The health and safety of our employees, clients, agencies and the patients we all serve is of the utmost importance to Careficient. Our clinical, billing, and compliance teams are closely monitoring the situation regarding COVID-19 and the impact it is having to provide care.

We recognize new information, processes, updates continues to flow from CMS, national, local authorities and this is creating even more challenges for agencies across the country.

Careficient will continue to monitor and proactively act on the impact of COVID-19.

We’ve created the following resource and will continue to keep it up to date with the latest and most relevant developments. You can click on each date for details.

COVID-19 Updates - April 30th, 2020

CMS has announced the following blanket waivers that are retroactive to March 1, 2020

HOME HEALTH AND HOSPICE:
1) Modified the requirement 484.80(d) that agencies must assure that each home health or hospice aide receives 12 hours of in-service training in a 12 month period. CMS is postponing the deadline for completing this requirement until the end of the first full quarter after the declaration of the Public Health Emergency (PHE).

2) Modified the requirement 418.76(h)(2)/484.80(h)(1(iii) for HHAs, which requires an annual onsite supervisory visit (direct observation) for each aide that provides services on behalf of the agency. All postponed annual supervisory visits must be completed no later than 60 days after the expiration of the Public Health Emergency.

3) Extending the deadline for the requirement at 484.110(e) which requires the agency to provide a patient a copy of their medical record at no cost during the next visit or within 4 business days to 10 business days.

4) Modifying the requirement at 418.58(a-d)/484.65(a-d) to narrow the scope of the QAPI program to concentrate on infection control issues while retaining the requirement that remaining activities should continue to focus on adverse events.

HOME HEALTH:
1) CMS is waiving the requirement 484.58(a), which was a new regulation as of November 29, 2019, to provide detailed information regarding discharge planning to the patient/family in selecting a post-acute care provider by using and sharing data that includes another HHA, SNF, IRF and LTCH quality measures and resource use of measures.

HOSPICE INPATIENT FACILITIES:
1) Modifying 418.110(c)(2)(iv) to the extent necessary to permit facilities to adjust scheduled inspections, testing and maintenance frequencies and activities for facility and medical equipment.

2) Temporarily modifying 483.470(j)(1)(i) provisions to the Life Safety Code (LSC) and Health Care Facilities Code (HCFC) to the extent necessary to permit these facilities to adjust scheduled inspection, testing and maintenance frequencies and activities required by the above codes. The following LSC and HCFC inspection, testing and maintenance are considered critical and are NOT included in this waiver:

  1. sprinkler system monthly electric motor driven and weekly diesel engine driven fire pump testing.
  2. portable fire extinguisher monthly inspection
  3. elevators with firefighter’s emergency operations monthly testing
  4. emergency generator 30 continuous minute monthly testing and associated transfer switch monthly testing.
  5. means of egress daily inspection in areas that have undergone construction, repair, alterations or additions to ensure its ability to be used instantly in case of emergency.

3) Waived 418.110(d)(6) which requires an outside window or outside door in every sleeping room to permit these providers to utilize facility and non-facility space that is not normally used for patient care to be utilized for temporary patient care or quarantine.

COVID-19 Updates - April 1st, 2020

HOME HEALTH

Homebound status: COVID-19 will be added as one of the homebound reasons and a patient that needs skilled care can qualify for services even if COVID-19 is the only homebound reason.

A Nurse Practitioner, Clinical Nurse Specialist, Physician Assistant can now order Home Health and certify, recertify and sign the plan of care.

Home Health agencies can perform the initial assessment and determine homebound status remotely or by record review. Telehealth requires a live audio and video mode with the patient. Skype and Facebook Live are appropriate and HIPAA regulations have been relaxed to cover these.

If rehabilitation services is the only service ordered by the provider the therapist may do the initial assessment via record review or remotely.

Home Health agencies can provide visits via telehealth within the 30 day episode. The visits must be included in the plan of care and specifically noted as such. For example: 4 nursing visits weekly, 2 via telehealth and 2 in person. Telehealth cannot replace needed in-person visits ordered on the Plan of Care.

For payers that pay per visit the telehealth visit will be paid at the in person visit rate. For payers that use PDGM we do not have final clarification if the telehealth visits will count towards the LUPA threshold.

Waived on-site HHA supervisory visits. These can be done via telehealth or phone.

The comprehensive assessment may be completed within 30 days and delayed OASIS submission is permitted. Patients still must have an assessment to determine and be able to appropriately meet their care needs

MACs can extend the auto-cancellation date of RAPs during the PHE. Contact your MAC.

An accelerated/advance payment is intended to provide necessary funds when there is a disruption in claims submission and/or claims processing. During the PHE any Medicare provider/supplier who may submit a request to the appropriate Medicare Administrative Contractor (MAC). Each MAC will work to review requests and issue payments within seven calendar days of receiving the request.

HOSPICE

Hospices can provide services to a Medicare patient receiving routine home care through telehealth, if it is feasible and appropriate to do so. Telehealth is not telephone solely, but live audio/video via a non-public means (Facetime, Skype, etc.)

Encounters for purposes of patient re-certification for the Medicare hospice benefit can now be conducted via telehealth.

Aide supervisory every 14 days can be waived. If the patient is still receiving in-person visits then the aide supervisory visit needs to be done

Waive the use of volunteers

Hospices continue to complete the comprehensive assessment, the timeframe for updating the assessment may be extended from 15 to 21 days.

Waive requirements for non-core services (therapy)

Accelerated and Advanced Payment- same as home health Health and Hospice can start using the waivers immediately and do not need to apply for them from CMS. The blanket waivers have a retroactive effective date of March 1, 2020, through the end of the emergency declaration.​

Which patients are at risk for severe disease for COVID-19?

Based upon CDC data, older adults or those with underlying chronic medical conditions may be most at risk for severe outcomes.

How should HHAs screen patients for COVID-19?

When making a home visit, HHAs should identify patients at risk for having COVID-19 infection before or immediately upon arrival to the home. They should ask patients about the following:

  • International travel within the last 14 days to countries with sustained community transmission. For updated information on affected countries visit: https://www.cdc.gov/coronavirus/2019-ncov/travelers/index.html
  • Signs or symptoms of a respiratory infection, such as a fever, cough, and sore throat.
  • In the last 14 days, has had contact with someone with or under investigation for COVID19, or are ill with respiratory illness.
  • Residing in a community where community-based spread of COVID-19 is occurring.

For ill patients, implement source control measures (i.e., placing a facemask over the patient’s nose and mouth if that has not already been done).

Inform the HHA clinical manager, local and state public health authorities about the presence of a person under investigation (PUI) for COVID-19. Additional guidance for evaluating patients in U.S. for COVID-19 infection can be found on the CDC COVID-19 website.

CMS regulations requires that home health agencies provide the types of services, supplies and equipment required by the individualized plan of care. HHA’s are normally expected to provide supplies for respiratory hygiene and cough etiquette, including 60%-95% alcohol-based hand sanitizer (ABHS). State and Federal surveyors should not cite home health agencies for not providing certain supplies (e.g., personal protective equipment (PPE) such as gowns, respirators, surgical masks and alcohol-based hand rubs (ABHR)) if they are having difficulty obtaining these supplies for reasons outside of their control. However, we do expect providers/suppliers to take actions to mitigate any resource shortages and show they are taking all appropriate steps to obtain the necessary supplies as soon as possible.

How should HHAs monitor or restrict home visits for health care staff?

When making a home visit, HHAs should identify patients at risk for having COVID-19 infection before or immediately upon arrival to the home. They should ask patients about the following:

  • Health care providers (HCP) who have signs and symptoms of a respiratory infection should not report to work.
  • Any staff that develop signs and symptoms of a respiratory infection while on-the-job, should:

    • Immediately stop work, put on a facemask, and self-isolate at home;
    • Inform the HHA clinical manager of information on individuals, equipment, and locations the person came in contact with; and
    • Contact and follow the local health department recommendations for next steps (e.g., testing, locations for treatment).

  • Refer to the CDC guidance for exposures that might warrant restricting asymptomatic healthcare personnel from reporting to work (https://www.cdc.gov/coronavirus/2019- ncov/hcp/guidance-risk-assesment-hcp.html)

HHAs should contact their local health department for questions, and frequently review the CDC website dedicated to COVID-19 for health care professionals: https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html

Do all patients with known or suspected COVID-19 infection require hospitalization?

Patients may not require hospitalization and can be managed at home if they are able to comply with monitoring requests. More information is available here: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-home-care.html

What are the considerations for determining when patients confirmed with COVID-19 are safe to be treated at home?

Although COVID-19 patients with mild symptoms may be managed at home, the decision to remain in the home should consider the patient’s ability to adhere to isolation recommendations, as well as the potential risk of secondary transmission to household members with immunocompromising conditions. More information is available here: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-home-care.html

When should patients confirmed with COVID-19 who are receiving HHA services be considered for transfer to a hospital?

Initially, symptoms maybe mild and not require transfer to a hospital as long as the individual with support of the HHA can follow the infection prevention and control practices recommended by CDC. (https://www.cdc.gov/coronavirus/2019-ncov/infection-control/controlrecommendations.html)

The patient may develop more severe symptoms and require transfer to a hospital for a higher level of care. Prior to transfer, emergency medical services and the receiving hospital should be alerted to the patient’s diagnosis, and precautions to be taken including placing a facemask on the patient during transfer. If the patient does not require hospitalization they can be discharged back to home (in consultation with state or local public health authorities) if deemed medically and environmentally appropriate. Pending transfer or discharge, place a facemask on the patient and isolate him/her in a room with the door closed.

What are the implications of the Medicare HHA Discharge Planning Regulations for Patients with COVID-19?

Medicare’s Discharge Planning Regulations (which were updated in November 2019) Page 4 of 7 requires that HHA assess the patient’s needs for post-HHA services, and the availability of such services. When a patient is discharged, all necessary medical information (including communicable diseases) must be provided to any other service provider. For COVID-19 patients, this must be communicated to the receiving service provider prior to the discharge/transfer and to the healthcare transport personnel.

What are recommended infection prevention and control practices, including considerations for family member exposure, when evaluating and caring for patients with known or suspected COVID-19?

The CDC advises the patient to stay home except to get medical care, separate yourself from other people and animals in the home as much as possible (in a separate room with the door closed), call ahead before visiting your doctor, and wear a facemask in the presence of others when out of the patient room. For everyone in the home, CDC advises covering coughs and sneezes followed by hand washing or using an alcohol-based hand rub, not sharing personal items (dishes, eating utensils, bedding) with individuals with known or suspected COVID-19, cleaning all “high-touch” surfaces daily, and monitoring for symptoms. We would ask that HHA’s share additional information with families. Please see https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-preventspread.html and https://www.cdc.gov/coronavirus/2019-ncov/community/home/index.html.

Detailed infection prevention and control recommendations are available in the CDC Interim Infection Prevention and Control Recommendations for Patients with Confirmed Coronavirus Disease 2019 (COVID-19) or Persons under Investigation for COVID-19 in Healthcare Settings: https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html

Are there specific considerations for patients requiring therapeutic interventions?

Patients with known or suspected COVID-19 should continue to receive the intervention appropriate for the severity of their illness and overall clinical condition. Because some procedures create high risks for transmission (close patient contact during care) precautions include: 1) HCP should wear all recommended PPE, 2) the number of HCP present should be limited to essential personnel, and 3) any supplies brought into, used, and removed from the home must be cleaned and disinfected in accordance with environmental infection control guidelines.

What Personal Protective Equipment should home care staff routinely use when visiting the home of a patient suspected of COVID-19 exposure or confirmed exposure?

If care to patients with respiratory or gastrointestinal symptoms who are confirmed or presumed to be COVID-19 positive is anticipated, then HHAs should refer to the Interim Guidance for Public Health Personnel Evaluating Persons Under Investigation (PUIs) and Asymptomatic Close Contacts of Confirmed Cases at Their Home or Non-Home Residential Settings: https://www.cdc.gov/coronavirus/2019-ncov/php/guidance-evaluating-pui.html

Hand hygiene should be performed before putting on and after removing PPE using alcohol based hand sanitizer that contains 60 to 95% alcohol.

PPE should ideally be put on outside of the home prior to entry into the home. If unable to put on all PPE outside of the home, it is still preferred that face protection (i.e., respirator and eye protection) be put on before entering the home. Alert persons within the home that the public health personnel will be entering the home and ask them to move to a different room, if possible, or keep a 6-foot distance in the same room. Once the entry area is clear, enter the home and put on a gown and gloves.

Ask person being tested if an external trash can is present at the home, or if one can be left outside for the disposal of PPE. PPE should ideally be removed outside of the home and discarded by placing in external trash can before departing location. PPE should not be taken from the home of the person being tested in public health personnel’s vehicle.

If unable to remove all PPE outside of the home, it is still preferred that face protection (i.e., respirator and eye protection) be removed after exiting the home. If gown and gloves must be removed in the home, ask persons within the home to move to a different room, if possible, or keep a 6-foot distance in the same room. Once the entry area is clear, remove gown and gloves and exit the home. Once outside the home, perform hand hygiene with alcohol-based hand sanitizer that contains 60 to 95% alcohol, remove face protection and discard PPE by placing in external trash can before departing location. Perform hand hygiene again.

When is it safe to discontinue Transmission-based Precautions for home care patients with COVID-19?

The decision to discontinue Transmission-Based Precautions for home care patients with COVID-19 should be made in consultation with clinicians, infection prevention and control specialists, and public health officials. This decision should consider disease severity, illness signs and symptoms, and results of laboratory testing for COVID-19 in respiratory specimens. For more details, please refer to: https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-inhome-patients.html.

Considerations to discontinue in-home isolation include all of the following:

*Initial guidance is based upon limited information and is subject to change as more information becomes available. In persons with a persistent productive cough, SARSCoV-2-RNA might be detected for longer periods in sputum specimens than in upper respiratory tract (nasopharyngeal swab and throat swab) specimens.

Protocols for Coordination and Investigation of Home Health Agencies with Actual or Suspected COVID-19 Cases

During a home health agency survey, when a COVID-19 confirmed case or suspected case (including PUI) is identified, the surveyors will confirm that the agency has reported the case to public health officials as required by state law and will work with the agency to review infection prevention and education practices. Confirm that the HHA has the most recent information provided by the CDC.

The State should notify the appropriate CMS Regional Office of the HHA who has been identified as providing services to a person with confirmed or suspected COVID19 (including persons under investigation) who do not need to be hospitalized;

The State should notify the appropriate CMS Regional Office of the HHA who has been identified as providing services to a person with confirmed COVID-19 who were hospitalized and determined to be medically stable to go home.

CMS is aware of that there is a scarcity of some supplies in certain areas of the country. State and Federal surveyors should not cite providers/suppliers for not having certain supplies (e.g., personal protective equipment (PPE) such as gowns, respirators, surgical masks and alcohol based hand rubs (ABHR)) if they are having difficulty obtaining these supplies for reasons outside of their control. However, we do expect providers/suppliers to take actions to mitigate any resource shortages and show they are taking all appropriate steps to obtain the necessary supplies as soon as possible. For example, if there is a shortage of ABHR, we expect staff to practice effective hand washing with soap and water. Similarly, if there is a shortage of PPE (e.g., due to supplier(s) shortage which may be a regional or national issue), the facility should contact the appropriate local authorities notifying them of the shortage, follow national guidelines for optimizing their current supply, or identify the next best option to care for patients. If a surveyor believes a facility should be cited for not having or providing the necessary supplies, the state agency should contact the CMS Regional Office.