Section for Long-Term Care Regulation Update

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3/26/2021

    Section for Long-Term
       Care Regulation
           Update

                     S HE LLY WILLIAMS ON, ADMINIS TRATO R

1

    Outbreak Status
    Where we are:
      As of March 25, 2021, 58 communities have a current outbreak.
       These are levels not seen since July, 2020.
    Where we were:
      At our peak (December 13, 2020), 674 communities had a current
       outbreak.
    From the beginning:
      Outbreaks have occurred in 934/1,196 (78%) long term care
       communities.

2

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3/26/2021

    Positivity Rates
    CMS generated positivity rates (https://data.cms.gov/stories/s/COVID-
    19-Nursing-Home-Data/bkwz-xpvg) as of March 8, 2021
      Red (10% or greater – testing 2x/week) – 3 counties
      Yellow (between 5 and 10% - testing 1x/week) – 43 counties
      Green (below 5% or 20 or less tests – testing 1x/month) – 69
       counties
    In December, 2020
      Red - 46 counties
      Yellow - 66 counties
      Green – 3 counties

3

    DHSS Website
    COVID-19 Main Page –
    https://health.mo.gov/living/healthcondiseases/communicable/novel-
    coronavirus/
    Reporting of Outbreaks -
    https://health.mo.gov/living/healthcondiseases/communicable/novel-
    coronavirus/
    COVID-19 Dashboard -
    http://mophep.maps.arcgis.com/apps/MapSeries/index.html?appid=8e
    01a5d8d8bd4b4f85add006f9e14a9d
    Health Care Professionals Page -
    https://health.mo.gov/living/healthcondiseases/communicable/novel-
    coronavirus/professionals.php

4

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3/26/2021

    DHSS Website
    PPE Resources -
    https://health.mo.gov/living/healthcondiseases/communicable/novel-
    coronavirus/ppe.php
    Testing Supplies (through MSPHL) -
    https://health.mo.gov/living/healthcondiseases/communicable/novel-
    coronavirus/specimen-collection-supplies.php
    BinaxNOW Testing Supplies –
    https://mophep.maps.arcgis.com/apps/opsdashboard/index.html#/782
    d206fd20a40d3b7ff4ea3b2a2d17c
     LTC Reopening Guidance –
    https://health.mo.gov/living/healthcondiseases/communicable/novel-
    coronavirus/professionals.php#collapseSix

5

    Vaccine Update
    Clinics through CVS/Walgreens
       1st clinics completed
       2nd clinics ~98% completed
       3rd clinics – ~ 80% completed. Will be administering 1st dose at 3rd
        clinic
    2nd doses for those receiving 1st dose at 3rd clinic
       Regional Implementation Teams (RITs) and Missouri National Guard
        will be coordinating with local partners to administer 2nd doses to
        those who received their 1st dose at the third clinic by CVS or
        Walgreens.

6

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3/26/2021

Vaccine Update
Ongoing Vaccination Efforts
 Several options for communities to ensure ongoing vaccine availability for residents and staff
 Becoming a vaccinator
 Working with a pharmacy to provide onsite vaccine
 Taking residents and staff to a pharmacy for vaccine
 Working with local partners – LPHAs, FQHCs, etc.
 Working with local hospital – especially for residents who received 1st dose in hospital

Those ordering vaccine for long term care communities should forward their confirmation email
to covidvaccineorders@health.mo.gov to ensure vaccine is prioritized.
Communities will need to work with their medical providers to decide which vaccine meets their
needs. The department will not assist with this decision.
The University of Missouri-Columbia COVID Accountability Team (CAT) team will be available to assist
communities with determining which option best meets their needs and with navigating through the
process.
Contact QIPMO at https://nursinghomehelp.org/contact/ for assistance.

Guidance
Testing Guidance
Currently no changes to CMS/CDC or DHSS guidance.
Visit Guidance
CMS revised guidance issued March 10th.
DHSS revised guidance issued on March 25th.
 Guidance includes visit guidance as well as merging other guidance
documents related to reopening, beauty and barber visits, resident
outings, etc.

3/26/2021

     Visit Guidance
     Revised Visit Guidance – key changes
       Facilities should allow indoor visitation at all times and for all
        residents (regardless of vaccination status), except for a few
        circumstances when visitation should be limited due to a high risk of
        COVID-19 transmission (note: compassionate care visits should be
        permitted at all times):
          Limit indoor visitation for unvaccinated residents, if the nursing home’s
           COVID-19 county positivity rate is >10% and

3/26/2021

     Visit Guidance
        Provides guidance to describe how visitation can still occur when
         there is an outbreak, but there is evidence that the transmission of
         COVID-19 is contained to a single area (e.g., unit) of the facility.
           Immediately begin outbreak testing and suspend indoor visitation until
            at least one round of facility-wide testing is completed.
             If the first round of testing reveals no additional cases in areas with no COVID cases,
              visitation can resume for residents in areas with no COVID-19 cases
             If first round of testing reveals additional cases in other areas, indoor visitation should be
              suspended for all residents until criteria to discontinue outbreak testing is met.

11

     Visit Guidance
     Notes that compassionate care visits and visits required under federal
      disability rights law should be allowed at all times, for any resident
      (vaccinated or unvaccinated).
     States that while visitor testing and vaccination can help prevent the
      spread of COVID-19, visitors should not be required to be tested or
      vaccinated (or show proof of such) as a condition of visitation.
       Applies to Office of the State Long-Term Care Ombudsman and protection
        and advocacy systems.

12

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3/26/2021

DHSS Guidance
Essential Caregivers – removed the number of essential caregivers that
can be designated. Only one essential caregiver should be present at
any given time.
Providers of Services - Entry of personnel/contractors as determined
necessary by the facility. Visits may be limited as described above when
an outbreak exists.
Resident Outings
 Screen and increase monitoring
 Place on transmission based precautions if develop signs and symptoms.
 Consider placing on transmission based precautions and testing if resident
leave frequently or for a prolonged length of time, such as over 24 hours.
 Residents who have had COVID-19 in past 90 days and are off of transmission
based precautions to not need to quarantine following an outing.

Sewershed Testing
Sewershed testing has been successful in identifying outbreaks early in care facilities.
This has allowed additional testing and quarantine to quickly address the outbreak
and minimize duration of the outbreak. Currently working on methods to look at
variants.
Results indicate that sewage data best correlates with confirmed COVID-19 case
counts with a 4 to 6 day time lag, suggesting wastewater results can be an early
indicator of disease transmission.
Efforts underway to recruit 20 communities to participate in this testing. Ideally,
communities would have 50 or more residents.
Please contact the Department of Health and Senior Services Environmental Public
Health Tracking Team at EPHTN@health.mo.gov or 866-628-9891 or 573-751-6102
to express interest in the project or to ask any additional questions.

3/26/2021

                        Sampling sites (so far)
 -63 wastewater treatment
 facilities (WWTF) in Missouri

 -6 state mental hospitals

 -21 state prisons

 -5 veterans homes

 -5 Universities

 -(2 WWTF in Boise, Idaho)

15

         CDC Study
         Objectives:
            Estimate COVID-19 vaccine effectiveness
            Estimate COVID-19 vaccine impact on viral shedding
         Characteristics of Study Site:
            150-200 residents preferred
            Serial testing of asymptomatic residents after identified case
            Ideal vaccination rate for residents of 30-70%
            At least one completed vaccine clinic
         Outbreak Type:
            At least 10 cases among residents within a 2 week period, 30+cases preferred

16

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3/26/2021

     CDC Study
     Data Required:
        Patient demographics
        Assay type (PCR testing strongly preferred)
        Vaccination status, manufacturer and date of vaccination(s)
        Symptoms and onset date
        Previous infection with COVID-19
        Staff case status and vaccination coverage data

     Contact Amy Pierce amy.pierce@health.mo.gov for questions or interest in
     participating in study.

17

     SLCR Activities
     Outbreak Response
     Focused Infection Control Surveys
        2,099 completed since mid-May
     Routine Surveys and Complaint Investigations
        Focus on complaint backlog and overdue surveys
     Common F880 Citations
        Positive/negative residents in same room
        PPE use
        Hand hygiene
        Mask use

18

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3/26/2021

     State Regulations
     Nursing Facility Level of Care
        Proposed regulations published on February 16, 2021 -
         https://www.sos.mo.gov/CMSImages/AdRules/moreg/2021/v46n4F
         eb16/v46n4b.pdf

     Certified Nurse Assistant
        Rules expected to be filed this month.

19

     Electronic Monitoring
     Rules published as a result of passage of legislation in 2020.
     https://www.sos.mo.gov/CMSImages/AdRules/csr/current/19csr/19c30-
     91.pdf
     -Allows residents, guardians or legal representatives to install electronic
     monitoring devices in resident rooms
     - Each facility shall use an electronic monitoring device
     acknowledgment form developed by the department and adopted by
     regulation
     - There must be consent from other residents residing in the room,
     using a form prescribed for such purpose by the department

20

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3/26/2021

     Electronic Monitoring
     - The facility shall require a resident who conducts authorized electronic
     monitoring, or the resident's guardian or legal representative, to post
     and maintain a conspicuous notice at the entrance to the resident's
     room. The notice shall state that the room is being monitored by an
     electronic monitoring device
     - The resident or the resident's guardian or legal representative shall
     pay for all costs associated with conducting electronic monitoring,
     except for the costs of electricity
     - Each facility shall post a notice at the entrance to the facility stating
     that the rooms of some residents may be monitored electronically by,
     or on behalf of, the residents and that the monitoring is not necessarily
     open and obvious. The department by rule shall prescribe the format
     and the precise content of the notice

21

     Resources
     Subscribe to the LTC Information Update Listserv by
     visiting and following the prompts at:
       http://cntysvr1.lphamo.org/mailman/listinfo/ltcr_information_update

     To view past Listserv posts and the LTC blog, visit:
       http://health.mo.gov/blogs/ltcblog/

     Visit the site below to view newsletters and additional
     resources:
       http://health.mo.gov/seniors/nursinghomes/providerinfo.php

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3/26/2021

     Resources
      http://www.cms.hhs.gov/Medicare/Provider-Enrollment-and-
     Certification/SurveyCertificationGenInfo/

       CMS Quality, Safety and Oversight Group Memos – click on ‘Policy
        and Memos to States and Regions’
         Normally released on Fridays

      https://qsep.cms.gov/welcome.aspx

      https://qcor.cms.gov

23

     QUESTIONS
                        Section for Long Term Care Regulation
                                         573-526-4872

                           Shelly.williamson@health.mo.gov

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