COVID-19 Regulations for Skilled Nursing Facility Physicians by State

Updated: 7/24/2020

 

Since the onset of the pandemic, long-term care facilities have suffered disproportionate impact from COVID-19. As new nursing home infection information is gathered and analyzed, national and local protocols are rapidly changing in response.

 

Skilled nursing facilities (SNFs) are receiving ongoing guidance from agencies such as the Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC). This guidance refers to visiting policies, infection response, and COVID-19 testing protocols. Changing regulations have implications for SNF residents and staff, including physicians. It is critical to understand both national and statewide rules so that you and the facilities in which you practice can maintain compliance, follow recommended or required protocols, and stop the spread of the virus. 

 

Vohra Wound Physicians, the nation’s most trusted wound care solution, urges physicians to stay abreast of COVID-19 updates and to follow national and statewide guidance. Vohra serves patients residing in nearly 3,000 SNFs across the country and maintains continuity of care by also supporting seniors with wounds at home through Vohra’s telemedicine program.

 

Editor’s Note: Vohra Wound Physicians is on the front lines of the COVID-19 pandemic. If you are a physician interested in joining the team click here to see where you are needed most.

 

To help you stay informed about SNF COVID-19 response, we have compiled information about national regulations as well as local protocol for some of the hardest hit states.

Total confirmed COVID-19 cases in nursing home residents by state

Total confirmed COVID-19 cases in nursing home residents by state, according to CMS data. Some of the states with the highest cases are California, Illinois, Pennsylvania, New York, New Jersey, and Massachusetts. (Includes data up to 7/12/20)

Skip directly to your state for the latest information on COVID-19 Testing Locations and Guidelines for HealthcareProfessionals working in SNFs Don’t see your state listed?

 

Check back as this article is updated on a regular basis, and refer to the HHS website for community-based testing sites across the US.

 

Arizona
California
Connecticut
Illinois
Florida
Massachusetts
New Jersey
New York
Ohio
Pennsylvania
Texas
Washington

SNF COVID-19 National Guidance 

Regulatory healthcare agencies including CMS and the CDC are consistently updating their guidance for SNFs nationwide and releasing revised protocols and recommendations.

Testing Developments

CMS announced that it will be providing point-of-care COVID-19 tests to all nursing homes across the country. These tests provide results far more quickly than typical viral tests and are conducted on-site. This will decrease strain on laboratories and help SNFs more effectively manage infection spread. The initial rollout, which will occur the week of July 19, will initially distribute these tests to 2,000 nursing homes. It is important to note that point-of-care testing has been shown to produce false-negative results, and some studies have found them to have an error rate of up to 20%.

Two antigen point-of-care tests are also becoming increasingly available and may help SNFs more quickly assess COVID-19 infections in their facilities. These tests, the BD Veritor System for Rapid Detection of SARS-CoV-2 and the Sofia SARS Antigen FIA test, are both used to test nasal swab samples. Both tests deliver results in 15 minutes. By the end of September, BD hopes to produce two million tests per week

SNF Resident and Healthcare Personnel Testing Considerations

CDC guidelines as of July 1 emphasize that nursing home residents and healthcare personnel should be closely monitored for signs of COVID-19. Residents should have their temperature taken at least once per day and should receive viral COVID-19 tests if they have consistent symptoms. Facility healthcare personnel, including physicians, should be considered for testing if they have symptoms, if they are asymptomatic but have had known or suspected exposure, or if they have been previously diagnosed and need to assess infectiousness. A 24-hour testing turnaround time is advised to ensure that interventions are effective. Testing protocols should be practiced in addition to typical SNF infection prevention and control (IPC) protocols. State regulations should also be followed.

Beginning March 4, CMS suspended non-emergent SNF inspections in order to focus more heavily on COVID-19 spread and response. As of June 19, CMS has required Medicare to cover COVID-19 testing for SNF residents that exhibit symptoms or have had exposure to the virus. They have also addressed common SNF reopening questions and published a list of COVID-19 accomplishments. CMS recommends that SNFs follow CMS and CDC guidance for testing and reopening. On July 14, the federal government also announced that it would provide rapid COVID-19 tests to nursing homes in geographic hotspots.

The prevalence and spread of the virus vary significantly throughout different states, so SNFs and healthcare providers must also remain aware of state-specific COVID-19 infection rates and guidelines.  

Continue reading to learn more about regulations in hard-hit states.


View these Resources from the CDC and CMS

Average COVID-19 cases per 1,000 nursing home residents by state

Average COVID-19 cases per 1,000 nursing home residents by state, according to CMS data. States with the highest infection rate include New Jersey, Connecticut, Massachusetts, Rhode Island, and Washington, D.C. (Includes data up to 7/12/20)

Physician Careers

Arizona

Cases

Arizona testing data shows nearly 150,000 cases of COVID-19 and over 2,000 deaths. As cases spike across the United States, the state has the highest rate of infection per capita in the nation. Adult intensive care unit (ICU) hospital beds are 90% full across the state and over 50% of ventilators are in use. Over 70% of COVID-related deaths occur in those aged 65 and older. In Arizona, 17.5% of the population falls into this age bracket. The state has over 140 nursing facilities.

 

Response

As case levels have increased throughout the state and hospital resources are strained, the Arizona Department of Health Services has issued updated guidance. On June 26, they announced activation of Crisis Standards of Care protocols, a framework developed for disaster response. This is the first time that these protocols have been activated in Arizona’s history as well as the first time in the United States. Crisis Standards of Care allow hospitals to allocate resources to patients most in need and provide them with the flexibility to determine to whom they will provide care once they no longer have the resources to treat each patient. COVID-19 has also caused Arizona to face a nursing shortage.

 

Testing

Arizona nursing homes are now undergoing weekly COVID-19 testing. While it does not appear that there is a consistent protocol in place, SNFs are strongly urged to regularly test staff, particularly those that travel between different facilities. Testing is available through state public health laboratories and commercial laboratories. All results must be electronically reported to the Arizona Department of Health Services. SNFs must also report number of COVID-positive residents, COVID-19 admissions criteria, available beds, and available PPE. 

 

Resources

California

Cases

The State of California has had approximately 350,000 cases and over 7,000 deaths. Nearly 16,000 cases have presented in SNFs and about 84% of deaths occur in those aged 60 and older. The California Department of Public Health has been criticized for undue leniency when surveying SNFs and assessing their infection protocols throughout the pandemic. Less than 3% of surveys found infection control protocol deficiencies in California SNFs that were experiencing or approaching high levels of cases. California SNF leadership is encouraged to remain critical of infection protocols in the event that state surveys do not accurately determine infection preparedness. 

Response

In June, The California Department of Public Health began requiring SNFs to report COVID-19 information by 12PM PT each day. The Department of Public Health then reported those cases to the CDC on behalf of providers. Failure to report could result in enforcement action. 

Testing

California has not released a universal testing plan but aims to have all nursing home residents and staff tested. Testing guidelines published by the California Department of Public Health on May 1 and updated on July 14 describe testing prioritization for the state. Under the July 14 revision, there are four tiers of priority, where the first two address individuals with direct ties to healthcare settings: Tier One Priority includes those who have been hospitalized with COVID-19 symptoms, those who have been identified by contact tracing, and those who have been in close contact with confirmed cases. Tier Two Priority includes SNF residents and SNF healthcare workers, including physicians. 

This guidance also emphasizes that viral COVID-19 tests can remain positive once an individual is no longer infectious, so return-to-work criteria should focus on symptoms and facility protocols in addition to test results.


California SNFs are responsible for creating COVID-19 mitigation plans for their own facilities. These plans should include infection control policies, information about relationships with commercial laboratories to provide testing, and plans for addressing staffing shortages. All staff, including physicians, should be regularly tested and restricted from working if they exhibit symptoms. 

 

Resources

Physician Careers

Connecticut

Cases

Connecticut’s Official State website reports nearly 50,000 COVID-19 cases in the state and over 4,000 deaths. Approximately 6,000 cases and 1,800 deaths have occurred in Connecticut nursing homes. Connecticut has one of the highest rates of COVID-19 cases and deaths in nursing home residents in the country. Over 60% of COVID-19 deaths in the state have been nursing home residents.

 

Response

 

SNFs must regularly report data on COVID-19 within their facility through the CDC’s National Healthcare Safety Network (NHSN). This data includes facility census, positive resident and staff COVID-19 cases, and resident and staff confirmed or suspected COVID-19 deaths. The Connecticut Army and Air National Guard have also partnered with the Department of Health to inspect Connecticut SNFs and ensure facility safety and infection control. These visits are both preventative and corrective in nature and are expected to continue through August. 

On June 17, Phase 2 of Connecticut’s reopening plan began. This allowed indoor dining, increased capacity allowances, and reopened many indoor recreation facilities, such as gyms and movie theaters. However, Stage 3, which was originally slated to start on July 20, is being delayed due to continued cases in the state. This will limit the use of bars and restaurants and affect capacity restrictions “for the foreseeable future.”

 

Testing

In June, Governor Lamont required weekly testing for all nursing homes in the state unless they have been COVID-free for two weeks. This includes both residents and staff. Testing is being paid for by state and federal funding until August 31. The Department of Public Health has paired SNFs with Nursing Home Testing Contractors. These contractors provide testing materials, aid in mandatory reporting management, and help coordinate care for employees that test positive.

Resources

Florida

Cases

Department of Health testing data shows that Florida has had over 300,000 COVID-19 cases and nearly 5,000 deaths. This case number demonstrates that it is one of the hardest hit regions in the United States. Staff and residents of long-term care facilities account for approximately half of COVID-19 deaths in the state. Approximately 3% of long-term care facility residents and staff are COVID-positive, and cases are steadily climbing. 

Florida has had consistently high levels of COVID-19 cases throughout the pandemic. Health officials postulate that this is due to the significant number of tourists traveling in and out of the state and the high levels of congregation and close contact on beaches and in social settings.

Response

On June 15, Florida state officials announced that all SNF staff, including physicians, must be tested for COVID-19 every two weeks, effective July 7. The Agency for Healthcare Administration (AHCA) also expects nursing homes to test all residents that are experiencing symptoms. In response to a recent spike in cases, several counties are reversing reopening measures and implementing curfews. 

Testing

Per the Mandatory Testing rule, starting July 7, Florida nursing home staff will not be permitted to enter SNFs without receiving COVID-19 testing. Testing materials will be provided and paid for by the state and will be mailed to facilities for self-administered testing. The amount of testing kits provided will depend upon facility staffing levels. SNFs can update this information in the AHCA’s Emergency Status System (ESS). Once testing protocol is underway, SNFs must maintain on-site documentation of staff testing status and update ESS with staff test results daily.

If a staff member tests positive, they must exit the facility and practice self-isolation. They will not be permitted to return to work until they have two negative tests separated by 24 hours. In the event that a significant number of staff members becomes ill, SNFs should update their Comprehensive Emergency Management Plan to include protocols that account for staffing shortages. SNFs that do not comply with staff testing regulations may be subject to fines and license revocation. 

 

Resources

Illinois

Cases

Illinois has had over 160,000 cases of COVID-19 and over 7,000 deaths. Over 23,000 of these cases have occurred in SNFs. Nursing homes have experienced nearly 4,000 deaths.

Response

All Illinois SNFs must complete the Illinois Long-Term Care Facility Assessment for COVID-19. SNFs are also required to have a comprehensive COVID-19 testing plan and response strategy that conform to CDC guidelines. These plans must include policies on PPE, methods for obtaining and conducting testing, and information about the personnel required to care for residents and execute the testing plan. SNFs are able to have outdoor visitors as long as they follow Illinois Department of Public Health (IDPH) state guidance. IPDH has also released SNF PPE guidance describing use of masks, gloves, gowns, and eye protection in different care settings.

Testing

SNFs are responsible for partnering with laboratories for testing, but the Illinois Department of Public Health (IDPH) can provide guidance. Contracted laboratories will provide testing kits directly to the SNF. If staff or residents test positive, retesting frequency and timing should be determined by the facility and their local health department with input from the IDPH and CDC recommendations. Facilities that have not had identified cases in 28 days should follow their facility’s regular testing plan to ensure continued safety. Testing should be performed in addition to existing infection prevention and control protocols.

 

Resources

Physician Careers

Massachusetts

Cases

Massachusetts has had over 107,000 COVID-19 cases and over 8,000 deaths. Long-term care facilities, including SNFs, have had about 24,000 probable or confirmed cases and over 5,300 probable or confirmed deaths.

 

Response

On June 30, the Massachusetts Executive Office of Health and Human Services released a memorandum regarding long-term care surveillance testing. Under this memorandum, long-term care facilities were required to conduct new baseline COVID-19 testing for all residents and staff by July 19. Information collected during testing should include COVID-19 status as well as staff member age, gender, race, ethnicity, area of residence, disability, primary language, and occupation.

 

Testing

SNFs must independently coordinate staff and resident COVID-19 testing using a qualified testing provider. SNFs will pay for COVID-19 testing, including that for staff, but will receive a reimbursement from the state in the amount of $100 per test. If staff choose to get tested outside of the SNF, they are responsible for paying for their test. Staff who previously tested positive do not need to be re-tested.

If surveillance testing reveals no new positive cases in facility staff, the facility should begin conducting tests every two weeks on 30% of its staff. If this surveillance testing reveals new positive cases in staff, the facility should begin weekly testing of all staff until there are no new positive cases for 14 days. Currently, recovered or previously-positive staff members do not need to be included in this surveillance program.

 

Resources

 

New Jersey

Cases

The first COVID-19 case in New Jersey was announced on March 4. Now, the state’s data dashboard indicates that New Jersey has had over 175,000 cases of COVID-19 and nearly 14,000 deaths. Particularly for long-term care facilities, New Jersey has been one of the hardest hit states in the country. New Jersey has 90,000 residents in nursing homes and assisted living facilities. Long-term care facilities have had nearly 13,000 staff cases and over 24,500 resident cases as well as over 6,700 resident deaths and over 100 staff deaths.

 

Response

SNF visitation was suspended beginning March 14 to prevent infection spread among residents and staff. On June 21, family members were once again allowed to visit loved ones in SNFs as long as they followed specific policies. SNFs were required to update their infection control protocols by May 19 and to complete facility-wide testing by May 26 by directly contracting with a laboratory. Individuals who tested negative at baseline had to be retested within 3-7 days to confirm their COVID-19 status. SNFs must regularly submit facility testing data to the New Jersey Office of Emergency Management portal.

 

Testing

Following the results of the May 26 baseline testing, SNFs had to adhere to retesting guidance in accordance with CDC protocol to ensure staff and resident safety. Currently, SNF staff must be tested regularly in accordance with their facility’s policies. New Jersey has also made free testing available throughout the state, so staff members may be tested of their own accord. 

 

Resources

Physician Careers

New York

Cases

New York has had over 400,000 cases of COVID-19 and over 25,000 fatalities. Over 85% of COVID-related deaths occurred in those aged 65 and older. The first nursing home case in New York was a staff member on March 5. The first nursing home resident tested positive in New York on March 11. New York State has approximately 100,000 nursing home residents – more than any other state in the nation – in over 600 facilities. The New York State Department of Health (NYSDOH) identified staff illness as a key source of SNF resident illness. Estimates indicate that by May, nearly one in three SNF staff members were infected. 

Response

In February, the New York State Department of Health (NYSDOH) issued guidance to nursing homes regarding PPE inventory and infection control.  On March 13, Governor Cuomo banned nursing home visitation statewide and created strict noncompliance penalties.

Testing

On May 10, New York State mandated twice-weekly testing for SNF staff, including physicians. Now, twice-weekly testing must be conducted for all regions in phase I reopening. Regions in phase II must conduct once-weekly testing. Facilities must file plans with the Department of Health detailing the staff to be tested. Tests must be conducted at least two days apart. Asymptomatic staff members may continue to work while they wait for test results. Personnel who refuse testing are prohibited from entering the facility or providing nursing home care services. Positive tests must be reported to the Department of Health by 5PM the next day. 

Effective March 13, and updated July 10, all nursing home staff, including physicians, must be health-checked at the start of each shift. Staff with symptoms at the start of their shift or who develop symptoms during their shift must immediately go home.

SNFs are responsible for establishing relationships with laboratories or testing centers in order to perform testing for their employees. SNFs may submit claims for CARES Act coverage of tests, and the state may facilitate reimbursement through FEMA. 

 

Resources

Ohio

Cases

The state of Ohio has had about 73,000 COVID-19 cases and nearly 3,000 deaths. There have been approximately 8,000 cases in long-term care facility residents and 4,000 cases in facility staff. Long-term care facilities account for nearly 70% of the state’s COVID-19 death toll.

Response

In June, Ohio began reopening its economy, but nursing home visitation remained prohibited. Effective July 20, SNFs will be able to welcome visitors again. Visitation will only be permitted outdoors and will require adherence to safety standards. The state is supporting testing in all facilities unless they opt out because they have plans to conduct testing on their own. The Ohio Department of Health (ODH) is also surveying PPE availability and using tracking systems to monitor inventory and need (within Ohio’s five-tiered testing priority list, nursing home residents fall into Priority 2. Priority 1 addresses people with symptoms, hospitalized, and healthcare personnel). ODH is also providing infection control incentive payments for SNFs based on the results of Infection Control Surveys.
 

Testing

On May 22, the Director of the ODH ordered Ohio nursing homes to strategically test residents and require employee testing in accordance with ODH guidelines. SNFs can utilize state-scheduled testing to complete this requirement. The Ohio National Guard (ONG) is assisting in nursing home testing and can perform approximately 50 tests per hour at each facility. The ONG will also deliver the testing kits to laboratories. If SNFs choose to forgo state support for testing and to develop independent testing plans, they must meet requirements for employee testing. 

Asymptomatic staff are permitted to work while awaiting COVID-19 results, but SNFs must enforce infection control protocols and PPE usage. SNFs should also perform daily temperature and symptom checks on staff members. If staff members test positive, they should isolate at home. New employees should be tested.

Resources

Physician Careers

Pennsylvania

Cases

Pennsylvania data indicates about 100,000 cases and over 7,000 deaths. Nursing home residents account for nearly 70% of COVID-19 deaths in the state. Pennsylvania has more than 700 nursing homes housing over 80,000 residents.

Response

Pennsylvania has announced a partnership with Omnicare, a CVS Health company, to increase COVID-19 testing at SNFs. Under this partnership, Omnicare will administer up to 50,000 tests to SNF residents and staff. CVS Health has also opened approximately 70 drive-through COVID-19 testing sites across the state. SNFs are prohibited from allowing visitors until they have gone two weeks without a new case among residents or staff. In addition, SNFs must practice universal mask-wearing and social distancing.
 

Testing

In early June, the Pennsylvania Department of Health released an order requiring nursing facilities across the state to conduct universal testing by July 24. This order includes testing for both residents and staff and aims to identify asymptomatic cases to prevent further virus spread. Facilities are expected to develop testing strategies independently but can request state support if needed. The order also specifies that SNFs must report COVID-19 test results and inform the Department of Health when the directive has been completed. SNFs that are not complying with reporting requirements can face fines and administrators may face prison time. Beyond this directive, Pennsylvania guidance urges SNFs to perform weekly testing of residents and staff until there are 14 days with no new cases.

 

Texas

Cases

The Texas COVID-19 dashboard shows that the state is nearing 300,000 COVID-19 cases and approximately 3,500 fatalities. There have been nearly 10,000 cases among nursing home residents and over 1,000 fatalities. Texas has reported record highs of COVID-related deaths in the past few days. Close to 50% of the state’s deaths have been linked to SNFs. Texas nursing homes have a history of deficiencies with infection control protocols, so COVID-19 has posed a significant challenge.

 

Response

Starting June 11, the Texas Department of Health and Human Services began conducting regular on-site assessments of infection control protocols at nursing facilities. These visits are intended to be consultative and to provide guidance to help prevent virus spread. On May 11, Governor Greg Abbott directed all nursing home residents and staff throughout the state to be tested.
 

Testing

The health care company Omnicare has partnered with the state of Texas to provide testing across the state. Omnicare testing in SNFs began on July 15 and aims to process approximately 100,000 tests in the next month. These tests will be conducted on-site and provide same-day results for both staff and residents. As this plan begins to roll out, SNF representatives are still frustrated with the lack of regular, comprehensive staff testing. 

 

Resources

Physician Careers

Washington

Cases

The first known positive COVID-19 case in a nursing home in the United States was in Kirkland, Washington in February 2020. The state has had over 40,000 cases and over 1,000 fatalities. Approximately 89% of deaths occurred in those over age 60. Over 50% of total deaths are associated with long-term care facilities. 


Response

In March, SNF visitation was strictly limited and then completely banned in order to prevent the spread of COVID-19. Since the original spike in cases, the state has worked to ensure appropriate PPE and testing availability.

Testing

In May, the Department of Health and the Department of Social and Health Services required Washington nursing homes to test all residents and staff, including physicians, by June 12. Test kits were provided by the Department of Health. Health experts now worry that a second wave will impact Washington SNFs. A second order requiring testing in all SNFs is expected to be released soon. In the meantime, SNFs should prepare for testing by establishing contact with testing laboratories, securing PPE, and developing a testing plan. Positive tests must be reported to the Department of Social and Health Services. Staff members who test positive are advised to follow CDC return-to-work guidelines.

Resources

What to Expect Moving Forward

As new information is gathered about infection spread and death rate, guidance and regulations are continually updated. It’s helpful to regularly check CMS, CDC, and state Department of Health websites for updated resources. SNFs may also want to update their emergency protocols and infection control procedures to prevent ongoing spread. When possible, contact tracing is recommended.

 

Vohra Wound Physicians urges physicians to remain aware of and adhere to the latest state and federal regulations and to conduct patient visits virtually when appropriate. During SNF staff shortages, Vohra enables continuity of care via the Vohra@Home telemedicine platform. 


Nationwide Resources

Don’t see your state listed? Check back as this article is updated on a regular basis and refer to the HHS website for community-based testing sites across the US.

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