On March 30, 2020, the Centers for Medicare and Medicaid Services (CMS) released a Quality, Safety & Oversight Group (QSO) memorandum (QSO-20-22-ASC, CORF, CMHC, OPT, RHC/FQHCs) addressing standards for infection control and prevention of Coronavirus (COVID-19) in certain outpatient care facilities, including ambulatory surgery centers (ASCs), community mental health centers (CMHCs), comprehensive outpatient rehabilitation facilities (CORFs), outpatient physical therapy or speech pathology services (OPTs), rural health clinics (RHCs) and federally qualified health centers (FQHCs).
The QSO memo addresses questions received by CMS from stakeholders and provides guidance to outpatient care settings other than hospital outpatient departments to address the COVID-19 pandemic and to provide guidance in reducing the likelihood of transmitting COVID-19 to other individuals.
Following up on its prior recommendation, CMS re-emphasizes the importance for all providers to delay non-essential medical, surgical and dental procedures to preserve personal protective equipment (PPE). Although CMS stops short of issuing an edict, CMS supplements its message by encouraging outpatient facilities to communicate with state and local health departments to reallocate PPE, bed capacity and ventilators to address community shortages.
CMS also reminds outpatient facilities that the Medicare Conditions of Participation do not require such facilities to provide 24-hour care. Therefore, if it is in a facility’s and patients’ best interest to cancel an appointment and to close operations temporarily, that practice may be acceptable. Facilities should follow their emergency preparedness policies and procedures to determine when a temporary shutdown is appropriate and to ensure patients are properly notified. This temporary shutdown would not be considered voluntary termination of the facility’s Medicare agreement under 42 CFR § 489.52 or § 416.35(a)(3), and CMS will not take any administrative action as long as the facility resumes operations or voluntarily terminates its Medicare enrollment within 30 days after the public health emergency is lifted.
To the extent practicable, facilities should announce their temporary closure on public-facing websites and social media platforms in addition to posting signs on entrance doors. Facilities that close temporarily are encouraged to contact local health officials to share ventilators and PPE if possible.
CMS advises facilities to identify patients at risk for having COVID-19 infection before or immediately upon arrival at the facility by screening individuals for fever or other COVID-19 symptoms, recent travel to a country with restrictions on entry to the United States, contact with a person with known or suspected COVID-19, or residing in a community where community-based spread of COVID-19 is occurring. CMS further encourages outpatient facilities to ask patients to call ahead to report fever or respiratory symptoms so they can be triaged to a hospital setting. If circumstances permit, outpatient care providers should contact patients shortly before their appointments to reconfirm the absence of fever or respiratory symptoms.
If space restrictions allow, outpatient care providers should establish limited entry points for all patients and should consider establishing alternative entry points for screening patients before entry. Any individual who demonstrates symptoms should be given a face mask at check-in and told to wear it for the duration of their visit. Outpatient care facilities should post signs at entrances with instructions in all appropriate languages advising patients to contact a staff member about any fever or respiratory symptoms that they are experiencing.
Outpatient facilities do not have the same frequency of visitors as may be seen in other care settings; however, CMS recommends that outpatient care facilities communicate with patients about any changes to policies and procedures regarding appointments and any visitor restrictions. CMS also encourages outpatient facilities to implement for visitors the same screening restrictions in place for patients and to restrict visitation rights to symptomatic visitors. Facilities should also consider setting limitations on visitation depending on the type of care provided. For some facilities, this may mean a restriction on the number of visitors. For other facilities this may mean restricting visitors only to those who provide assistance, are participating in joint therapy or are under a certain age.
Staff Screening and Access to PPE
Outpatient facilities should implement the same screening practices for staff as have been implemented for patients. Any staff that demonstrate symptoms while on the job should immediately stop work, don a facemask, self-isolate at home and inform the appropriate persons, including the local health department, about individuals, equipment and locations that the staff member contacted. Staff with confirmed or suspected COVID-19 should be restricted from returning to work based on guidelines from the Centers for Disease Control and Prevention (CDC). (See alsohttps://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html for risk assessments applicable to healthcare workers exposed to COVID-19 infected patients)) Furthermore, outpatient facilities should be diligent while cleaning and disinfecting surfaces; however, they should be equally diligent about providing staff with sufficient PPE to prevent exposure to infectious agents or chemicals.
Outpatient facilities are encouraged to have sufficient stock of supplies necessary to ensure hand and respiratory hygiene and cough etiquette for patients, visitors and staff, including no-touch trash receptacles, tissues and alcohol-based hand sanitizer. In addition to supplies for hygiene, CMS reiterated that outpatient facilities must maintain adequate supplies and equipment required by patients’ individualized plans of care. Given supply shortages, however, CMS will not cite facilities for having inadequate supplies for reasons outside of their control. In such an event, facilities should take action to mitigate any shortages and demonstrate that they are taking all reasonable steps to obtain necessary supplies.
Facilities are also instructed to notify local and state health departments regarding shortages of supplies and to follow national guidelines for optimizing their current supplies and/or to implement safe alternatives for patient care. Outpatient care facilities may be cited for not having or providing necessary supplies for reasons that they could control or for hoarding supplies in violation of President Trump’s March 23, 2020, Executive Order.
Key Takeaways: Outpatient facilities are encouraged to delay non-essential procedures and to share stores of PPE and ventilators with other front-line COVID-19 care providers to the extent practicable. If outpatient facilities decide to cease operations temporarily, CMS will not consider that cessation to constitute voluntary termination of the facility’s Medicare agreement as long as operations resume within 30 days after the public health emergency declaration is lifted. If outpatient facilities continue operations during the COVID-19 crisis, they should screen patients and staff for infections, revise their policies to reduce visitation practices and use best efforts to ensure ample access to PPE.