COVID-19 in the Long-Term Care Setting: The CMS Perspective.

Safeguarding the health and promoting the well-being and quality of life of the most vulnerable and fragile citizens is a top priority for the Centers for Medicare & Medicaid Services (CMS). In response to the Coronavirus Disease 2019 (COVID-19) pandemic, numerous regulatory policies and 1,135 waivers of federal requirements have been implemented by CMS to give long-term care providers and professionals flexibility to meet the demands of resident and patient care needs during this public health emergency. Goals for these policies and waivers are increasing capacity, enhancing workforce and capability, improving oversight and transparency, preventing COVID-19 transmission, and reducing provider burden. J Am Geriatr Soc 68:1366-1369, 2020. Published 2020. This article is a U.S. Government work and is in the public domain in the USA.

As the largest payer for healthcare services, the Centers for Medicare & Medicaid Services (CMS) sets quality and safety standards for all participating healthcare facilities, and it has been facilitating the healthcare system transformation to focus on value‐based care. Geriatricians are critical to these efforts, providing high‐value care to older adults that aligns with their personal and healthcare goals. The Coronavirus Disease 2019 (COVID‐19) pandemic has created enormous demands across all healthcare settings including skilled nursing facilities/long‐term care (SNF/LTC) facilities, challenging us and threatening the health and safety of older adults who are our beneficiaries and your patients.

In response to the public health emergency, CMS has implemented numerous regulatory policies and 1,135 waivers of federal requirements1 to give healthcare facilities and professionals flexibilities to respond to surge demands (Table 1 summarizes the CMS response to the COVID‐19 pandemic). This includes the “Hospital without Walls” initiative, under which hospitals can deliver care in temporary expansion sites.2, 3 As part of this initiative, LTC facilities can be repurposed as expansion sites including being designated as a COVID‐19 patient care facility. The creation of COVID‐19 patient care facilities can achieve population separation and transmission mitigation. Based on need and with approval of the states, CMS is waiving requirements to allow for the opening or use of non‐SNF buildings for unmet COVID‐19 isolation and treatment.4 CMS has eased several requirements to allow resident transfer to different rooms and also between facilities, as well as to use rooms in the facilities temporarily, such as activity rooms, meeting/conference rooms, or dining rooms, for resident care to expand surge capacity and for the purposes of cohorting and infection control.

Table 1

Response of the Centers for Medicare & Medicaid Services to the COVID‐19 Pandemic

Goal	Response	For more information
Increase capacity	Waive physical environment requirements (“Hospital without Walls”) Waive transfer requirements for cohorting or separation purposes Waive coverage requirements (3‐day hospital stay)	https://www.cms.gov/newsroom/press‐releases/trump‐administration‐makes‐sweeping‐regulatory‐changes‐help‐us‐healthcare‐system‐address‐covid‐19   https://www.cms.gov/files/document/covid‐long‐term‐care‐facilities.pdf   https://www.cms.gov/files/document/summary‐covid‐19‐emergency‐declaration‐waivers.pdf
Enhance workforce and capability	Waive training and certification requirement of newly hired nursing aide staff Allow physician delegation of tasks or required visits to a PA, NP, or CNS Certain requirements waived to allow physicians and nonphysicians and other professionals to provide services via telehealth Greater flexibility for remote patient monitoring	https://www.cms.gov/files/document/covid‐long‐term‐care‐facilities.pdf   https://www.cms.gov/files/document/summary‐covid‐19‐emergency‐declaration‐waivers.pdf   https://www.cms.gov/files/document/covid‐19‐nursing‐home‐telehealth‐toolkit.pdf   https://www.cms.gov/Medicare/Medicare‐General‐Information/Telehealth/Telehealth‐Codes   https://www.govinfo.gov/content/pkg/FR‐2020‐04‐06/pdf/2020‐06990.pdf
Improve oversight and transparency	QAPI program to focus on adverse events and infection control in LTC facilities Provided supplemental funding to SSAs for focused infection control surveys, complaint surveys, and reopening surveys of LTC facilities Requiring LTC facilities to inform residents and families of COVID‐19 cases and to report confirmed COVID‐19 cases directly to the CDC through the NHSN	https://www.cms.gov/files/document/covid‐long‐term‐care‐facilities.pdf   https://www.cms.gov/files/document/cares‐act‐financial‐guidance‐state‐survey‐agencies.pdf   https://www.cms.gov/newsroom/press‐releases/trump‐administration‐announces‐new‐nursing‐homes‐covid‐19‐transparency‐effort   https://www.cms.gov/files/document/qso‐20‐26‐nh.pdf   https://www.govinfo.gov/content/pkg/FR‐2020‐05‐08/pdf/2020‐09608.pdf   https://www.cms.gov/files/document/qso‐20‐29‐nh.pdf
Prevent COVID‐19 transmission	Issued guidance and recommendations (in collaboration with CDC) Urged state and local leaders to consider PPE and testing needs of LTC facilities Increased payment for COVID‐19 testing and sample collection	https://www.cms.gov/newsroom/press‐releases/trump‐administration‐issues‐key‐recommendations‐nursing‐homes‐state‐and‐local‐governments   https://www.cms.gov/files/document/qso‐20‐14‐nh‐revised.pdf   https://www.cms.gov/files/document/qso‐20‐26‐nh.pdf   https://www.cms.gov/files/document/4220‐covid‐19‐long‐term‐care‐facility‐guidance.pdf   https://www.cms.gov/newsroom/press‐releases/cms‐increases‐medicare‐payment‐high‐production‐coronavirus‐lab‐tests‐0   https://www.cms.gov/files/document/cms‐2020‐01‐r.pdf   https://www.cms.gov/files/document/admin‐info‐20‐06‐clia.pdf
Reduce provider burden (“Patients over Paperwork”)	Granted exceptions and extensions from QRP reporting requirements 30‐day suspension of Pre‐Admission Screening and Annual Resident Review Relaxed time frames for MDS assessments and transmission and relief for submitting staffing data	https://www.cms.gov/newsroom/press‐releases/cms‐announces‐relief‐clinicians‐providers‐hospitals‐and‐facilities‐participating‐quality‐reporting   https://www.cms.gov/files/document/covid‐long‐term‐care‐facilities.pdf   https://www.cms.gov/medicareprovider‐enrollment‐and‐certificationsurveycertificationgeninfopolicy‐and‐memos‐states‐and/nursing‐home‐five‐star‐quality‐rating‐system‐updates‐nursing‐home‐staff‐counts‐and‐frequently‐asked   https://www.cms.gov/files/document/qso‐20‐12‐all.pdf   https://www.cms.gov/files/document/qso‐20‐28‐nh.pdf

Abbreviations: CDC, Centers for Disease Control and Prevention; CNS, clinical nurse specialist; NHSN, National Health and Safety Network; COVID‐19, Coronavirus Disease 2019; LTC, long‐term care; MDS, Minimum Data Set; NP, nurse practitioner; PA, physician assistant; PPE, personal protective equipment; QAPI, Quality Assurance and Performance Improvement; QRP, quality reporting program; SSA, state survey agency.

With the CMS expansion of telehealth options for professionals, it is now feasible to provide higher levels of care in the LTC setting including specialty care. With the appropriate staffing, a ventilator‐capable SNF may provide a realistic alternative for COVID‐19 patients stabilized during hospitalization for continued convalescence and recovery. We believe telehealth brings a new opportunity to enhance healthcare quality in LTCs that includes specialty consultations, where appropriate. As such, CMS is waiving some requirements for physicians and nonphysician practitioners to perform in‐person LTC resident visits. Instead, CMS will allow such visits to be furnished, as appropriate, via telehealth options, described in the Long‐Term Care Nursing Homes Telehealth and Telemedicine ToolKit.5

To further enhance and broaden workforce capacity during the COVID‐19 pandemic, CMS now allows for physician delegation of tasks or required visits to a physician assistant, nurse practitioner, or clinical nurse specialist.3, 4, 6 To expand workforce capacity, CMS is also waiving the requirements that an LTC facility may not employ a nursing aide for longer than 4 months unless the person met certain training and certification requirements. Some of the best practices that healthcare organizations are using to improve physician workforce capacity include redeployment of employed physicians, utilization of available trainee staff, and recruitment of community and retired physicians.

Importantly, these flexibilities complement infection control practices to prevent COVID‐19 transmission. In close collaboration with the Centers for Disease Control and Prevention (CDC), CMS released guidance and recommendations to decrease the spread of COVID‐19 in LTC facilities.7, 8, 9 These recommendations include restricting visitors and nonessential healthcare personnel, screening for all LTC staff, residents, and visitors for COVID‐19 symptoms, canceling communal dining and group activities, and assuring that all LTC staff use appropriate personal protective equipment (PPE) when they are interacting with residents, to the extent that PPE is available and per CDC guidance on conservation of PPE.10 CMS has narrowed the scope of the Quality Assurance and Performance Improvement program to focus on adverse events and infection control to help ensure LTC facilities focus on aspects of care delivery most closely associated with COVID‐19 during the public health emergency.4, 6 We additionally announced awarding supplementary funding to state survey agencies to complete focused infection control surveys, complaint surveys based on COVID‐19 trend data, and reopening surveys of LTC facilities with previous COVID‐19 outbreaks.11

CMS has urged state and local leaders to consider the needs of LTC facilities with respect to supplies of PPE and COVID‐19 tests.12 CMS has additionally increased payment for high throughput technology COVID‐19 testing in LTC facilities13, 14 and also will provide payment for sample collection.15 Finally, to improve transparency, CMS will be requiring LTC facilities to inform residents and families of all COVID‐19 cases and to report confirmed COVID‐19 cases directly to the CDC.16, 17, 18 CMS will begin posting data from the CDC National Healthcare Safety Network for viewing by facilities, stakeholders, or the general public. The COVID‐19 public use file will be available on https://data.cms.gov/.19

Finally, we must not lose sight of the care needs of residents who do not have COVID‐19 but are at risk of transmission. LTC facilities are expected to provide the most appropriate care for all residents, regardless of COVID‐19 status. CMS is expanding availability of renal dialysis services to LTC residents by temporarily waiving the requirement that dialysis facilities provide these services directly on their main premises.20 To enable clinicians to better focus on the care needs of residents during this public health emergency and as a continuation of the “Patients Over Paperwork” initiative, CMS has temporarily given LTC providers relief from many paperwork, reporting, and audit requirements.21 For example, CMS announced it is granting exceptions from reporting requirements and extensions for clinicians and providers participating in Medicare quality reporting programs with respect to upcoming measure reporting and data submission for those programs. Additionally, CMS is temporarily relaxing the time frame requirements for Minimum Data Set assessments and transmission and providing relief for submitting staffing data through the Payroll‐Based Journal system. Due to the prioritization and suspension of certain surveys, the inspection domain of the Five Star Quality Rating System reported on Nursing Home Compare will temporarily be held constant to ensure the rating system reflects fair information for consumers.22

CMS most recently announced the independent Coronavirus Commission for Safety and Quality in Nursing Homes that will conduct a comprehensive assessment and provide independent recommendations to help inform immediate and future responses to COVID‐19 in LTC facilities.23 The commission will include residents, families, resident/patient advocates, leading industry experts, clinicians, medical ethicists, administrators, academicians, infection control and prevention professionals, state and local authorities, and other experts selected through a nomination process.

We are ever mindful that the care LTC residents need is so much more than the delivery of healthcare services. Ingenuity and innovation can arise during austere times such as these. Geriatricians and other geriatric health professionals, we applaud you for your commitment, and we express our deepest gratitude for your service.

For the latest information about COVID‐19 prevention, symptoms, and answers to common questions, visit https://www.cdc.gov/coronavirus/2019-ncov/index.html.

The full CDC guidance to prepare LTC facilities and nursing homes for COVID‐19 can be found at https://www.cdc.gov/coronavirus/2019‐ncov/hcp/long‐term‐care.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019‐ncov%2Fhealthcare‐facilities%2Fprevent‐spread‐in‐long‐term‐care‐facilities.html#facilities‐should‐do.

CMS coronavirus press releases are available at https://www.cms.gov/about‐cms/emergency‐preparedness‐response‐operations/current‐emergencies/coronavirus‐press‐releases.