Steven Littlehale

The coronavirus pandemic has forced providers to make dramatic changes to their care delivery systems. Facilities have struggled with personal protective equipment and staffing challenges while also attempting to follow federal and state regulatory guidance that has been, at the very least, fluid.

Recently, I moderated a webinar with three of my colleagues from Zimmet Healthcare that attempted to shine a light on these issues and provide guidance on how to remain compliant during this pandemic. The following are some of the most useful soundbites from a very fruitful hour long conversation. You’ll hear from consultant Marie Infante; Sheryl Rosenfield, director of clinical operations; and Ari Stawis, director of professional services and development.

Authorities during the public health emergency 

Steven Littlehale: There are probably a few too many cooks in the kitchen, quite frankly, and they are all telling what to do and how to do it. By whose authority should we be taking action and direction?

Marie Infante: One of the operational pressures that has come up in the past three months is the guidance and directives and executive orders and waiver information and issuances that have been raining down from both the federal and the state governments. As a general rule, the feds — in this case CMS and CDC — probably set the strongest floor as far as expectations are concerned.

[That said,] states look very, very different. There are two points to this that are important for everybody. [First,] the federal regulations and guidance will provide a stable floor for you, and then you need to be tuned into what your specific state directives are. That will give you a path forward in terms of sorting through all this information. A good example is the reopening guidance. It’s going to look like a very different picture depending on where your state is as far as disease and incidence.

Ari Stawis:  A perfect example of the conflict you allude to, Steven, is the difference for resident testing and employee testing. New York State recently revised their executive order: Anyone in Phase 2 is required to test once a week but New York City was in Phase 1, so they were still required to test twice a week. Regarding the reopening guidelines, CDC and the feds said, “Here’s your floor, and now it’s up to you to have constant testing.” That word “constant” is vague, and each state is really handling it differently.

What’s the recommendation for facilities when they find themselves feeling conflict between these authorities on their practice?

Infante: The strictest standard is going to apply as far as accountability is concerned, and so that’s where management ought to be looking in terms of how to direct their efforts and their priorities.

Infection control

On June 1, when CMS sent a memo to state survey agency directors, it was a bit of an expected bombshell. It appears that CMS has lowered the bar on what would be considered acceptable while simultaneously increasing the penalties. Can you talk about the new infection control surveys and how skilled nursing facilities can best prepare?

Infante: All of the national publicity and new information that has evolved about the danger of COVID in a nursing home or any congregate living setting has been pretty profound. It’s been emotional story after emotional story about how nursing homes have been caught in this firestorm. CMS has responded to this in trying to provide support as has the CDC, but it was inevitable that the government would feel pressure to take a strong stand and enforce the infection control guidance that is out there. Consequently, CMS announced this initiative about enhanced enforcement for the focused infection control surveys. 

By the end of July, all survey agencies must complete a focused infection control survey on all the nursing homes within their state. I think the message for providers is that, if you have not had a focused infection control survey in the past few months, you will be getting at least one by the end of July.

As of July 3, 88.1% of all nursing homes had this survey. 

Rosenfield: On May 20, CMS issued additional clarifications and expansions of F-tags associated with what’s going on right now. CMS has stated that they’re going to add on quality of care components to the other individual Care and Environment Tags — so you could be getting two or three or four tags in one situation. We used to call it “piling on” in “survey school.” They’re coming in and doing an infection control–focused survey, but with that, they can add on more tags. Among the top 10 tags that we are seeing with infection control tags being cited is F656, which requires complete care plans that “meets the all of the residents needs with timetables”; F309, which requires the facility to provide care and services to maintain or improve the highest well-being; and also F684 to provide appropriate treatment and care according to orders, resident preferences and goals.

Infante: CMS has recommended strongly that facilities use the infection control self-assessment tool as part of their ongoing development of their infection control and prevention processes. This is a recommendation that would be foolish to overlook. There are aspects of the focused survey protocol that are very prescriptive, much more so than just about anything I’ve seen.

Consider the information surveyors want to see upon entrance: The configuration of the facility is probably one of the most important. They’re going to be getting information about how you’re doing traffic control, how you’re monitoring your entrances and exits, how — if necessary — you’re cohorting, what you’re doing with your dementia units, and other various aspects.

They’re going to ask for a list of all the residents who have confirmed or suspected cases, which means that your significant change protocols and your identification of people that are demonstrating either typical or even atypical symptoms of COVID are going to be very important. There’s going to be a brief exit conference, and to a large extent, CMS is going to be looking at off-site activities to prep their survey teams and minimize their amount of time on-site in the interest of safety. They’ll be reviewing your weekly reporting to the CDC, to the health network, about your incidence of both confirmed and suspected COVID cases for employees and residents.

You need to be prepared not only in terms of being aware of what your current information is telling the public — in this case the survey agencies — but the best advice right now is to be using the self-assessment tool for looking at how your efforts with infection control and prevention measure up to what CMS is looking for. The tool is a checklist, one that’s incredibly extensive and in-depth. [It’s] a focus not only for nursing staff and clinical staff, but also for management, because it goes to what resources staff need in order to deal effectively with this infection control survey. 

Infante: CMS did a thorough job putting just about every aspect of resident quality of care into this survey protocol. I want to highlight some of the onsite survey activities that are going to be part of this, in addition to the entrance conference issues. The resident care observations are going to be around hand hygiene practices. 

What’s available in the resident room as far as alcohol-based hand sanitizer, soap and water? Are the nursing assistants and nursing and care staff properly using and discarding PPE? Where is the PPE located; are there sufficient amounts? It’s going to be important to convey whether you [have] adequate supplies or whether you’re using conservation protocols, and it’s important that staff know the difference. 

They’re going to be looking at cleaning of medical equipment, particularly if you’re doing things like sharing blood pressure cuffs or other equipment, and whether you’re putting in place effective transmission-based precautions. And this is what is going to be looked at just as they walk through the building to see what’s going on.

Some more specific environmental observations include signage, at entrances and exits, around employee time clocks, and in resident rooms. They’re going to be observing screening: What are you doing with your residents? What are you doing with your staff when they report to work? “Staff” in this case is a very expansive concept, because it includes contractors, dietary, housekeeping staff — who may be under different supervision standards depending on how you contract for these services. It includes your practitioners, your physicians, and anybody else who happens to be part of the traffic in the facility. 

They expect everybody to be screened, which means you should be screening the surveyors when they come in, too. We hope the surveyors are going to bring their own PPE, but in case they don’t, make sure you have adequate supplies set aside so they can abide by your standards.

Littlehale: We know facilities have received citations because they didn’t properly screen the surveyor then they arrived at the facility.

Infante: I think the interviews are going to be key here. Surveyors will be interviewing relevant staff, which includes anybody from your CNAs to your dietary people to your housekeeping staff, about whether they know what your policies and procedures are; whether they’re tuned to appropriate surveillance knowledge; whether they have knowledge to pick up signs and symptoms and significant changes with residents. Surveyors will also interview your management staff about notifying the local health officials, for example, if you get cases. All these notification requirements have not gone away just because you now have weekly CDC reporting.

That reporting you mentioned about suspected cases, confirmed cases, et cetera is also listed on Nursing Home Compare. I could go right now and see what every single facility in the United States has reported and those that are non-compliant. What are you hearing on these [local and national] task forces about these infection control surveys?

Rosenfield: Written policies are key. A question we get frequently is, “Do the physicians have to sign off on the policies?” Yes, especially with updated and changing policies to meet requirements for changing surveys in a post-COVID world. Your MDs must be involved, and it’s critical that there’s evidence that speaks to that. What I’m hearing is policies aren’t updated; policies are not reviewed by the medical team.

CMS is asking about testing policies, training, and supervision, along with monitoring.  As facilities begin to have a decline or zero rate of infection, they need policies and protocols for dining rooms, the activity rooms, even the hairdresser when they return. These relate back to the previously mentioned F tags noted during the surveys. How do you organize that? 

Infante: The other thing is your communication plan around letting families and legal representatives know what the status of COVID is in your facility. They’re going to be looking at whether it’s passive — “go to the website, we have it posted there” — or whether you actively issue letters or have town hall meetings. And that’s part of the survey protocol as well. In addition, expect to be asked [about] your plan for crisis staffing. If people are found to be positive, what are you going to do in order to ensure that there’s adequate staff in the building?

The elephant in the room is this: Checking a box on a survey tool is one thing, but having access to the required equipment; having access to safe, reliable, consistent equipment and staff to put it on or use the equipment is another. A checklist doesn’t make staff and equipment materialize. What should a provider do if they simply don’t have access to the right equipment and staff? 

Stawis: PPE is new information to document that previously never was included in your infection control recordkeeping requirements. Who is responsible for documenting that, your procurement professional? It’s extremely important to document all your efforts in obtaining PPE: “This is who I spoke to, this was the pricing that I was given, that’s why we did or didn’t go with a particular product.” To your second point of staff: Do we have enough staff? What are we doing to try to pull staff into the building? Those are two major components that have not been included when it came to infection control.

Littlehale: And make sure that documentation is retrievable. Three years from now, we have to know where that documentation resides and have it comprehensive enough that it makes sense. 

Stawis: In some markets, access to PPE has become more stable. The craziness of some months ago — I know that there were articles written about meeting a guy in a parking lot in order to get PPE — those days are hopefully over. There are still reported instances of PPE being used outside of recommended manufactured guidelines. Documentation is as important as ever.


We’re going to focus specifically on the Provider Relief Fund, and on the grant element of that fund. Marie?

Infante: It was a surprise after the passage of this act that Congress was able to act so quickly to release billions of dollars into relief funds. But, these funds came with strings attached. Understand that if you took the money, if you haven’t given it back yet or you intend to keep it, that you are attesting — as it says on the HHS website — that you are going to abide by these terms and conditions. The funds need to be accounted for. You need to be aware of what recordkeeping you need to be following in order to account for these funds.      

So, why don’t you take the money and not sign the attestation statement?

Infante: You are believed to have attested. Silence is acquiescence! If you don’t affirmatively sign the attestation statement, that is effectively saying to HHS, “I accept your terms and conditions.” It’s important to be exact about your accounting. These funds are also subject to overpayment responsibilities, and if you can’t account for COVID-related expenses for all the money you’ve received, you’ve effectively received an overpayment that has to be given back to the government.

What should providers be documenting? How are they supposed to be documenting? And if a provider is already receiving government relief funds, is it a double-dip?

Infante: Let me answer your last question first. You can’t account for excess payroll costs, for example, under the CARES relief fund grant and also be using a payroll protection loan that you got from the government. That would be an example of double-dipping. Under any circumstances, this is not acceptable.

And you might even do that unknowingly. Who’s going to be specifically looking for those line items?

Infante: That’s exactly right. It’s not like the CARES funding came with orange dollars as opposed to green dollars. The important thing to know is that this is COVID-related expenses we’re talking about; this is not time to use the money to pay your car leases or whatever else you can think of. I think Ari can give us a little more information about the kinds of allowable costs we’re talking about.

Stawis: First off, from a time frame perspective, the initial requirements were to submit documentation regarding how you used the funds 10 days after the quarter ends. That July 10th requirement has passed and providers are still waiting on guidelines to meet this requirement. 

From a categorization perspective, we’ve been recommending creating separate GL codes for COVID expenses. That way it’s easy to identify what is considered a COVID expense and what is not. What’s your hazard pay, what’s your hazard pay hourly rate, what’s your shift differential for your hourly rate during COVID? You might not get this just by running a report, but the government is going to ask for it.

The categories of allowable costs: First, from a revenue end, the sources of COVID stimulus, and the lost revenue. We’re looking at worked wages per department, employee benefits per department, contracted labor per department — and again, we’re comparing pre-COVID and during COVID — supplies, other non-labor costs, and construction — but specifically for COVID-related expenses, like an isolation unit.

One other important point that I want to mention is testing for residents and employees. The testing is paid through consolidated billing for Part B. If a resident has Part B benefits, that will be paid through consolidated billing. If someone is on only Part A, then that is now a facility expense. What we are expecting is that all of those facility expenses related to the testing will then be included on the CARES Act in regards to the burn rate from the government. But again, talking about compliance, for some residents the testing is going to be paid through Part B, while for others it’s going to be on the facility to pay that.

My brain is spinning with that last comment. So, not only do you have to track this and report it, you have to do it down to the resident level and by payer type in order to meet this requirement?

Stawis: Yes, it’s important from a compliance perspective. It gets back to the naughty word of “double-dip”: If you have someone on Part B and then you’re also putting it on the CARES Act, that could be an issue.

Who in the facility is taking ownership of this?

Stawis: Among the clients we’ve been working with, it’s really been the finance team: the CFOs, the controllers, the accountants. They’ll need to know how to classify and how to identify all of these costs in order to properly bucket [them for] when the time comes to submit. 

Conclusion and takeaways

What is the most essential thing you want listeners to leave with?

Stawis: Number one, documenting for infection control; understanding that there are new pieces of documentation that are required, which include PPE and staffing. The second thing is, make sure that all staff has access to PPE, even after hours or on weekends. The last thing you want is that your PPE is not available because it’s locked in the housekeeping director’s office and he/she isn’t here today. The third thing is, from the CARES Act, just remember that there are strings attached.

Rosenfield: Healthcare is local. You must know what’s going on in your community. You must have an infection preventionist completing the infection prevention tracking documentation from your individual State and CMS. Complete the self-assessment. Have your medical director involved. Your QAPI programs, training and teaching is continuous. This is going to be a permanent part of daily facility policy and practice. It’s a new world for all of us.

Infante: Your compliance plan is a dynamic, evolving thing; a hallmark of a good compliance plan is that it’s responsive. Collaboration is necessary under these circumstances; there’s a compliance role for everyone here. Communication and trust are essential, to every one of your stakeholders, but particularly right now to your staff and to your families and the residents that are under your care. That’s the biggest risk mitigation tool you have, is that trust.

Littlehale:  A standout you all touched on is that compliance must be interdisciplinary. It’s not a person. It’s not an additional hat. It’s not an “and other” part of someone’s job description. It is your culture. It has to be lived, breathed by everyone in your organization, or it just completely falls apart and becomes something you put in a binder up on a shelf. That binder on the shelf is a liability. 

Steven Littlehale is a gerontological clinical nurse specialist, chief innovation officer at Zimmet Healthcare Services Group, and chief clinical officer emeritus at PointRight Inc.