Emergency Preparedness News and Announcements

Control and Prevention of Coronavirus Disease 2019 in Nursing Homes

Center for Clinical Standards and Quality/Quality, Safety  & Oversight Group

Ref: QSO-20-14-NH

DATE:            March 4, 2020

TO:                State Survey Agency Directors

FROM:          Director, Center for Clinical Standards and Quality/Quality, Safety  & Oversight Group

SUBJECT:     Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in nursing homes

Memorandum Summary

  • CMS is committed to taking critical steps to ensure America’s health care facilities and clinical laboratories are prepared to respond to the threat of the COVID-19.
  • Guidance for Infection Control and Prevention of COVID-19 – CMS is providing additional guidance to nursing homes to help them improve their infection control and prevention practices to prevent the transmission of COVID-19.
  • Coordination with the Centers for Disease Control (CDC) and local public health departments – We encourage all nursing homes to monitor the CDC website for information and resources and contact their local health department when needed (CDC Resources for Health Care Facilities: https://www.cdc.gov/coronavirus/2019- ncov/healthcare-facilities/index.html).

Background

CMS is responsible for ensuring the health and safety of nursing homes by enforcing the standards required to help each resident attain or maintain their highest level of well-being. In light of the recent spread of COVID-19, we’re providing additional guidance to nursing homes to help control and prevent the spread of the virus.

Guidance

Facilities should monitor the CDC website for information and resources (links below). They should contact their local health department if they have questions or suspect a resident of a nursing home has COVID-19. Per CDC, prompt detection, triage and isolation of potentially infectious patients are essential to prevent unnecessary exposures among patients, healthcare personnel, and visitors at the facility. Therefore, facilities should continue to be vigilant in identifying any possible infected individuals. Facilities should consider frequent monitoring for potential symptoms of respiratory infection as needed throughout the day. Furthermore, we encourage facilities to take advantage of resources that have been made available by CDC and

CMS to train and prepare staff to improve infection control and prevention practices. Lastly, facilities should maintain a person-centered approach to care. This includes communicating effectively with patients, patient representatives and/or their family, and understanding their individual needs and goals of care.

Facilities experiencing an increased number of respiratory illnesses (regardless of suspected etiology) among patients/residents or healthcare personnel should immediately contact their local or state health department for further guidance.

In addition to the overarching regulations and guidance, we’re providing the following information (Frequently Asked Questions) about some specific areas related to COVID-19:

Guidance for Limiting the Transmission of COVID-19 for Nursing Homes

How should facilities monitor or limit visitors? Facilities should screen visitors for the following:
International travel within the last 14 days to restricted countries. For updated information on restricted 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.
Has had contact with someone with or under investigation for COVID-19.
If visitors meet the above criteria, facilities may restrict their entry to the facility. Regulations and guidance related to restricting a resident’s right to visitors can be found at 42 CFR

§483.10(f)(4), and at F-tag 563 of Appendix PP of the State Operations Manual. Specifically, a facility may need to restrict or limit visitation rights for reasonable clinical and safety reasons. This includes, “restrictions placed to prevent community-associated infection or communicable disease transmission to the resident. A resident’s risk factors for infection (e.g., immunocompromised condition) or current health state (e.g., end-of-life care) should be considered when restricting visitors. In general, visitors with signs and symptoms of a transmissible infection (e.g., a visitor is febrile and exhibiting signs and symptoms of an influenza-like illness) should defer visitation until he or she is no longer potentially infectious (e.g., 24 hours after resolution of fever without antipyretic medication).”

How should facilities monitor or restrict health care facility staff?

The same screening performed for visitors should be performed for facility staff (numbers 1, 2, and 3 above).

  • Health care providers (HCP) who have signs and symptoms of a respiratory infection should not report towork.
  • 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 facility’s infection preventionist, and include 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).

Facilities 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).

When should nursing homes consider transferring a resident with suspected or confirmed infection with COVID-19 to a hospital?
Nursing homes with residents suspected of having COVID-19 infection should contact their local health department. Residents infected with COVID-19 may vary in severity from lack of symptoms to mild or severe symptoms or fatality. Initially, symptoms maybe mild and not require transfer to a hospital as long as the facility can follow the infection prevention and control practices recommended by CDC. Facilities without an airborne infection isolation room (AIIR) are not required to transfer the patient assuming: 1) the patient does not require a higher level of care and 2) the facility can adhere to the rest of the infection prevention and control practices recommended for caring for a resident with COVID-19. (https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html)

The resident 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 facility should be alerted to the resident’s diagnosis, and precautions to be taken including placing a facemask on the resident during transfer. If the patient does not require hospitalization they can be discharged to home (in consultation with state or local public health authorities) if deemed medically and socially appropriate. Pending transfer or discharge, place a facemask on the patient and isolate him/her in a room with the door closed.

When should a nursing home accept a resident who was diagnosed with COVID-19 from a hospital?

A nursing home can accept a patient diagnosed with COVID-19 and still under Transmission- based Precautions for COVID-19 as long as it can follow CDC guidance for transmission-based precautions. If a nursing home cannot, it must wait until these precautions are discontinued.

CDC has released Interim Guidance for Discontinuing Transmission-Based Precautions or In- Home Isolation for Persons with Laboratory-confirmed COVID-19. Information on the duration of infectivity is limited, and the interim guidance has been developed with available information from similar coronaviruses. CDC states that decisions to discontinue Transmission-based Precautions in hospitals will be made on a case-by-case basis in consultation with clinicians, infection prevention and control specialists, and public health officials. Discontinuation will be based on multiple factors (see current CDC guidance for further details).

Note: Nursing homes should admit any individuals that they would normally admit to their facility, including individuals from hospitals where a case of COVID-19 was/is present.

Other considerations for facilities:

  • Review CDC guidance for Infection Prevention and Control Recommendations for Patients with Confirmed Coronavirus Disease 2019: https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html
  •  Increase the availability and accessibility of alcohol-based hand sanitizer (ABHS), tissues, no touch receptacles for disposal, and facemasks at healthcare facility entrances, waiting rooms, patient check-ins, etc.
    • Ensure ABHS is accessible in all resident-care areas including inside and outside resident rooms.
  • Increase signage for vigilant infection prevention, such as hand hygiene and cough etiquette.
  • Properly clean, disinfect and limit sharing of medical equipment between residents and areas of the facility.
  • Provide additional work supplies to avoid sharing (e.g., pens, pads) and disinfect workplace areas (nurse’s stations, phones, internal radios, etc.).

What other resources are available for facilities to help improve infection control and prevention?

Contact: Email DNH_TriageTeam@cms.hhs.gov

Effective Date: Immediately. This policy should be communicated with all survey and certification staff, their managers and the State/Regional Office training coordinators immediately.

/s/
David R. Wright cc: Survey and Operations Group Management

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