On March 30, 2020, CMS issued updates to its March 9, 2020, memo from the Quality Safety and Oversight (QSO) Group on controlling and preventing the spread of Coronavirus (COVID-19) in dialysis facilities and other facilities. (See our original On the Subject here.) Below is a summary of the noteworthy additions to the updated memo, which focus on dialysis facilities and services.
The March 30, 2020, dialysis facility QSO memo (QSO022019-ESRD Revised) focuses on several practices to limit the transmission of COVID-19 in dialysis facility settings through screening patients and staff, isolating patients with suspected or confirmed COVID-19 infections, and transferring patients to alternative dialysis locations. The memo also addresses specific practices applicable to special purpose renal dialysis facilities (SPRDFs).
Identifying Risk of COVID-19 in Patients and Staff
Dialysis facilities are encouraged to screen all patients, staff and visitors for COVID-19 symptoms using the four criteria listed our prior On the Subject. Patients who present with signs and symptoms of respiratory infections should be identified prior to entering the dialysis treatment area and should be required to wear a face mask at check-in and until they leave the facility. Dialysis facilities are also encouraged to post signage at the facility entrance instructing patients to notify staff if they have a fever or respiratory infection symptoms so that appropriate precautions may be exercised. Staff who demonstrate signs and symptoms of respiratory infection should not report to work, or if symptoms arise at work, they should immediately stop working, don a face mask, self-quarantine at home, and inform the dialysis facility administrator of any patients or staff with whom they came into contact.
Caring for Patients with COVID-19 Symptoms
CMS recognizes that patients will continue to need dialysis treatment during the symptomatic stage of a COVID-19 infection, so dialysis facilities are encouraged to provide masks to symptomatic patients and to have space in waiting areas to segregate ill patients from other patients by at least six feet. If possible, dialysis treatment of symptomatic patients should occur in a separate room with the door closed or otherwise away from the main flow of traffic, and at least six feet from other patient stations. Medically stable patients who do not have other care needs could be asked to wait outside the facility until staff call the patient on their cell phone.
Facilities should continue to follow infection control requirements, including hand hygiene, PPE, isolation, routine cleaning and disinfection procedures. For patients who receive at-home dialysis treatments, CMS emphasizes that monthly monitoring in onsite locations should continue in accordance with these precautions. If a dialysis facility anticipates having any PPE shortages, the facility should communicate with their state and local public health officials.
Transferring Patients to Alternative Sites
Dialysis facilities should consider transferring patients to another treatment site if the facility cannot fully implement the recommended precautions or if the patient requires care that the facility is unable to provide. Transport personnel and the receiving facility should be notified in advance of the patient’s healthcare needs, and the patient should wear a face mask and remain separated from other patients while awaiting transfer.
Special Purpose Renal Dialysis Facilities (SPRDFs)
Dialysis facilities may apply for SPRDF certification to serve dialysis patients in a temporary location, including hospitals and long-term care facilities, under emergency circumstances if COVID-19 presents an access-to-care issue such that patients would otherwise be unable to obtain treatment in the geographic service area. (42 CFR § 494.120; State Operations Manual Chapter 2, Section 2272). SPRDF certification may also be requested for situations where a dialysis facility encounters symptomatic patients whom it must cohort in order to limit and contain exposure.
SPRDF certifications are effective for eight months in any 12-month period. Once the SPRDF certification expires, facilities must have a plan for the safe and coordinated transfer of its patient(s) to a permanent outpatient dialysis setting. To participate in bill Medicare, the SPRDF must complete and submit a Medicare enrollment application; complete and submit an end-stage renal disease certification application; obtain any applicable state requirements (e.g., licensure, certificate of need); and undergo a federal survey (although services may be provided before the survey is completed). SPRDF certifications do not require a Section 1135 waiver.
Key Takeaways: Dialysis services remain necessary for patients infected with COVID-19 or demonstrating signs and symptoms of respiratory infections. Dialysis facilities are advised to provide masks and segregate symptomatic patients by at least six feet if a private room or separate wing is not available. A dialysis facility may enroll in Medicare and be certified as a special purpose renal dialysis facility for up to eight months in emergency situations such as the current public health crisis with the spread of COVID-19.