Service

CMS Waiver

Home Health Agency (HHA)

Requests for Anticipated Payments

• CMS is allowing Medicare Administrative Contractors to extend the auto-cancellation date of Requests for Anticipated Payment during emergencies.

Reporting

• For submission of comprehensive assessments, CMS is extending the five-day time frame to 30-days
• CMS is waiving the 30-day deadline for submission of the customary Outcome and Assessment Information Set.

Initial Assessments

• CMS is modifying its requirements to allow for remote or records-review initial assessments. 42 CFR §484.55(a).
• CMS will relax which professional discipline must perform the assessment, but it expects HHAs to align needs of the patient to the proper professional discipline to the greatest extent possible.
  • Specifically, CMS will allow Occupational Therapists (OT) to perform initial and comprehensive assessment for patients with OT-needs, not merely those patients for whom an OT-need is the basis for home healthcare. 42 CFR §484.55(a)(2) and §484.55(b)(3).
• The existing regulations will continue to prevent OTs and other therapists from performing assessments in nursing-only cases. 42 CFR §484.55(a) and (b)(2).

Onsite Visits

• CMS is waiving the usual requirements of 42 CFR §484.80(h):
  • that a nurse conduct an onsite patient visit from every two (2) weeks and
  • that a nurse or other professional conduct an onsite visit every two (2) weeks to oversee and review care by an aide, but virtual supervision is encouraged.

Hospice

Volunteers

• CMS is waiving the requirement for hospices to use volunteers for at least 5% of patient care hours. 42 CFR §418.78(e).

Assessments

• The deadline for hospices to update comprehensive assessments of patients is extended from 15 to 21 days. 42 CFR §418.54 and 54(d).

Non-Core Services

• Hospices will not have to provide non-core services, including physical therapy, OT and speech-language pathology. 42 CFR §418.72

Supervisory Onsite Visits

• Hospices are exempt from the usual requirements for a nurse to conduct an onsite supervisory visit every two (2) weeks, including the requirement for a nurse or other professional to conduct an onsite visit every two (2) weeks to evaluate the performance of aides 42 CFR §418.76(h).

Aide Training and Testing

• CMS is temporarily allowing hospices to utilize pseudo patients, such as a person trained to participate in a role-play situation or a computer-based mannequin device, instead of actual patients for purposes of competency testing of hospice aides. 42 CFR §418.76(c)(1).
• CMS is waiving the requirement that hospices must assure that each hospice aide receives 12 hours of in-service training in a 12-month period. 42 CFR §418.76(d).

Long-Term Care Facilities

Admission

• The usual three-day prior hospitalization requirement is waived for coverage of a SNF stay for patients who experience dislocations, or are otherwise affected by COVID-19. §1812(f) of the Social Security Act.
• For patients who recently exhausted their SNF benefits, a new SNF coverage period can be renewed without the patient first having to start a new benefit period for those beneficiaries who have been delayed or prevented commencing or completing the process of ending their current benefit period.

Reporting Minimum Data Set

• CMS is waiving the usual 14-day timeframe for Minimum Data Set assessments and transmission. 42 CFR §483.20.

Staffing and Data Submission

• CMS is waiving the quarterly requirements for submitting staffing data through the Payroll-Based Journal system. 42 CFR §483.70(q).

Admission and Pre-Admission Screening

• CMS will allow allowing nursing homes to admit new residents who have not received Level 1 or Level 2 Preadmission Screenings, but on or before the 30^th day of admission, new nursing home patients with a mental illness or intellectual disability should be referred promptly by the nursing home to State PASARR program for Level 2 Resident Review. 42 CFR §483.20(k).

Physical Environment

• Provided that the state has approved the location as one that sufficiently addresses safety and comfort for patients and staff, CMS is allowing non-SNF buildings to be temporarily certified and available for isolation for COVID-19-positive residents.
• CMS will waive certain conditions of participation and certification requirements for opening a nursing facility if the state determines there is a need to quickly stand up a temporary COVID-19 isolation and treatment location.
• CMS is also waiving requirements to temporarily allow a long-term care facility to use non-resident space for residents to help with surge capacity. This includes activity rooms, meeting/conference rooms and dining rooms, as long as residents can be kept safe, comfortable and other applicable requirements for participation are met. 42 CFR §483.90.

Resident Groups

• CMS is waiving the requirements which normally ensure that residents can participate live in resident groups. 42 CFR §483.10(f)(5).

Training and Certification of Aides

• CMS is waiving the requirements which prohibit a SNF or NF from employing anyone for longer than four months without meeting certain training and certification requirements. CMS is not waiving the prohibition on hiring a nurse aide for more than four months on a full-time basis unless that individual is competent to provide nursing and nursing related services.
• CMS will still require facilities to ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents’ needs. 42 CFR 483.35(d) (with the exception of 42 CFR 483.35(d)(1)(i)).

Physician Visits

• CMS is waiving the requirement for physicians and non-physician practitioners to perform in-person visits so as to allow for telehealth options. 42 CFR §483.30.

Resident Roommates and Grouping

• CMS is waiving the “notice,” “consent” and “right to refuse” provisions that apply to grouping or cohorting residents with respiratory illness symptoms and/or residents with a confirmed diagnosis of COVID-19. 42 CFR 483.10(e) (5), (6), and (7).

Transfers and Discharges

• CMS is waiving a myriad of requirements (with some exceptions) to allow a long-term care (LTC) facility to transfer or discharge residents to another LTC facility solely for the following cohorting purposes:
  • Transferring residents with symptoms of a respiratory infection or confirmed diagnosis of COVID-19 to another facility that agrees to accept each specific resident, and is dedicated to the care of such residents;
  • Transferring residents without symptoms of a respiratory infection or confirmed to not have COVID-19 to another facility that agrees to accept each specific resident, and is dedicated to the care of such residents to prevent them from acquiring COVID-19; or
  • Transferring residents without symptoms of a respiratory infection to another facility that agrees to accept each specific resident to observe for any signs or symptoms of a respiratory infection over 14 days.
• Exceptions and Requirements:
  • The transferring facility must receive confirmation from the receiving facility. The confirmation may be in writing or verbal with the transferring facility documenting the date, time and person receiving the confirmation.
  • Note that 42 CFR §483.10 (“Resident Rights”, CMS are only waiving the requirement, under §483.10(c)(5) for advance notification of options relating to the transfer or discharge to another facility. Otherwise, all requirements related to §483.10 are not waived.
  • Similarly, in 42 CFR §483.15 (Admission, Transfer, Discharge), CMS is only waiving the requirement for the written notice of transfer or discharge to be provided before the transfer or discharge. This notice must be provided as soon as practicable. 42 CFR § 483.15(c)(3), (c)(4)(ii), (c)(5)(i) and (iv) and (d).
  • In §483.21 (Comprehensive Person-Centered Care Planning), CMS is only waiving the timeframes for certain care planning requirements for residents who are transferred or discharged for the purposes related to COVID-19. Receiving facilities should complete the required care plans as soon as practicable.
  • These requirements are also waived when transferring residents to another facility, such as a COVID-19 isolation and treatment location, with the provision of services “under arrangements.” In these cases, the transferring LTC facility is still considered the “provider,” so it need not issue a formal discharge. The transferring LTC facility is then responsible for reimbursing the other provider that accepted its resident(s) during the emergency period. 42 CFR 483.10(c)(5); 483.15(c) (3), (c)(4)(ii), (c)(5)(i) and (iv), (c)(9), and (d); and § 483.21(a)(1)(i), (a)(2)(i), and (b) (2)(i).

Physician Services

• Physician Delegation of Tasks in SNFs. CMS will allow physicians to delegate any tasks to any duly qualified PA, NP or clinical nurse specialist. Still, the task delegated must continue to be under the supervision of the physician.
• Exception: Physicians are still prohibited from delegating that which is prohibited from delegation under state law or by the facility’s own policy. 42 CFR §483.30(e)(4).
• Physicians may delegate any required physician visit to a PA or NP or clinical nurse specialist who is not an employee of the facility, who is working in collaboration with a physician and who is licensed by the state and performing within the state’s scope of practice laws. 42 CFR §483.30(c)(3),(4), (f).
• Note: the facility must still be able to provide physician services 24 hours a day.

Intermediate Care Facility for Individuals with Intellectual Disabilities

Staffing

• CMS will allow the facility to provide sufficient Direct Support Staff (DSS) so that Direct Care Staff (DCS) are not required to perform support services that interfere with direct client care. DSS perform activities such as cleaning of the facility, cooking and laundry services; DSC perform activities such as teaching clients appropriate hygiene, budgeting, or effective communication and socialization skills. 42 CFR §483.430(d)(3),(4).

Community Outings

• CMS is authorizing the facility to implement social distancing precautions with respect to on and off-campus movement. CMS is lifting the requirement which requires facilities to provide social, religious, and community group activities. The federal and/or state emergency restrictions will dictate the level of restriction from the community based on whether it is for social, religious or medical purposes. CMS specifically notes that states may have also imposed more restrictive limitations. State and federal restrictive measures should be made in the context of competent, person-centered planning for each client. 42 CFR §483.420(a)(11).

Training

• CMS is waiving, in-part, the otherwise mandatory requirements related to routine staff training programs unrelated to the public health emergency. 42 CFR §483.430(e)(1)
• CMS is not waiving requirements focusing on the clients’ developmental, behavioral and health needs and being able to demonstrate skills related to interventions for inappropriate behavior and implementing individual plans. CMS is also not waiving initial training for new staff hires or training for staff around prevention and care for the infection control of COVID-19. 42 CFR §483.430(e)(2)-(4).

Disabilities

• CMS recognizes that active treatment will need to be modified. The requirements that each client must receive a continuous active treatment program is waived to the extent the requirements would violate current state and local requirements for social distancing, staying at home, and traveling for essential services only. In accordance with 42 CFR §483.440(c)(1), any modification to a client’s Individual Program Plan (IPP) in response to treatment changes associated with the COVID-19 crisis requires the approval of the interdisciplinary team. For facilities that have interdisciplinary team members who are unavailable due to the COVID-19, CMS would allow for a retroactive review of the IPP (42 CFR §483.440(f)(2)) in order to allow IPPs to receive modifications as necessary during the COVID-19 crisis.