IHCA Member COVID- Update: CMS Directs More Visitor Restrictions

Last night, the Center for Medicare and Medicaid Services (CMS) issued new guidance via a memorandum that is based on the newest recommendations from the Centers for Disease Control and Prevention (CDC). It directs nursing homes to significantly restrict visitors and nonessential personnel, as well as restrict communal activities inside nursing homes. All individuals other than essential health care staff and visits for end-of-life situations should no longer enter skilled nursing facilities (SNFs) until further notice. This new guidance should be used in place of last week’s AHCA guidance.

Below is a quick summary of the new guidance prepared by AHCA:

  • Restrict all visitors, volunteers and non-essential health care personnel (e.g., barbers) except for certain compassionate care situations, such as end-of-life situations. Facilities are expected to notify potential visitors to defer visitation until further notice (through signage, calls, letters, etc.).
  • Visits for end-of-life situations are to be handled on a case-by-case basis, include screening of the visitor, use of personal protective equipment (PPE) and hand hygiene by the visitor and limited access to the facility (resident’s room or location designated by the facility).
  • Cancel all group activities and communal dining.
  • Implement active screening of residents and health care personnel for respiratory symptoms, including actively checking temperatures for a fever (all health care personnel at beginning of shift and residents at least daily).
    • Document absence of symptoms
    • Those with symptoms of a respiratory infection (fever, cough, shortness of breath or sore throat) should not be permitted to enter the facility at any time (even in end-of-life situations).
  • Screen and monitor residents when visitors, staff or others report respiratory symptoms within 14 days of interacting with the residents.
  • Surveyors are allowed but if they have a fever or respiratory symptoms they should not enter.
    • Ombudsman should only be allowed in for compassionate situations AND if they don’t have a fever or respiratory symptoms.
  • Identify staff who work at multiple facilities and actively screen and restrict them appropriately.
  • Enforce sick leave policies for ill health care personnel that are non-punitive, flexible and consistent with public health policies allowing ill health care personnel to stay home.
  • Some governors or public health officials may have orders about visitors. For Medicare and Medicaid-certified facilities, this new guidance supersedes governor and public health officials’ orders, unless the state-level orders go beyond this new guidance. Then CMS expects facilities to adhere to additional requirements imposed by the state or local authorities.

CMS is also temporarily halting all non-emergency survey activity. We expect to hear more about this from the Department of Inspections and Appeals (DIA) when they join our all member call Tuesday morning.

Assisted living communities are not affected by the new CMS guidance. In the case of ALs, NCAL’s visitor restriction guidance continues to be our recommendation to prevent the virus from entering ALs.

1135 waivers:

CMS also announced an intention to implement certain ‘blanket waivers’ as a result of President Trump’s national emergency declaration under the Stafford Act. These include a suspension of Medicare’s three-day stay requirement before a SNF admission, a loosening of out-of-state licensing requirements in some cases, MDS timeframe requirements, and several other areas. Please note: the waiver guidance is NOT in force presently; we expect to see the Section 1135 waiver making the authorizations official sometime this weekend. Until then, providers should hold on changes in current practice until the waiver is issued.

IHCA has certain concerns about the implementation of the three-day stay waiver specific to protocols around transfer of COVID-19 patients to SNFs. We are sharing those concerns with relevant partners and expect to have guidance out on Tuesday’s all provider call at 10:00 am. IHCA has posted 1135 waiver guidance on its website here.


The Iowa Department of Public Health (IHPH) announced last night a new testing framework for COVID-19.  Providers no longer need to contact IDPH for test approval for cases that meet department’s criteria:

  • Hospitalized patients with fever and respiratory failure and no alternate diagnosis
  • Hospitalized older adults (>60 years of age) with fever or respiratory symptoms (cough, difficulty breathing) and chronic medical conditions (e.g., diabetes, heart disease, immunosuppressive medications, chronic lung disease or chronic kidney disease)
  • Any persons (including healthcare providers) with household contact with a laboratory confirmed case of COVID-19 in the 14 days prior to becoming ill with fever or respiratory symptoms (e.g., cough, difficulty breathing)
  • Any persons with a history of international travel to a country with a Level 3 CDC travel health warning (https://www.cdc.gov/coronavirus/2019-ncov/travelers/index.html) or have taken an international cruise in the 14 days prior to becoming ill with fever and respiratory symptoms (e.g., cough, difficulty breathing) and no alternate diagnosis

If patients meet this testing criteria, please submit the specimen to the State Hygienic Laboratory in accordance with the following guidance: https://shl.uiowa.edu/dcd/covid19.xml.

More on testing here.  For an illness checklist, click here.