CMS/CDC Guidance Changes SummarySummary of CMS and CDC Guidance Changes (09/23/22)
DISCLAIMER: The CMS intent behind the guidance updates was to align with that CDC guidance updates so that both CDC and CMS are speaking in the same language. CDC and CMS acknowledged the need to relax some of the practices that are not indicated at this point in the pandemic and in particular CMS followed CDC in having guidance for testing and quarantine that is no longer based on whether a resident or staff is up to date with their vaccinations.
Previous guidance has been archived and no longer exists in the current guidance for healthcare settings. It is important to note that you need to check your local and state guidance while CDC and CMS have changed their guidance and brought these reliefs described there may be guidance from your local and state health departments which is more restrictive. MHCA has contacted the Maine DHHS Division of Licensing and confirmed with Bill Montejo that they DO NOT anticipate releasing any additional memos regarding these changes.
Key Infection Prevention and Control Updates:
- Routine testing of staff is no longer required. You do not need to test your staff on any sort of routine basis any longer. Facilities can opt to perform this at their discretion, but you're no longer required by CMS or CDC to do any kind of routine testing of your staff.
- You still need to test based on exposure, but you no longer need to test asymptomatic staff.
- Outbreak definition largely remains the same, the one change is that a resident who is admitted to transmission-based precautions would not qualify as an outbreak. In addition, if a resident is admitted directly to transmission-based precautions /with COVID or a known exposure and develops COVID while in transmission-based precautions an outbreak is not triggered.
- You should be instructing all your staff, regardless of vaccination status to report any of the following criteria to occupational health, infection preventionists or another facility point of contact to be properly managed. This would include a positive COVID test, symptoms, or a higher risk exposure.
- You should be testing residents or staff with symptoms or signs of COVID immediately regardless of vaccination status as soon as possible but no earlier than 24 hours if it's an exposure that's being tested.
- For residents or staff who test positive, facilities should follow CDC guidance that states residents should be based placed on transmission-based precautions or work restrictions until the CDC criteria to discontinue has been met.
- Requirement for outbreak testing hasn't changed. You should be performing testing for all residents and staff regardless of vaccination status. Testing is recommended immediately but not earlier than 24 hours after exposure. If they're negative, you will test again 48 hours after the first negative test and if again 48 hours after the second negative test so this will be typically be on day one (1) day three (3) and day five (5).
- Contact tracing approach may be more challenging because it requires you to identify all potential contacts within the organization where a broad-based approach is preferred if you can't identify all potential contacts or manage them.
- A broad-based approach would mean testing on an entire unit, floor or facility based on where the outbreak is.
Refusal of Testing:
- Facilities must have procedures in place to address staff or residents who refuse testing.
- For staff who have signs or symptoms of COVID-19 and refused testing are prohibited from entering the building until the return-to-work criteria are met. If outbreak testing has been triggered and a staff member refuses to be tested, they should be restricted from the building until the outbreak testing has been completed and the facility should follow its occupational health and local jurisdiction policies with respect to any asymptomatic staff who refuse testing during an outbreak.
- For residents who want to exercise their right to decline testing for COVID-19 facilities should have procedures in place that ensure that those residents who refuse testing are managed in accordance with the CDC guidance for the use of transmission-based precautions. In discussing testing with residents, CMS/CDC recommends that you use person centered approaches when explaining the importance of testing and understanding why the resident might be refusing testing.
- CMS released a new QSO memo that rescinds what was previously an enforcement discretion for the use of COVID tests on asymptomatic individuals outside of the test instructions. By way of background, in December of 2020 when HHS and the administration started sending out antigen tests to nursing homes one of the problems, we encountered was that a lot of those antigen tests were only recommended for people with symptoms and at the time there were actually being sent for the screening testing of staff, so this posed a problem for facilities performing this testing under their clia waiver.
- Fast forward to September of 2022, most antigen tests are now recommended for serial testing of asymptomatic staff so if you're using them on people who are asymptomatic you can use them as long as you're testing at a frequency defined on the test. It's usually every couple days for three test periods and that means that you're using the test within it's instructive use so it can be used on someone who's asymptomatic as long as it's recommended for serial testing. So since this is now rescinded when you're performing tests in your facility under that clia waiver you need to make sure that you understand the manufacturers use for the test that you're using. The FDA website has a list of all antigen tests that have been approved by the FDA and what they're approved for.
- It's very easy to find what they're approved for and again most of them are approved for testing on symptomatic people within a certain number of days as well as serial testing of asymptomatic people there are some that are only recommended for symptomatic people so you do need to make sure that you understand the manufacturer's instructions for use when you're using these tasks.
- New admissions no longer must be quarantined or isolated unless they have confirmed or suspected COVID-19. The new guidance is based on your current community transmission levels though so if community transmission is high testing is recommended at admission and if negative again test 48 hours after the first test and if negative again test 48 hours up in the second test and again. Admissions should be advised to wear source control for 10 days following their admission and we recommend that facilities develop and follow policies for new admissions and what they can do during this testing protocol.
- If community transmission levels are NOT high:
- Testing and source control is at the discretion of the facility. You are not required to test or use source control upon resident admission. Source control is of course recommended for individuals who have suspected or confirmed COVID-19 infection, had close contact with someone with COVID-19 within the last 10 days or if the facility is experiencing outbreak.
- CDC clearly states that residents who leave the facility for less than 24 hours do not need to quarantine except in certain situation described in the CDC's transmission-based precaution guidance such as having symptoms. If they leave from more than 24 hours they should be then managed as a new admission using the criteria above.
- CDC and CMsS have offered several guidance reliefs around visitation the biggest being that they removed references to up-to-date vaccination status from the visitation guidance entirely so the visitation guidance no longer hinges on whether or not a resident has been vaccinated and boosted.
- They also removed the requirement to screen all who enter the facility but they've added the guidance that facilities are now required to post guidance signs at entrances regarding recommendations for visitors who have had a positive viral test for COVID-19 symptoms or if had close contact with someone with COVID-19.
- In terms of additional reliefs that were provided in the visitation guidance for face coverings and masks again it hinges on community transmission level. If you're in a county with high community transmission everyone should wear face coverings or masks in the facility.
- If the community transmission levels are not high, face coverings and masks are optional. It is still the safest practice.
- Face masks are required during an outbreak.
- During an outbreak resident and their visitors when alone in the resident's room or visitation area are not required to mask and they may have physical contact. That applies within high low moderate substantial community transmission.
- When a roommate is present during a visit it's always safest for the visitor to wear a face covering or mask.
- Facilities policies regarding face coverings and masks must be based on recommendations from the CDC and state and local health departments (Maine CDC) as well as individual facility circumstances. Make sure that you're checking your state and local health requirements so that you're following those requirements in addition to the federal requirements.
- As laid out in the visitation memo by CMS facilities should provide guidance such as posted signs at entrances regarding the recommended actions for visitors who had a positive test, symptoms or close contact. Visitors with confirmed infection or symptoms should defer non urgent visitation until they have met CDC criteria for healthcare settings to end isolation.
- Should a resident choose to leave the facility you should remind them that the resident in any of the individual accompanied them should follow all recommended infection prevention control practices such as wearing a face covering or mask or performing hand hygiene and this is especially important for those individuals at higher risk for severe illness and when community transmission is high.
- Visitation and activities during an outbreak investigation are allowed. You have to allow visitors during an outbreak, but you can recommend that deferring visitation is the safest option. Visitors should be made aware of the potential risk of visitation during an outbreak investigation and adhere to the core principles of infection prevention control.
- Guidance changes for CDC include two categories for consideration: 1) community transmission levels that are high and 2) community transmission levels are not high.
- If community transmission levels are high everyone should wear source control. CMS refers to this as face coverings and masks. Healthcare personnel could choose not to wear source control when in areas restricted from patient access so those examples are your offices or break rooms or places that patients don't come into.
- If community transmission levels are not high source control is only recommended for individuals who have suspected or confirmed respiratory infection, had close contact with someone with COVID-19 and for 10 days after that contact, reside or work in areas of the facility experiencing a COVID-19 outbreak or have otherwise had source control recommended by public health.
- When the community transmission levels are high everyone in those areas where the healthcare professional can encounter residents should wear source control. N95s are only used in select situations such as when aerosol generating procedures such as nebulizer treatments are used or during care of patients with COVID-19 or in area or units where there is an outbreak. Eye protection is used during
- We continue to work on advocating for CMS to bring relief to that but your facilities are still required to make those notifications according to the time frame that specified in regulation.
- The vaccine mandate is still in effect and if you recall on the vaccine mandate required staff to have at least the primary series which is considered fully vaccinated never in the vaccine mandate was there the component to be up to date or have your booster while it did indicate that you had to track individuals vaccination statuses for up to date and so on it did not require staff to be up to date.