Association Executive Directors Community

Dear Association Executives - Following up on the discussion during yesterday's Association Executives weekly meeting, below and attached, please find from CMS guidance on COVID-19 testing and residential facilities released yesterday. 


Centers for Medicare & Medicaid Services (CMS) Recommendations Re-opening Facilities to Provide Non-emergent Non-COVID-19 Healthcare

As states and localities begin to stabilize and COVID-19-related healthcare demand decreases, it is
important to safely resume care in order to treat ongoing health needs that are currently being
postponed. Guidelines for Opening Up America Again are still applicable to all areas, and can be
found at the following link: https://www.whitehouse.gov/openingamerica/#criteria. As such, if
States or regions have determined with their public health officials that they passed the Gating
Criteria (symptoms, cases, and hospitals) announced on April 16, 2020, then they may proceed to
Phase I, and subsequently to Phase II of re-opening. Consistent with those recommendations,
facilities should check with their State and local authorities to confirm if Gating Criteria have
been met in their area.

This document refers only to areas in Phase II: States and regions with no evidence of a rebound
that satisfy the Gating Criteria. In this document we recommend:
• Optimization of telehealth services, when available and appropriate, continues to be recommended
to minimize the need for in-person services. Ensuring that individuals with disabilities have tools
for effective communication is a key part of optimizing telehealth services.
• All individuals at higher risk for severe COVID-19 illnessi should continue to shelter in place
unless their conditions warrant in-person healthcare. More detailed information about vulnerable
and other populations who may need to take precautions is described below.
• For care that cannot be provided virtually, these recommendations - which are part of a series of
phased recommendations - may guide healthcare systems, providers, and facilities as they consider
delivering in-person care to non-COVID-19 patients in regions with lower or declining-
without-rebound, levels of COVID-19.
Non-emergent, Non-COVID care (NCC) should be offered to patients, as clinically appropriate, in
localities or facilities that have the resources to provide such care, as well as the ability to
quickly respond to a surge in COVID-19 cases, if necessary. Decisions should be consistent with
Federal, State, and local orders, and CDC guidance and made in collaboration with State and local
public health authorities. Careful planning is required to safely deliver in-person care to
patients requiring NCC, and all aspects of care must be considered - for example:
• Adequate facilities, workforce, viral testing (https://www.cdc.gov/coronavirus/2019-
ncov/testing/diagnostic-testing.html) for SARS-Cov-2, PPE, and supplies across all phases of care
in the healthcare system.
• Adequate workforce across all phases of care (such as availability of clinicians, nurses,
anesthesia, pharmacy, imaging, pathology support, and post-acute care).
General Considerations
Healthcare systems and clinicians must preserve the capacity to care for potential surges of
COVID-19 patients and ongoing fluctuations of COVID-19 needs, including plans for rapid deployment
of alternative care sites through the Hospitals Without Walls program
(https://www.cms.gov/files/document/covid-hospitals.pdf).
However, hospitals also must have the flexibility to resume non-emergent but clinically necessary
care for patients with non-COVID-19 needs, in accordance with the following general considerations:

• In coordination with State and local public health officials, evaluate the incidence and trends
for COVID-19 in the area where in-person care is being considered, including metrics related to
local and regional healthcare system capacity. In Phase II, the State or region should have no
evidence of a rebound and have already satisfied the Gating Criteria.
• Evaluate the necessity of the care based on clinical needs:
a. Prioritize services that, if deferred, are most likely to result in patient harm.
b. Prioritize at-risk populations who would benefit most from those services (for example, those
with serious underlying health conditions, those most at-risk for complications from delayed care,
or those without access to telehealth).
• Establish NCC zones where all patients can be screened for symptoms of COVID-19, including
temperature checks (see Facility Considerations section below). Staff should continue to be
routinely screened as should others who work in the facility, including physicians, nurses,
housekeeping, delivery, and all people who enter the area (https://www.cdc.gov/coronavirus/2019-
ncov/hcp/infection-control-recommendations.html and https://www.cdc.gov/coronavirus/2019-
nCoV/hcp/clinical-criteria.html).
• Sufficient resources should be available to the facility across phases of care, (e.g., post-acute
and long- term care), including PPE, sufficient healthcare workers, facilities, supplies, and
screening and testing capacity, without jeopardizing surge capacity
(https://www.cdc.gov/coronavirus/2019-ncov/hcp/us- healthcare-facilities.html).
• Participation in a registry or national data collection system, such as the National Healthcare
Safety Network, is strongly encouraged to help track patient outcomes, facility and system impacts,
and resource allocation. COVID-19 reporting is required in some facilities (nursing homes). These
data can be used to inform the region and the State as it considers entering Phase III. Submission
of information also contributes to the collective understanding and system level learning.

Facility Considerations

• When a facility makes the determination to provide in-person, non-emergent NCC, the facility
should take steps to reduce the risk of COVID-19 exposure and transmission in any newly created NCC
areas. These areas should be separate from COVID-19 care zones to the extent feasible. Approaches
include use of a separate building or of designated rooms or floors with a separate entrance and
minimal crossover with COVID-19 care areas
(https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-
control-recommendations.html#Patient_Placement).
• For in-hospital care and procedures, to the extent feasible, designate space specifically for
COVID-19 Care or NCC through the use of strategies such as separate floors or dedicated space
(e.g., separate operating rooms, radiology suites, procedure labs). Avoid crossover of patients,
staff, supplies, and personnel as feasible.
• Within the facility, administrative and engineering controls should be established to facilitate
social distancing, such as minimizing time in waiting areas, spacing chairs, and maintaining low
patient volumes.
• The number of visitors should be minimized. Actively assess all visitors for COVID-19 symptoms
upon entry to the facility. If COVID-19 symptoms are present, the visitor should not be allowed
entry into the facility and should be referred for care as appropriate.

Testing for SARS COV-2 to Ensure Safer Patient and Staff Care

• For hospitalized patients and those imminently undergoing a procedure or operation, when
possible, viral testing should be prioritized and performed 24 hours prior to the procedure or
admission, including for patients in the labor and delivery areas. If testing is not available,
patients should self- isolate for 14 days in advance to minimize the risk of virus transmission
from an asymptomatic but COVID-positive person.
• For patients who test positive for COVID-19, the clinical team should consider the risks and
benefits of proceeding with or postponing the procedure. If care is delivered, it should be done in
a COVID-19 care zone with appropriate precautions.
• Screening of clinical staff who work in a NCC environment is recommended daily upon arrival (see
Workforce Availability section). Other staff entering the NCC zones should be screened and tested,
as appropriate.
• Upon entry to the facility, if visitors have symptoms or test positive on screening, they should
be excluded from the NCC zone, encouraged to follow isolation, and seek care as appropriate.
• Testing results, either from labs or points-of-care, should be reported appropriately to the
state health department consistent with state and local requirements.

PPE and Supplies

• Consistent with the CDC's infection control recommendations
(https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html), CMS
recommends that healthcare providers and staff wear surgical facemasks at all times, unless they
are delivering care that would require an N95 respirator.
• Procedures on the mucous membranes, including the respiratory tract, with a higher risk of
aerosol transmission, should be done with great caution, and staff should utilize appropriate
respiratory protection such as N95 respirators and face shields. If N95 respirators are needed,
they must be used in the context of a comprehensive respiratory protection program that complies
with the provisions of the Occupational Safety and Health Administration's (OSHA) Respiratory
Protection Standard (29 CFR 1910.134). This includes medical exams, annual fit testing (which may
be waived during the public health emergency to preserve facemasks), and training.
(https://www.osha.gov/memos/2020-03-
14/temporary-enforcement-guidance-healthcare-respiratory-protection-annual-fit).
• Patients and visitors should wear cloth face coverings that can be bought or made at home.
Facilities should be prepared to provide cloth face coverings or facemasks for patients and
visitors, which may include family members or caregivers, who do not have one upon entry
(https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/diy-cloth-face-coverings.html).
• Every effort should be made to conserve PPE, including following protocols for extended use and
re- use when necessary (https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html).
• Adequate supplies of PPE, equipment, medication, and supplies must be ensured to the
greatest extent possible and should not detract from the community's ability to respond to a
potential surge in COVID-19 cases.

Workforce Availability

• Workforce must be sufficient to respond quickly to augment COVID-19 care as necessary.
• Facilities should have a plan for screening and potentially testing the workforce for COVID-19
following CDC recommendations.
• Staff should be routinely screened for symptoms of COVID-19 daily upon arrival. If symptomatic,
staff should be tested, should not enter the facility, and should follow appropriate care and
isolation procedures (https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-
recommendations.html#monitor_manage).
• Staff who will be working in NCC zones should be limited to working in NCC areas and should
not rotate into COVID-19 care zones unless absolutely necessary. If required to rotate into
COVID-19 care zones, they should be particularly careful to use appropriate PPE and appropriate
sanitation protocols.
• Staff diagnosed with or suspected of having COVID-19 should follow the CDC Return to Work
Guidance to the greatest extent possible (https://www.cdc.gov/coronavirus/2019-ncov/hcp/return-to-
work.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-
ncov%2Fhealthcare-facilities%2Fhcp-return-work.html).
• Staffing levels in the community must remain adequate to cover a potential surge in COVID-19
cases.

Sanitation Protocols

• Ensure that there is an established plan for thorough cleaning and disinfection prior to using
spaces or facilities for patients with NCC needs.
• Ensure that equipment such as anesthesia machines used for patients diagnosed positive for
COVID- 19 are thoroughly decontaminated, following CDC guidelines
(https://www.cdc.gov/coronavirus/2019-
ncov/hcp/infection-control-recommendations.html#infection_control).

i Populations at Higher Risk of Severe COVID-19 Illness
By CDC definition
(https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher- risk.html),
populations at higher risk for severe COVID-19 illness include, but are not limited to, older
adults (aged 65 and older) and people with serious underlying chronic conditions such as chronic
lung disease, serious heart conditions (like congestive heart failure, coronary artery disease, and
pulmonary hypertension), diabetes, severe obesity, moderate-to-severe asthma, liver disease,
hemoglobin disorders and compromised immune function. At-risk populations also include people who
live or are receiving care in a nursing home or long-term care facility or who require dialysis for
chronic kidney disease. Furthermore, individuals with disabilities have a disproportionate rate of
underlying health conditions that place them at risk for severe COVID-19 illness.

For management of higher risk patients, CDC recommends that clinicians take these precautions:
• Develop a care plan with each patient and patient-specific plans for how to receive
unscheduled, urgent care if the need arises. Clinicians should provide each patient with
instructions for a 24/7 call-in line and how to contact the practice if they have symptoms or
concerns. A care plan should include any reasonable accommodations the patient may need in order to
be screened and treated as well as supportive services to address functional and social needs to
maintain their health status at home.
• To the extent possible, provide care remotely (e.g., by telemedicine).
• Limit major surgical procedures as much as clinically possible.
• Hospital staff should be prepared to properly screen and provide a facemask to a family member or
caregiver of an individual requiring such support.
• When in-person care is necessary, arrange for patients to minimize exposure through practices
such as:
Healthcare workers entering into the home or facility where a vulnerable person is staying should
practice social distancing and follow appropriate CDC guidance to minimize the risk of infection.

They also need to know about populations who may need to take precautions such as people
experiencing homelessness, pregnant or breastfeeding women, people living with a disability, or
individuals from a racial or ethnic group

(https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/other-at-risk- populations.html).

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Neal Comstock
Director of Membership
National Council
NealC@TheNationalCouncil.org
202 748-8793
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