Notes from DQA Call on SNF COVID-19 Response, Held 3.31.20

On the afternoon of Tuesday, March 31, state long-term care officials held a sector-wide call entitled, COVID-19 Webinar for Long-Term Care Facilities. Click HERE to view the agenda.

Otis Woods, the Administrator of the Division of Quality Assurance welcomed the group to the call and reminded everyone that in the future assisted living-related issues will be discussed in a separate meeting, likely on Tuesdays.

The webinar turned to the Q&A section. Questions were accepted ahead of time and also during the webinar. 

Responses to the questions are italicized below.

Any question that does not have a response under it was not answered during the meeting. The questions will hopefully be addressed during the next meeting.

Question: Bureau of Communicable Diseases Memo- 3/20/2020 states “HCP who have been exposed to COVID-19 but are asymptomatic do not need to be excluded from work, but should self-monitor symptoms.”  (LeadingAge COVID-19 Update 3/20/20).  The “Interim US Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with COVID-19” (3/7/2020) provides that “HCP with potential exposures to COVID-19 in community settings should have their exposure risk assessed according to CDC guidance.  HCP who have a community or travel associated exposure should undergo monitoring as defined by that guidance.  Those who fall into the high or medium risk category described there should be excluded from work in a healthcare setting until 14 days after their exposure.

This seems to me to conflict one another?  One states HCP with exposure to COVID but without symptoms may work.  The other states if they have COVID exposure they should not be allowed to work for 14 days.  All our staff are screened and temps are taken twice daily.  Whether they were in Kentucky or Green Bay, we all have the potential for exposure?

Response (Jeanne Ayers and Dr. Chris Crnich): The CDC guidance states that healthcare providers may need to adapt this guidance. Dr. Crnich stated that almost every hospital dealing with COVID-19 positive patients has deviated from the guidance since it would exclude nearly every employee. There is not consistency across the healthcare continuum. High risk exposures should be immediately excluded. Low risk exposure should be required to use proper face masks with proper self monitoring. Jeanne agreed with Dr. Crnich.

Question: We’ve heard that a company called Aytu BioScience, a specialty pharmaceutical company, received confirmation from the U.S. FDA that they can distribute its COVID-19 IgG/IgM Rapid Test throughout the U.S.  Assisted living providers are interested in purchasing these tests but weren’t sure if they can administer these tests to their residents.  Is a doctor’s order required to administer the test.  Can a nurse administer the test?  Any details would be greatly appreciated.

Response (Jeanne Ayers): This wouldn’t be a useful test for long-term care since it detects antibodies 5-7 days after infection and it cannot be used to determine who is not infected. 

Question: Counties such as Washington/Ozaukee, Racine, Kenosha, Sauk, Jefferson, and the City of Appleton issued orders requiring the issue of PPE in all situations.  Washington/Ozaukee and Kenosha county is also mandating that staff not work in more than one facility.  Has DHS been able to work with these counties and all counties in Wisconsin to stress the importance of a consistent message throughout the state utilizing guidance provided by DHS?

Response (EOC Official and Jeanne Ayers): It has been brought to the guidance group with the Emergency Operations Center. We will be providing updates as we get them. While it would be ideal for nurses to have less travel between facilities, Jeanne Ayers, Administrator of the DHS-Division of Public Health said that it would be “consistent with our recommendations for them to continue to provide care” but taking the best practices necessary. It is important for nurses who are in contact with COVID-19 patients are a high-risk population. “It is not an order,” said Ayers, who expressed concerns about the implications that this order will place on workforce concerns.

Question: When will providers be notified if they are eligible for the PPE the state has received from the strategic national stockpile and how is the PPE being divided amounts provider-type: hospitals, skilled nursing facilities, assisted living facilities, etc.

Response (EOC Official): As far as determining eligibility, the second order request survey went out last week. The epidemiologist from DHS pull that data. Shipments have started going out. Agencies will be called prior to determine a 24/7 contact. Once that shipment is out the door, agencies will be called when the delivery driver is en route to the agency. The only call you receive will be to determine your 24/7 contact, you will not receive a call if you were determined to be eligible. Prioritization are determined by policy groups. For the second round of SNS, 45% of the allocation will be going to hospitals, long-term care has been allocated 35% of the allocation. Of the 35%, 70% will be going to skilled nursing facilities and nursing centers and 30% will be held in the event that there is a COVID-19 positive resident in a long-term care facility. Going forward, we are working on the process to request PPE. A follow-up question was asked if none of the PPE from the SNS will be going to assisted living facilities. Saveyah responded that there will not be any shipments going to assisted living facilities but that facilities with COVID-positive residents can request PPE from the held PPE from the SNS. 

Question: What are the expectations for facilities to report confirmed COVID 19 for residents and staff to DHS (and MCOs)?

Response (Jeanne Ayers): There is a requirement to report both suspected and confirmed cases to the local health department. The requirement would be at the MCO level.

Question: Are providers allowed to utilize homemade masks during this time? For example ones being made by volunteers in the community made of fabric/cotton.

Response (Dr. Chris Crnich): The literature is still mixed on their utility and could potentially increase risk of infection. DHS will let you know should the time come that you should consider using homemade face masks.

Question: Is it possible for local public health entities to release any data on facility residents who have confirmed cases of COVID-19?

Response: No, it is not possible due to resident privacy.

Question: Is it possible for local public health entities to release any data on facility staff who have confirmed cases of COVID-19?

Response (Jeanne Ayers): Facilities should be notified by the hospital or public health department if there is a positive case in their facility.

Question: Is it possible for the state to release any data on COVID-19 resident deaths in LTC facilities?

Response (Jeanne Ayers): No, it is not possible due to resident privacy.

Question: I am very interested in the Department’s perspective on the hospital discharge components of the blanket waiver dealing with COVID-19 positive residents and transfers, and what state regulations would need to be waived to provide the necessary flexibility to effectuate the intent of the CMS waiver in this pandemic crisis.

Response (Otis Woods): Because we have only yesterday received confirmation from CMS on the waivers, if there is a state statutory requirement, the waiver from CMS will not be applicable and it will need an additional state waiver. We continue to work with our legal staff and have identified a list of administrative rules that we will be sharing with DHS Secretary-Designee Palm and Governor Evers to issue a statewide waiver.

Question: What waiver requests that are related to DQA’s jurisdiction were included in the state’s waiver request submitted to the Joint Finance Committee that were not included in these waivers that will be advanced to the Joint Finance Committee?

Response (Otis Woods): It is very likely that everything we previously sent to the Joint Finance Committee was approved yesterday. The only provisions that come to mind relate to CNA training.

Question: What is the position of DQA regarding the recent Kenosha Public Health Department order?

Response (Otis Woods): It is an interesting order. I am big on making sure residents get the essential medical care they need. If a visit can be provided by other means, that is great. If there is an essential medical need and no other option is available, then the resident needs that care.

Question: The call on Friday was very confusing. If a resident is isolated due to symptoms or has tested positive, what are the expectations of the provider? Redirecting, distracting with activities are good strategies, but I think with potential outcome as serious as them potentially affecting other vulnerable residents we may need more to give more guidance. Similarly, what are some strategies we can suggest for providers who have independent and AL especially now with the Shelter at Home Executive Order?

Response (Kathy Lion and Kim Marheine): Kathy stated that whatever you can do to engage residents in activities is important. Isolate when you need to, and engage when you can. Pop in residents’ rooms to reassure them, especially if they have dementia. Engage in any activity you can that is safe. Kim stated that pop-ins are really important during these high-stress times. Please call the Ombudsman for suggestions.

Question: Can DHS provide an update on the status of obtaining waivers of certain regulations/requirements for chs. 83, 88, and 89?  Will there be a state-wide waiver for certain requirements?

Response (Nikki Andrews): We do have DQA 15-003 is still in effect and provides more information. We always entertain waiver requests from providers and have had a significant increase in the number of requests. Please use the form for a quicker turn around on your waiver request.

Question: DHS sent this memo out today:  Can you tell me which specific provider types this applies to?  Confused by the reference of “heightened scrutiny and non-residential settings”?

Response (Kathy Lyons): This relates to long-term care and adult daycares, adult day services, and pre-vocational services.

Question: As you know, to assist in addressing staffing shortages due to the COVID-19 pandemic, CMS is waiving the requirements that a facility may not employ anyone for longer than four months unless they meet certain training and certification requirements. This waiver allows nursing centers to temporarily employ individuals who have completed alternative training paths, as long as they are competent to provide relevant nursing and nursing related services. To fill this need, AHCA/NCAL is offering an 8-hour online Temporary Nurse Aide training course free to all providers as soon as all required state approvals, such as state occupational licensing and state regulatory requirements, are received. WHCA/WiCAL requests the state provide approval of this free curriculum so that facilities can get caregivers working in their buildings as soon as possible. Is that possible? What can we do to help with that?

Response (Nikki Andrews): We are looking at the 1135 and state statutory requirements. We will get more information on that as quickly as possible.

Funding Questions to be Forwarded to DMS for Response

Question: Providers, particularly those that rely on Family Care are very concerned that they will not be able to make payroll. The Direct Care Workforce payment is not coming until at least April 10th. The last two weeks they’ve had significant increases in payroll due to the increase in required staffing to satisfy the no congregate dining or activities, the necessary incentive pay to keep people on the floor and additional staffing shortages because of those who are symptomatic or must self-quarantine.

Response: This question will be sent to DMS officials.

Walk-On Questions

There were no additional questions.