AHCA: Update #67 | Reporting Accurately

Jackie Pappalardi and Nancy Leveille in Clinical & Quality

In This COVID-19 Update: 

  • Reporting to NHSN Accurately
  • CMS Toolkit for Nursing Homes
  • QIN-QUOs Targeting Assistance to Nursing Homes with Infection Control Deficiencies
  • CMS Issues New Blanket Regulatory Waivers
    • Paid Feeding Assistant
    • Life Safety Waivers
    • Hospital Swing Bed
    • Documentation Guidance for Reimbursement Waivers

Reporting Accurately to NHSN COVID-19 

In Update #65, we provided guidelines on accurately reporting staffing and PPE shortages to NHSN COVID-19 LTC module. As stated in the update, it is important the data reported to NHSN gives an accurate picture as this data will be used by state, federal governments and other stakeholders.
We have received questions about the staffing guidance and have revised as shown below based on review of the latest CDC instruction for NHSN reporting.   

NHSN asks, “Does your organization have a shortage of staff and/or personnel?” Any of the following situations support a YES response:  

  • Staffing less than your facility needs or internal policies for staffing ratios (despite efforts made by the facility to secure staff)  
  • Employing crisis strategies for staffing shortage 
  • Using any temporary positions per waiver allowances (such as temporary nurse aide or temporary feeding assistant) or agency staff, yet staffing ratios for facility needs and internal policies are still not met 

As a reminder, keep documentation of efforts to secure more PPE as well as staffing. Report to your local and state health departments if employing contingency and crisis strategies to conserve PPE and staffing. 

CMS Issues Nursing Homes Best Practices Toolkit to Combat COVID-19

CMS released a new toolkit intended to serve as a catalog of resources dedicated to addressing the specific challenges facing nursing homes as they combat COVID-19.

CMS says the toolkit provides resources and direction for quality improvement assistance and can help in the creation and implementation of strategies and interventions intended to manage and prevent the spread of COVID-19 within nursing homes. The toolkit outlines best practices for a variety of subjects ranging from infection control to workforce and staffing. It also provides contact information for organizations who stand ready to assist with the unique challenges posed by caring for individuals in long-term care settings. 

QIN-QIOs Targeting Assistance to Nursing Homes with Infection Control Deficiencies

CMS has contracted with 12 Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs) to work with providers, community partners, beneficiaries and caregivers on data-driven quality improvement initiatives designed to improve the quality of care for beneficiaries across the United States. The QIN-QIOs are reaching out to nursing homes across the country to provide virtual technical assistance for homes that have an opportunity for improvement based on an analysis of previous citations for infection control deficiencies using publicly available data found on Nursing Home Compare.

CMS Releases Additional Blanket Waivers 

On May 11th, CMS issued additional waivers for the healthcare community that provide the flexibilities needed to take care of patients during the COVID-19 public health emergency (PHE). This is in addition to the waivers that were released on April 30. The following blanket waivers are in effect, with a retroactive effective date of March 1, 2020 through the end of the emergency declaration. 

Paid Feeding Assistants 

CMS is modifying the minimum timeframe requirements for feeding assistant training to allow the training to be a minimum of 1 hour in length. CMS is not waiving any other requirements related to paid feeding assistants or the required training content which contains infection control training and other elements. Additionally, CMS is also not waiving or modifying the requirements which requires that a feeding assistant must work under the supervision of a registered nurse (RN) or licensed practical nurse (LPN). 

With this waiver, AHCA/NCAL’s Temporary Feeding Assistant training is allowable. However, additional state requirements may need to be waived to permit individuals completing this program to assist with care in your location. We encourage you to contact your state survey agencies and state occupational licensing agencies, where applicable.  

Specific Life Safety Code (LSC) for Multiple Providers

CMS is waiving and modifying waivers under for ICF/IIDs and SNF/NFs. Specifically, CMS is modifying these requirements as follows:  

Alcohol-based Hand-Rub (ABHR) Dispensers: CMS is waiving the requirements for the placement of ABHR dispensers for use by staff and others due to the need for the increased use of ABHR. However, ABHRs contain ethyl alcohol, which is considered a flammable liquid, and there are restrictions on the storage and location of the containers. This includes restricting access by certain patient/resident populations to prevent accidental ingestion.  

Due to the increased fire risk for bulk containers (over five gallons) those will still need to be stored in a protected hazardous materials area. In addition, facilities should continue to protect ABHR dispensers against inappropriate use.  

Fire Drills: Due to the inadvisability of quarterly fire drills that move and bring staff together, CMS will instead permit a documented orientation training program related to the current fire plan, which considers current facility conditions. The training should instruct employees, including existing, new or temporary employees, on their current duties, life safety procedures and the fire protection devices in their assigned area.  

Temporary Construction: CMS is waiving requirements that would otherwise not permit temporary walls and barriers between patients. 

Hospital Swing Bed Waiver 

The new blanket waivers include a waiver expanding the ability of hospitals to offer long-term care services to patients who do not require acute care but meet the SNF level of care criteria at 42 CFR 409.31. CMS is waiving the eligibility requirements for hospital providers of long-term care services (swing beds) at 42 CFR 482.58(a)(1)-(4) to allow hospitals to establish SNF swing beds payable under the SNF prospective payment system (PPS). This waiver provides additional options for hospitals with patients who no longer require acute care but are unable to find placement in a SNF. 

The waiver includes an array of limitations on hospital use of the waiver including applying to the MACs for additional swing beds and attesting: 

  1. they have made a good faith effort to exhaust all other options; 
  2. there are no skilled nursing facilities within the hospital’s catchment area that under normal circumstances would have accepted SNF transfers, but are currently not willing to accept or able to take patients because of the COVID-19 PHE; 
  3. the hospital meets all waiver eligibility requirements; and 
  4. they have a plan to discharge patients as soon as practicable, when a SNF bed becomes available, or when the PHE ends, whichever is earlier.  

AHCA/NCAL members concerned about inappropriate hospital use of the waiver should contact their MACs. Find the list of MACs and contact information here.

Guidance on Documentation for Use of COVID-19 SNF Reimbursement Waivers

The CMS waivers also consider requirements that would normally be in place for providers to receive reimbursement under Medicare or Medicaid. Most significant were the waiver of the 3-day prior inpatient hospital stay and the 60-day break in spell-of-illness requirements for SNF Part A benefit eligibility. 

Documentation will be critical to demonstrate an organization’s rationale for the use of the waivers. In a previous update, AHCA/NCAL offered visual flowchart guidance to help with coverage determinations of these 1135 waivers. AHCA/NCAL has provided key documentation guidelines  for supporting the employment of these waivers as it is foreseeable that after the emergency declaration is rescinded, CMS either through the Officer of the Inspector General (OIG) or through contractors will look to ensure that Medicare dollars were spent appropriately without fraud, waste and abuse.


Jackie Pappalardi, RN, BSN
Executive Director
518-462-4800 x16

Nancy Leveille, RN, MS
Director, Special Projects and Educational Development
518-462-4800 x20