COVID-19 Guidance for Home Health Agencies

On March 10, 2020, the Quality, Safety & Oversight Group at the Centers for Medicare & Medicaid Services (“CMS”) issued a memorandum entitled “Guidance for Infection Control and Prevention Concerning Coronavirus Disease 2019 (“COVID-19”) in Home Health Agencies (“HHAs”)” (“QSO Memo”) that announced recommendations for HHAs regarding taking appropriate action to address potential and confirmed COVID-19 cases and mitigate transmission including screening, treatment and transfer to higher-level care (when appropriate).

CMS Urges Prompt Detection, Triage, Monitor and Isolation

The QSO Memo directs that HHAs should contact their local health department if they have questions or suspect a patient or staff member has COVID-19. CMS identifies prompt detection, triage and isolation of potentially infectious patients as essential actions to prevent unnecessary exposures among patients and health care personnel. The QSO Memo directs that HHAs must frequently monitor patients, staff and visitors for potential symptoms of respiratory infection in the home care settings. CMS also encourages HHAs to take advantage of CDC resources that have been made available by the CDC and CMS to train and prepare staff to improve infection control and prevention practices.

Screening Patients for COVID-19

The QSO Memo instructs that HHAs should identify patients at risk for having COVID-19 infection before or immediately upon arrival to the home. HHAs should actively screen patients and ask about:

International travel within the last 14 days to countries with sustained community transmission (See the CDC’s list of affected countries);
Signs or symptoms of a respiratory infection, such as a fever, cough and sore throat;
Any contact In the past 14 days with a confirmed COVID-19 diagnosis, under investigation for COVID-19, or have a respiratory illness; or
Whether the individual resides or had resided in a community where community‑based spreading of COVID-19 is occurring.

Monitoring and Restricting Staff

CMS directs that:

Health care providers who have signs and symptoms of a respiratory infection should not report to work.
Any staff that develops 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’s clinical manager 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, etc.).

The QSO Memo also directs HHAs to the CDC guidance for exposures that might warrant restricting staff from reporting to work.

It is important for HHAs (and Hospices) to consider how they will monitor their staff. The patients these providers serve are very vulnerable to COVID-19. However, unlike nursing facilities and hospitals, HHAs and Hospices do not see their staff each day. Agencies must reinforce with their staff that if they have any signs or symptoms, they must not report to work. This will be extremely important for patient safety.

Personal Protective Equipment (“PPE”)

The QSO Memo details that if care is provided to patients with respiratory or gastrointestinal symptoms who are confirmed or presumed to be COVID-19 positive, then HHAs should refer to the CDC’s Interim Guidance for Public Health Personnel Evaluating Persons Under Investigation and Asymptomatic Close Contacts of Confirmed Cases at Their Home or Non-Home Residential Settings.

The QSO Memo offers guidance on hand hygiene, when to put on PPE, altering persons within the home ahead of a visit and removal of PPE after visits. Providers should consider providing staff with training on these guidelines, and reinforcing that training periodically as this situation continues. Infection control has been a recurring survey citation over the last few years, but, with COVID-19, infection control has become a much more serious patient care issue. As we saw in Washington, home health and hospice patients are far more susceptible to COVID-19. Agency staff must take this very seriously and be very cautious.

Supply Shortages and Citations for Lack of Supplies

The QSO Memo directs that state and federal surveyors should not cite HHAs for not having certain supplies, including PPE, respirators and surgical masks if the HHA is experiencing difficulty in obtaining these supplies for reasons outside of their control. CMS expects HHAs to take action to mitigate any resource shortages and show they are taking all appropriate steps to obtain the necessary supplies as soon as possible. If there is a shortage of PPE due to regional or national supplier shortage, the HHA should contact the 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 provider should be cited for not having or providing the necessary supplies, the state agency should contact the CMS Regional Office. This is important to keep in mind, but, as of March 17, 2020, CMS has suspended most survey activity. The more practical issue for HHAs and hospice providers is the need to acquire PPE and, when unable to, to document the efforts. Agencies need to look beyond just their normal medical supply vendors. For example, providers may want to reach out to construction companies, construction suppliers, farm suppliers and others who stock masks. If providers are unable to obtain PPE, providers will want to document that they “left no stone unturned.”