CMS Issues COVID-19 Infection Control Guidance for Intermediate Care Facilities and Psychiatric Residential Treatment Facilities

INTRODUCTION

On March 30, 2020, the Centers for Medicare and Medicaid Services (CMS) released a Quality, Safety & Oversight Group (QSO) memorandum (QSO-20-23-ICF/IID & PRTF) addressing standards for infection control and prevention of Coronavirus (COVID-19) in intermediate care facilities for individuals with intellectual disabilities (ICF/IIDs) and psychiatric residential treatment facilities (PRTFs). The QSO memo addresses questions received by CMS from stakeholders and provides guidance to ICF/IIDs and PRTFs to address the COVID-19 pandemic and to provide guidance regarding infection control, visitation and maintaining each client’s/resident’s well-being.

IN DEPTH

CMS recognizes that ICF/IIDs and PRTFs provide highly specialized and individualized care to clients and residents of such facilities. Accordingly, a one-size-fits-all approach to addressing COVID-19 infection control may not be appropriate.

ICF/IIDs and PRTFs should continue striving to identify possible infections in their clients, residents and staff. For these care populations, CMS encourages a person-centered approach to care, including communicating with the client/resident and their representatives and understanding the individual needs and goals of care. Staff should maintain open communication about COVID-19 and the infection control procedures that the facility is undertaking. This may include discussions regarding modifications or restrictions to individuals’ daily routines and should account for the individual’s age, preferred language, emotional, psychological and functioning status, and the use of any auxiliary aids or services.

CMS emphasizes that all individuals should receive COVID-19-related information appropriate to their functioning level but notes that an individual’s functioning level is not an appropriate reason to withhold communication. CMS also addresses several other considerations that these facilities must keep in mind during the COVID-19 crisis.

Staffing Shortages

CMS recognizes that the health and safety of clients, residents, visitors and staff are its highest priority. If a staff member is exposed to an individual with known or suspected COVID-19 infection, facilities should refer to the CDC Risk Assessment chart to determine whether the staff member should self-isolate and when that staff member may return to work.

Recognizing that facilities may quickly become short-staffed, CMS emphasizes that providers may ask for individual Section 1135 waivers if the existing CMS waivers are insufficient to address the needs of a particular ICF/IID or PRTF. (See our prior analysis of these waivers here and here.) Currently, CMS is not waiving any staffing requirements applicable to an ICF/IID facility, but one may be requested and reviewed on a case-by-case basis to address an individual facility’s circumstances.

ICF/IID facilities are encouraged not to combine residents of several homes to account for staffing shortages, as that practice may increase social interaction beyond recommended levels. However, for ICF/IIDs operating as multiple sites under a single CMS certification number, facilities may be permitted to cohort residents in a way to mitigate any transmission risk, depending on facts and circumstances and input from local and state public health authorities. If separately-certified ICF/IIDs find that they need to combine residents, they are encouraged to contact their state to discuss licensure requirements and to request an emergency Section 1135 waiver. Regardless of the circumstances, ICF/IID facilities should keep diligent records about which residents were moved and ensure appropriate measures have been taken to protect the health, safety and welfare of residents during transit.

Screening Staff and Visitors

Facilities are encouraged to screen staff and visitors for symptoms of COVID-19, including fever, respiratory infection and the other factors described above. If a staff member demonstrates signs and symptoms of COVID-19 infection, that staff member should stay home. If symptoms arise on the job, that individual should immediately stop work, don a face mask, self-isolate at home and inform the appropriate person(s), including local health authorities, about individuals, equipment and locations that the staff member contacted. For clients/residents who are restricted from having visitors, facilities should consider providing alternative means of communication for people who would otherwise visit, including virtual visits.

Community Activities

ICF/IID facilities should limit community activities by following Centers for Disease Control and Prevention (CDC) guidance on mass gatherings. On a national level, this means that individuals should practice social distancing, should avoid gatherings of more than 10 people for high-risk populations, and should refrain from going into the community except as needed for essential activities. State and local orders may further limit this guidance, and the vulnerability of certain populations may require heightened prudence at the facility’s discretion.

Care Plans for Individuals with COVID-19

ICF/IID facilities are authorized pursuant to 42 CFR § 483.440(c) to modify an individual program plan (IPP) with the approval of the facility’s interdisciplinary team. Such modification may be necessary to comport with the facility’s emergency preparedness policy while managing an individual’s active treatment plan. If a client/resident is found to have COVID-19, the IPP should identify the specific steps and procedures needed to quarantine the individual while taking all reasonable steps to protect the rights, safety and health of the individual, other clients/residents and staff.

CMS recommends following the current CDC guidance on infection prevention and control practices in consultation with local and state health authorities. If possible, an infected individual should remain in their room with the door closed. CMS recognizes that trial and error of multiple quarantine solutions may be necessary before finding an appropriate way to practice good infection control in these facilities. Adherence to a routine should be maintained to the extent practicable, including access to the outdoors, staff, and treatment while under quarantine.

Specialty care facilities with individuals confirmed or suspected of having COVID-19 infection should consider implementing telemedicine services in most circumstances and should contact their state health agency for guidance before transferring an individual to a hospital. If quarantine and infection control practices are sufficient and the individual does not require a heightened level of care, an airborne infection isolation room is not necessary. If a transfer becomes necessary, the facility should notify emergency medical services and the receiving facility about the individual’s health status and should place a face mask on the individual to wear during the transfer. If wearing a face mask is not possible or practicable, then a facility staff member wearing a face mask should provide supervision to ensure the individual remains isolated until transfer. CMS emphasizes the need for clear communication with the individual about what to expect during the transfer, in a level of detail appropriate for the circumstances.

An ICF/IID or PRTF facility may accept the transfer of an individual with COVID-19 infection only if the facility can follow CDC guidance on transmission-based precautions. If a facility can accept such transfers, it should consider dedicating a wing or room(s) for any individuals returning from the hospital, where they can receive step-down care until they remain for 14 days without symptoms.

Access to PPE

CMS reiterated that specialty care facilities must maintain adequate supplies and equipment required by clients’/residents’ IPPs. 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 the shortage and to follow national guidelines for optimizing their current supply and/or to implement safe alternatives for patient care. Specialty 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

ICF/IIDs and PRTFs face unique challenges in providing care to a vulnerable care population during the COVID-19 crisis while also adhering to proper infection control and prevention