  You may want to consider using empty resident rooms or rearranging office space to create a visitation area.

 

What is the home health agency’s responsibility for reporting positive COVID-19 cases?

All staff or client COVID-19 positive cases, regardless of where testing occurs should be reported to DIA.  All admissions to the agency who have been diagnosed with COVID should also be reported.   If the home health agency conducts Abbott rapid antigen testing, all tests results both positive and negative must be reported through the IDPH REDCap portal as required by CLIA waiver certification.

 

Will routine testing of home health employees be required?

While HHS has indicated that shipments of Abbott testing cards will soon be coming to HHA’s, there have been no testing requirements issued for test use.  NAHC, however believes that HHS intends agencies to use these tests for staff testing at this time.

 

10/8/2020

What does the State Hygienic Lab consider to be a nursing facility outbreak for the purposes of providing outbreak testing assistance?

The IDPH guidance dated September 30, 2020 defines an outbreak as “3 or more resident cases within the same 14 days period.  Providers may request assistance from the SHL with testing when that definition is met.  

 

When a facility is in outbreak status, how should testing every 3-7 days be determined?

Determining the frequency of testing during the 3-7 day period should be based upon a number of factors.  Providers should not just assume that conducing testing every 7 days, while meeting the regulation, is sufficient to protect residents and workers in cases where COVID is present.  The testing frequency should be based upon the number of positive cases found when conducting first testing after a positive case is identified and whether it includes residents.  Providers must also consider the current county positivity rate and the requirements for testing of employees.  When higher counts of positive cases exist in a facility, providers should be in contact with local public health officials and IDPH for recommendations on testing frequency.

 

What are the CLIA reporting requirements for Abbott BInaxNow tests?  Can a facility bill for these tests?

All CLIA waived COVID tests, that includes BD Veritor, Quidel SOFIA or Abbott tests, must be reported to IDPH via the REDCap portal system within 24 hours of test completion.  A facility may bill third party payers for these tests only if the facility has purchased the test materials.  If using government supplied testing supplies, you may not bill for those tests.

 

May nursing facility residents refuse the restrictions for visitation, dining, activities, etc., and opt to assume increased risk?   

Residents can refuse to follow certain requests by the facility however in general the facility will not be able to rely on resident refusal for failure to comply with regulations or guidance from a state or federal regulator. The answer to this type of question is highly context dependent. For example, residents may refuse to be tested for COVID. This is largely out of the staff’s control so long as they can document they have attempted to explain the importance, documented the conversation, and risks thoroughly etc. However, the fact of a resident’s displeasure with a regulation or requirement, for example, restrictions on the number of people in the dining room does not negate the facilities obligation to follow the regulation or guidance. The facility is ultimately responsible for ensuring compliance with the regulation and will be subject to the risk of any noncompliance.

 

What should assisted living providers be doing in response to the new IDPH and DIA visitation guidance that was issued September 30 for nursing facilities?

ICAL is currently developing a new visitation template for assisted living providers.  It will be available on the IHCA members only website soon.

 

How do county positivity rates impact visitation restrictions?

Facilities located in counties with low (≤ 5%) and medium (≤ 10%) COVID positivity rates may conduct outdoor, indoor and compassionate care visits.  Facilities with high (≥10%) positivity rates may conduct outdoor and compassionate care visits only.  Indoor visits would be prohibited.  Window visits are allowed regardless of positivity rates.   

 

What nursing facility visits are allowed when they are in “outbreak status”?  What definition triggers visitation restrictions?

According to CMS QSO 20-38-NH “ An outbreak is defined as a new COVID-19 infection in any healthcare personnel (HCP) or any nursing home-onset COVID-19 infection in a resident.”  A facility in outbreak status cannot outdoor or indoor visits until 14 days have passed since the last positive test.  Compassionate care visits, however, are allowed when a facility is in outbreak status if needed.

 

Can compassionate care visits take place when residents are in quarantine or isolation units?

Yes if the proper PPE is used for all visitors as would be required for all health care workers entering those areas.

 

Is touching allowed during compassionate care visits?

CMS QSO 20-39-NH describes several circumstances in which compassionate care visits should be allowed beyond the former understanding of “end of life”.   Those examples would describe situations in which touching may be needed or warranted.  Visitors should be garbed in appropriate PPE for the circumstances of the visit and instructed how to and/or assisted to don and doff PPE as needed.   

 

How does nursing facility management decide which residents qualify for compassionate care visits?

Again, CMS QSO 20-39-NH provides guidance to providers to make these decisions on a case by case, individualized basis.  There should be assessment in the resident’s medical record of the need for a compassionate care visit as well as evidence that the interdisciplinary care plan team deems it appropriate just as you would for other care plan interventions.  It may be appropriate for facilities to have a protocol for family members to request compassionate care visits when indoor or outdoor visitation is restricted due to COVID activity.

 

Can you expand on the need for nursing facility visitor screening and testing, and how we accommodate the scheduling, timing, and supervision of visits?

Screening of all visitors, whether indoor or outdoor visits, should occur according to your facility screening protocols.  CMS QSO 20-39-NH states that visitor testing is encouraged in medium or high-positivity counties if feasible, it is not required.  Facilities may also encourage visitors to be tested on their own prior to admission to the facility.  Facilities should have detailed visitation policies that include when and how visits may occur, how to schedule visits,  required screening, how to enter and exit the facility, required PPE, physical restrictions required during the visit, the number of visitors allowed per visit and visit frequency.  The policy should be drafted by your ability to provide staff and resources for screening and supervision and should also provide for accommodation of some visits during evening or weekend hours to allow working family members to visit.

 

Who is responsible for paying for testing of contracted workers and vendors who must enter nursing facilities?

It is the responsibility of the nursing facility to assure that contracted workers and vendors who require testing as described in QSO 20-38-NH are in fact tested.  Questions of payment for testing of subcontractor such as hospices and staffing agencies, etc, are left to providers to consider according to their individual contractual arrangements.

 

How does DIA determine when they will conduct an infection control survey?

CMS requires an on-site infection control survey within 3-5 days of a facility outbreak that is defined as 1 new positive case if no COVID has been previously identified or 3 or more new cases of COVID occur in a facility.

 

When there is conflicting guidance provided by federal requirements and state rules, which standard do we follow?

Unfortunately, there is not an easy answer to this question because it depends on the topic.  The state and the federal governments have different authority over different things. In general, the most restrictive regulation applies.  For instance, current DIA rules allow an LPN to serve in the capacity of DON.  However, federal rules require an RN in this position.  If you see a perceived conflict between guidance provided by state and federal regulators, please contact IHCA and we will be happy to provide guidance based on the specific scenario.

 

If an asymptomatic employee had a positive antigen test that was not cleared with 2 subsequent PCR tests as being a false positive, should that employee be tested at the normal staff schedule in the future?

IDPH guidance has been that individuals who test positive do not need to re-test for 90 days.  If this individual was asymptomatic and you decide to retest, you should do 2 subsequent PCR confirmatory tests within 48 hours of the original test.

 

Is visitation still linked to the availability and conventional use of PPE?

The new IDPH/DIA Visitation and Testing guidance replaces the former phased guidance which listed restrictions regarding the conventional use of PPE for advancing visitation phases.  QSO 20-39-NH does state that “Regardless of how visits are conducted, there are certain core principles and best practices that reduce the risk of COVID-19 transmission”.  Providers are encouraged to read the “Core Principles of COVID-19 Infection Prevention” listed in that QSO when planning for visitation protocols.   

 

Does the new CMS guidance allow changes to the communal dining restrictions?

New guidance found in QSO 20-39-NH states, “Residents may eat in the same room with social distancing (e.g., limited number of people at each table and with at least six feet between each person). Facilities should consider additional limitations based on status of COVID-19 infections in the facility.”

 

Do visitors have to be screened in and out of the facility, or just upon entry?

Guidance in QSO 20-39-NH lists this as one of the Core Principles of COVID-19 Infection prevention, “Screening of all who enter the facility for signs and symptoms of COVID-19 (e.g., temperature checks, questions or observations about signs or symptoms), and denial of entry of those with signs or symptoms.”

 

If a facility suspects they have a potential false positive antigen test, do they have to notify residents and families while waiting for confirmatory PCR test results?

Yes.  You should report the positive antigen test results to the REDCap portal.  You should then notify residents and families that you have a potential positive case.  You should consider the individual tested as presumptive positive and take appropriate quarantine actions.  Once the facility receives two confirmatory PCR negative results, notifications may go out to confirm it was a false positive and quarantine measures may be discontinued.

 

What should facilities do to ensure temporary nurse aides (AHCA 8-hour course) may continue to work after the public health emergency waivers are lifted?

We know that the federal public health emergency waiver now extends to January 2, 2020.  IHCA urges members to get employees who completed the AHCA Temporary Nurse Aide program into CNA training programs now if possible.  Options for CNA training may be found in IHCA’s Workforce Toolkit.  One option members may pursue is using the IHCA on-line CNA training course.  Information about your facility becoming a CNA training site can be found here.     

 

Can you please provide more information on the provider relief available for home health agencies?

Home Health providers have been included in Phase 1 and Phase 2 general distributions for provider relief funds and now may be eligible for Phase 3 funding.   Phase 1 paid providers at 6.2% of Medicare revenue from 2019, while Phase 2 included Medicaid providers to enable them to receive up to a total of 2% of reported gross revenue from patient care. Phase 3 funding is intended to ensure all providers have at least 2% of gross revenue funding.  Any remaining funds will then be distributed to providers as add-on payments.  Home health agencies may apply for Phase 3 funding here.