Skilled nursing facilities (“SNFs”) are facing many challenges as their residents and staff encounter COVID-19. During the COVID-19 pandemic, Centers for Medicare & Medicaid Services (“CMS”) and state departments of health have focused on infection control surveys, programs, and prevention. This week, the Centers for Disease Control and Prevention, Center for Preparedness and Response (the “CDC”) presented a webinar on “Applying COVID-19 Infection Prevention and Control Strategies in Nursing Homes” (the “CDC 2020 COVID-19 Infection Prevention and Control Strategies”).
This article identifies several key topics and areas that the CDC raised in the CDC 2020 COVID-19 Infection Prevention and Control Strategies that SNFs can use now to adapt their infection control programs and personnel.
Background – Infection Control – Sec. 483.80
42 CFR Section 483.80 requires facilities to establish and maintain an infection prevention and control program (“IPCP”) designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 42 CFR Section 483.80 details the elements that must be included in an IPCP. These elements include, but are not limited to:
- A system for preventing, identifying, reporting, investigating and controlling infections and communicable disease. This includes staff, visitors, volunteers and others performing contracted services to the SNF;
- Written standards, policies and procedures; and
- When and how isolation will be utilized for a resident.
The IPCP must have a system for reporting incidents and corrective action taken by the SNF in response to the incident(s). Section 483.80(f) requires each SNF to conduct an annual review of its IPCP and update its program as necessary.
42 CFR Section 483.80 also calls for the IPCP to be linked to the SNF’s facility assessment in Section 483.70(e) and for the SNF’s antibiotic stewardship program to be operational.
Infection Preventionist
42 CFR Section 483.80 requires SNFs to appoint an infection preventionist (“IP”) who is responsible for the SNF’s IPCP. The IP’s participation in the Quality Assessment & Assurance (“QAA”) is also required.
In addition, the IP:
- Must have professional training in nursing, microbiology, medical technology, epidemiology or a related field;
- Must be qualified by education, training, experience or certification;
- Must work at least part-time at the SNF; and
- Must have completed specialized training in infection prevention and control.
Proposed Regulations
On July 18, 2019, CMS published proposed revisions (“Proposed Rule”). CMS stated that it identified a number of existing skilled nursing facility requirements that could reduce unnecessary burdens on SNFs if they were simplified or eliminated. As of the date of this article, CMS has not finalized the Proposed Rule by publishing final regulations.
The Proposed Rule proposes to remove the requirement that the IP work at the SNF “part-time” or have frequent contact with the IPCP staff at the SNF. The Proposed Rule instead requires that the SNF must ensure that the IP has sufficient time at the SNF to meet the objectives of its IPCP.
CDC Recommendations and Reimagining Your Infection Prevention and Control Program
In the CDC 2020 COVID-19 Infection Prevention and Control Strategies, the CDC specifically called for:
Revisit the Role of the Infection Preventionist
The CDC 2020 COVID-19 Infection Prevention and Control Strategies called for SNFs to designate an individual for infection control duties, in SNFs this is the IP. The CDC called for this role’s actions to include:
- Report into the National Healthcare Safety Network (“NHSN”) Long-Term Care Facility COVID-19 Module weekly.
- Educate residents, health care personnel (“HCP”) and visitors about COVID-19.
- Implement source control measures, (e.g., universal face mask use).
- Have a plan for visitor restrictions.
- Create a plan for testing residents and HCP for SARS-CoV-2.
- Evaluate and manage HCP.
- Evaluate and manage residents with symptoms of COVID-19.
Dedicated Space
The CDC 2020 COVID-19 Infection Prevention and Control Strategies called for SNFs to prioritize a separate area for COVID-19 care and recommended space designated that is only for:
- Physically separated from other rooms or units (e.g., separate entry/exit).
- Space for staff (e.g. charting, break area and restrooms).
- Clean areas for personal protective equipment (“PPE”) donning.
- Space for PPE doffing and decontamination.
Dedicated Staff
The CDC 2020 COVID-19 Infection Prevention and Control Strategies called for SNFs to prioritize separate staff for COVID-19 care and recommended that the SNF:
- Dedicate a team to the COVID-19 care unit (at least direct care nursing staff).
- Bundling care tasks to conserve PPE and limit the number of entries.
- Provide supplies and supports for the team (e.g., uniform laundering, meals, work incentives).
Implement a Respiratory Protection Program
The CDC 2020 COVID-19 Infection Prevention and Control Strategies called for SNFs to implement a respiratory protection program that includes medical evaluations, training and fit testing.
Moving Residents Based on Symptoms
The CDC 2020 COVID-19 Infection Prevention and Control Strategies offered an example of a resident that had a high temperature for two days and slightly lower oxygen saturation. His roommate has no complaints and a negative symptom screen. In this case, the CDC called for the SNF to take the following actions:
- Implement Transmission-Based Precautions while evaluating asymptomatic resident (a) increase clinical monitoring of symptomatic residents (e.g., q shift); and (b) prioritize SARS-CoV-2 testing (viral detection).
- If available, the SNF could move to a private room while awaiting testing. However, the CDC stated that the SNF should not move residents into a COVID-19 unit based on symptoms alone.
- Leave roommate in the current bed while awaiting additional information.
- Notify local health department about the suspected case.
Action Items
SNFs should:
- Review and revise their infection control policies and procedures;
- Confirm that the IPs at the SNF meet the requirements of 42 CFR Section 483.80; and
- Implement a policy and procedure on how the IPs are included in the QAA and issue reports to the QAA.
If you have questions about this topic or would like assistance in compliance with the SNF compliance and ethics program requirements, please contact:
- Sean Fahey at (317) 977-1472 or sfahey@wp.hallrender.com;
- Todd Selby at (317) 977-1440 or tselby@wp.hallrender.com;
- Brian Jent at (317) 977-1402 or bjent@wp.hallrender.com; or
- Your regular Hall Render attorney.
More information about Hall Render’s Post-Acute and Long-Term Care services can be found here.
Hall Render’s attorneys and professionals continue to maintain the most up-to-date information and resources at our COVID-19 Resource page, through our 24/7 COVID‑19 Hotline at (317) 429-3900 or by contacting your regular Hall Render attorney.
Hall Render blog posts and articles are intended for informational purposes only. For ethical reasons, Hall Render attorneys cannot—outside of an attorney-client relationship—answer specific questions that would be legal advice.
