Public health emergency extended once again: Your WellSky COVID-19 Briefing
In this edition
Use the links listed below to jump between sections.
NEWS
Action to delay recoupment of accelerated advance payments
Extended provider relief funding
New funding for Community Transition Programs
The public health emergency has been extended
COMPLIANCE
New reporting requirements for Provider Relief Fund recipients
2020 expenses attributable to COVID-19 not reimbursed by other sources
Lost revenues attributed to coronavirus
Economic Injury Disaster Loans vs. Paycheck Protection Program Loans
CLINICAL
New CDC guidance on virus transmission
Article shares experiences of NYC home care staff during COVID-19
SNF infection control quality measure
Hospice election statement and addendum
ADMINISTRATIVE
Please note
The views, information, and guidance in this resource are provided by the author and do not necessarily reflect those of WellSky. The content provided herein is intended for informational purposes only. The information may be incomplete, and WellSky undertakes no duty to update the information. It is shared with the understanding that WellSky is not rendering medical, legal, financial, accounting, or other professional advice. WellSky disclaims any and all liability to all third parties arising out of or related to this content. WellSky does not make any guarantees or warranties concerning the information contained in this resource. If expert assistance is required, please seek the services of an experienced, competent practitioner in the relevant field. WellSky resources are not substitutes for the official information sources on COVID-19. Providers should continue to track developments on official CMS and CDC pages, including:
Current cases & maps
It has been just over a month since our last briefing. As I was gathering maps and charts for this edition, I was stunned by the similarity between the Centers for Disease Control and Prevention (CDC) map depicting cases reported in the seven–day period ending October 4 and the map that was run in our September 2 briefing. As children and young adults return to school, there are still six states — Texas, California, Wisconsin, Florida, Illinois, and North Carolina — with more than 10,000 new cases in the last week. Eight states make up 50% of the total number of Americans who have tested positive for the virus:
- California – 824,000 cases
- Texas – 766,000 cases
- Florida – 708,000 cases
- New York – 466,000 cases
- Illinois – 304,000 cases
- Arizona – 221,000 cases
- North Carolina – 218,000 cases
- New Jersey – 208,000 cases
The New York Times continues its reporting around the public health emergency. The two graphs that follow are well–known to readers and depict the new case and mortality trends. After a very brief dip in new cases in mid-September, the daily case counts began to go back up and haven’t stopped yet. Is this our fall surge? I’m not sure, but the trendline isn’t altogether encouraging.
Mid-September also saw a brief dip in deaths, but those too have since spiked slightly and leveled off.
The New York Times hotspot map does illustrate how things have changed, and for the sake of comparison, I have included the heat map as of September 1, followed by the same map as of October 4. The clear area of concern is now the Midwest, with Wisconsin in particular becoming the national focal point for case and mortality growth. Smaller communities in other Midwestern states are also showing high concentrations of new cases which constitute a greater percentage of their overall populations. Long story short, we aren’t out of the woods yet.
New York Times COVID-19 Heat Map as of September 1, 2020 (below)
New York Times COVID-19 Heat Map as of October 4, 2020 (below)
As we begin this issue of the briefing, here is where we stand. There are now 7.4 million confirmed cases of COVID-19 in the United States — an increase of 1.4 million cases in just over a month. We now have 209,000 mortalities attributed to the virus — an increase of 26,000 people lost in the same timeframe.
News
Action to delay recoupment of accelerated advance payments
Throughout most of September, post-acute care providers often asked when they could expect to see the start of zero–dollar remittances as the Medicare Administrative Contractors (MACs) began to recover accelerated payments. We now have the answer.
As a refresher, early in the public health emergency, the Centers for Medicare & Medicaid Services (CMS) authorized MACs to advance funds to providers that applied for accelerated payments. Reportedly, providers took advantage of the offer and secured about $40 billion in total advance payments. These payment advances amounted to a three–month operating cushion based on historical claims submission. The rub at the time was that while hospitals were granted extended repayment periods, post-acute providers were expected to begin repayment within 120 days. Most post-acute providers received their accelerated payments in mid-April, before the program was abruptly curtailed by CMS at the end of the month. That would have meant repayment beginning sometime toward the end of August extended over a period of 90 days. But as providers waited for the deductions to begin, nothing happened.
In the meantime, Democrats put forth two bills that addressed accelerated advance repayment terms. The first failed quickly in the Senate. But there were continuing expectations that the issue would be addressed. Hence, CMS’s delay in directing the MACs to begin the recoupment process. Finally, on September 30, the Senate passed the Continuing Appropriations Act, 2021 and Other Extensions Act that keeps the government operating through December 11. As a part of that bill, which was signed by the president on October 1, the Accelerated and Advance Payment (AAP) Program was revised. The revision essentially provides up to 29 months before AAP funds must be fully repaid. The interest rate has been reduced from 9.6% to 4% per year. Here is how it will work:
- Recoupment will begin one year from the date on which funds were received.
- Claim offsets will amount to 25% of the full Medicare payment amount for a period of up to 11 months thereafter. If the total advance is not repaid upon the conclusion of the 11–month period, recoupments will continue.
- During the following six-month period, claim offsets will be limited to 50% of the full payment amount until the advance and accrued interest is fully repaid.
To determine what a given provider’s repayment scenario looks like, we have to do a little math. By way of example, let’s say that Provider A received $1 million in advance payments on April 15, 2020.
- Repayment of the advance would begin on the same date a year later — in 2021. By that time, interest would have accrued for a total of $40,000, making the amount due at the time repayment begins, $1,040,000.
- For 11 months, assuming equal Medicare reimbursement in the amount of $333,333 per month, the offset would be 25% — meaning that the agency would receive $250,000 per month, and the MAC would retain $83,333 toward repayment of the advance plus accrued interest. At the end of the 11–month period, all but $147,450 of the principal amount would have been repaid.
- In the following month, the MAC would recoup the rest of what is owed — $147,450. In this scenario, that would occur in month 24 as the MAC increases the recoupment to its ceiling of 50%.
- The formula appears to take into account that reimbursement will fluctuate, but if it holds steady, repayment would — at least in theory — be accomplished sooner than the end of the maximum repayment period of 29 months.
So, we have a little more time before the MACs will start recouping, but April will be here sooner than we think. If you secured an advanced payment, start planning now and squirrel away some reserves for when your remits are reduced next year.
Extended provider relief funding
On October 1, the Department of Health and Human Services (HHS) announced that the Provider Relief Fund is being increased by another $20 billion. According to HHS, under the Phase 3 General Distribution, provider organizations that have already received prior Provider Relief Fund distributions can apply for additional funding to offset financial losses and increased operating expenses that can be attributed to COVID-19. Notably for new home health and hospice providers, those that began operations in 2020 will be eligible for this tranche of funding, even though they were not eligible for prior distributions.
The application period began October 5, and HHS is encouraging all who are interested in receiving Phase 3 funds to apply early. Of course, there is a catch for many post-acute providers, especially home health and hospice.
Remember that when the first general distributions were made, the distribution formula was predicated on 2019 Medicare Fee-for-Service revenue. Most home health and hospice providers with the bulk of their revenue coming from traditional Medicare services received an amount equal to about 6.2% of their prior year Medicare revenue. But, afterward, the formula was changed to 2% of total revenues as reported on the 2018 Medicare cost report. This round of additional funding is based on the second formula which will likely operate to preclude some, if not most, home health and hospice providers from participating. Here are the Phase 3 rules:
- Providers that previously received a General Distribution Provider Relief Fund payment are eligible to apply. This includes those that may have rejected their initial general distributions.
- Providers that have “already received payments of approximately 2% of annual revenue from patient care” may submit more information to become eligible for an additional payment.
- New providers that began operations in 2020 are eligible to apply.
- All provider applications will be reviewed to confirm payments already received. The total amount of Provider Relief Funds, including Phase 3 funding, cannot exceed the 2% revenue threshold. This is where many home health agencies and hospices will fall out of the eligibility mix.
Providers have until November 5 to apply.
New funding for Community Transition Programs
In late September, CMS announced that it is making $165 million in supplemental funding available to states currently operating the Money Follows the Person (MFP) demonstration program. The additional funding is designed to help Medicaid programs refine their efforts at effective care transitions for disabled and elderly adults coming home or to a community–based setting from long–term care in a skilled nursing facility (SNF) or nursing home. MFP began in 2007 but has been little used. However, as CMS notes the “devastation wrought by the coronavirus on nursing home residents,” it has also expressed its opinion that America is “over-reliant” on institutional long-term care facilities.
Thirty-two states plus the District of Columbia operate MFP programs: Alabama, Arkansas, California, Colorado, Connecticut, Georgia, Iowa, Idaho, Indiana, Kentucky, Louisiana, Maryland, Maine, Minnesota, Missouri, Montana, North Carolina, North Dakota, New Jersey, Nevada, New York, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, South Dakota, Texas, Vermont, Washington, Wisconsin, and West Virginia. Each state would receive up to $5 million in additional funding for planning and expansion of capacity through 2021. Funds are intended to be used for:
- Increasing the use of home– and community-based services (HCBS) while reducing utilization of institutionally based services.
- Eliminating barriers in state law, state Medicaid plans, and state budgets that restrict the use of Medicaid funds to enable Medicaid-eligible individuals to receive support for appropriate and necessary long-term services and supports in the settings of their choice.
- Strengthening the ability of Medicaid programs to provide home– and community–based services to people who choose to transition out of institutions.
- Establishing procedures aimed at quality assurance and improvements in home– and community–based services.
More information can be found at https://www.medicaid.gov/medicaid/long-term-services-supports/money-follows-person/index.html.
The public health emergency has been extended
The current public health emergency has been renewed, and it is now set to expire on January 21, 2021. This means that healthcare providers have another 90 days of applicable §1135 Waivers at their disposal. Nonetheless, as many have realized, when it comes to steering the ship, 90 days is not much time to change direction on habits that have become ingrained over a period of many months. If the public health emergency is not extended again, post-acute providers will have to consider the applicable §1135 Waivers that are now in place and adjust their operations accordingly. As a refresher, here is the current list. My advice is to reverse course on the things that are under your control to the extent possible, because that will reduce the list of changes that need to be made later on.
For home health:
- Request for Anticipated Payment (RAP) auto-cancellation extensions will revert to the prior timeframe when the public health emergency expires. There is nothing to be done here, but watch and realize that, come January 1, there is no assurance that the waiver will save home health providers from the RAP penalties if RAPs are not timely submitted within the first five days of the payment period.
- OASIS assessments will revert to the five-day completion timeline and 30-day submission requirement. As I have often advised, these two waivers don’t really help agencies when it comes to getting paid, as the OASIS must be present in order for the MAC to calculate the claim reimbursement.
- Once the public health emergency expires, aide supervision visits at least every 14 days will be required as in-person visits and no longer available through record review only. Annual onsite supervisory visit requirements will also be reinstituted.
- As the emergency period ends, therapists will only be able to perform the initial/comprehensive assessment if services are limited to therapy services and with an order from the certifying physician as an illustration of that intent (see 42 CFR §484.55). Otherwise, if non-therapy services are contemplated, or in the absence of a specific advance order from the certifying physician that limits services to therapy only, the assessment would be performed by a registered nurse (RN).
- Home health agencies will again be required to provide discharging patients with quality and resource–use information for other providers that they may choose for services after they are no longer in the care of the agency.
- The timeline for providing requested medical records will resume to the four-day window, after we are out of the emergency declaration period.
- Quality Assurance and Performance Improvement (QAPI) programs would be resumed and would include a focus on quality issues in addition to infection control and/or adverse events.
For hospice:
- The 5% volunteer requirement would be resumed as the emergency expires.
- The timeframe for the comprehensive assessment by the interdisciplinary team would revert back to at least every 15 days.
- Non-core service obligations would revert to the standard.
- Onsite aide supervisory visit requirements and annual onsite supervision would be resumed.
- Aide competency testing with pseudo-patients would resume.
- QAPI programs would be resumed and would include a focus on quality issues, in addition to infection control and/or adverse events.
For skilled nursing facilities (SNFs):
- The three-day prior hospitalization rule would be reinstituted as a precursor for SNF coverage under Medicare Part A.
- Minimum Data Set (MDS) submission requirements would revert to established timeframes.
- Level 1 and Level 2 pre-admission screening and annual resident reviews would again be required.
- Physical environment waivers related to use of non-SNF buildings to be temporarily certified and available for use for isolation would expire.
- Aide training, certification, and competency demonstration requirements would resume, based on applicable regulatory guidance at 42 CFR §483.35.
- The requirement for physician and non-physician practitioners to perform in-person visits would be reinstituted. These visits would no longer be eligible for telehealth.
- Resident grouping and resident transfer/discharge waivers would be rescinded.
- As with home health and hospice, the QAPI program would be required to resume based on the applicable Conditions of Participation.
- Nurses-aide training requirements of at least 12 hours of training annually would be resumed.
- Discharge planning requirements for assisting residents in selecting other post-acute providers would resume based on discharge planning guidelines put into place in late 2019.
- The timeline for providing requested medical records will resume to the two-day window.
- The eight-hour training for paid feeding assistants would be resumed.
All of these things are potential survey issues after the waivers expire, and providers should be keenly aware of the need to pivot and change course if and when the public health emergency ends — especially if it ends at a time that is close to an anticipated survey.
Compliance highlights
New reporting requirements for Provider Relief Fund recipients
As I reported “way back when,” the reporting requirements for Provider Relief Funds (PRF) were expected on August 17, but, alas, they didn’t materialize. Finally, over a month later, HHS issued guidelines which will arrive as an unwelcome surprise to many, especially when it comes to some eleventh-hour changes related to how funds may be used. The main issues relate to the calculation of “lost revenue” due to COVID-19 and attributable expenses. To say the very least, things just got a lot more complicated.
Healthcare providers that received from $10,000 to $499,999 must report, retroactively by quarter, when the portal opens in January 2021. The HHS document states the following with respect to reporting parameters:
“Recipients will report their use of PRF payments by submitting the following information:
- Healthcare related expenses attributable to coronavirus that another source has not reimbursed and is not obligated to reimburse, which may include General and Administrative (G&A) or healthcare related operating expenses (further defined within the data elements section. . . )
- PRF payment amounts not fully expended on healthcare related expenses attributable to coronavirus are then applied to lost revenues, represented as a negative change in year-over-year net patient care operating income (i.e. patient care revenue less patient care related expenses for the Reporting Entity, as defined, that received funding), net of the healthcare related expenses attributable to coronavirus calculated under step 1. Recipients may apply PRF payments toward lost revenue, up to the amount of their 2019 net gain from healthcare related sources. Recipients that reported negative net operating income from patient care in 2019 may apply PRF amounts to lost revenues up to a net zero gain/loss in 2020.”
If funds are not expended by the close of 2020, providers will have an additional six months into 2021 in which to use remaining amounts toward expenses attributable to COVID-19 that are not reimbursed by other sources to apply toward lost revenues in an amount not to exceed the 2019 net gain. According to HHS, the reporting period from January through June of 2021 will be compared to the same period in 2019.
2020 expenses attributable to COVID-19 not reimbursed by other sources
Let’s hit the bottom half of the Income Statement first and talk about expenses because that constitutes step one in the process. Expenses incurred may be related to treating confirmed or suspected COVID-19 cases, as well as preparations for possible or actual cases and maintaining the organization’s capacity to deliver services.
Expenses “attributable to coronavirus” are net of other reimbursement including payments received from any government program such as Medicare or Medicaid, patients, or their insurance companies. This means that eligible expenses must be deducted from both expected and realized patient service reimbursement. Only the expenses net of actual or available reimbursement will apply for purposes of the calculation. Expenses will fall into one of two categories — General and Administrative (G&A) Expenses or Other Healthcare–Related Expenses.
General and Administrative expenses include the following:
- Mortgage or rent payments.
- Insurance — property, malpractice, liability insurance related to business operations.
- Staffing — workforce expenses including training, staffing, temporary employee or contractor payroll and other employees. There are salary limits for employees, and the current maximum is $197,300 per person that can be included as a G&A expense for purposes of the PRF calculation. Note that there is no mention here of distributions paid to owners/investors who are not actively engaged in the day-to-day conduct of the business.
- Fringe Benefits — including insured benefits, hazard pay, travel reimbursement, health insurance, etc.
- Lease Payments — for new equipment and software, for example.
- Utilities/Operations — other third–party vendor payments that are not included in staffing expenses as well as electricity, gas, cleaning, internet, telephone, etc.
- Other costs not classified in any of the preceding six categories that are still generally included in overhead expenses of the entity.
Healthcare-related expenses include the following:
- Supplies that are used to prevent, prepare for, or respond to the coronavirus during the reporting period. This includes personal protective equipment (PPE) and other supplies.
- Equipment used to prevent, prepare for, or respond to the coronavirus. Agencies that acquired laptops or other computer equipment to facilitate remote work should consider including those expenses.
- Information technology including expenses paid for systems that enable or preserve the ability to deliver care, including IT expenses that may be related to a remote workforce. Here is where employee reimbursement for internet capability and other technology expenses should be considered and included.
- Other healthcare–related expenses not captured in the three items above.
Lost revenues attributed to coronavirus
Lost revenue is now attributed to a negative change in year-over-year net income from patient care services. Originally, we were led to believe that providers would be able to calculate lost revenue by comparing 2020 revenue to 2019 revenue — a nice, straightforward “apples–to–apples” comparison. So, if 2020 revenue ends up being less than 2019, one could reasonably assume that the revenue decline was directly related to COVID-19, and we have lost revenue. Unfortunately, we now know that is not what HHS currently has in mind.
The September 19 guidance indicates that we must use net operating income from one year to the next as the measure. And, there is a cap on how much lost revenue a single provider can claim. Let’s walk through the process:
First, total patient service revenue from all sources must be calculated for both 2019 and 2020. This includes Medicare, Medicaid, commercial insurance, self-pay, and any other charges attributable to other sources. In addition, the provider must include other assistance that was or is received during 2020, including from the following sources:
- Paycheck Protection Program (PPP)
— Notably, the guidance does not specify how PPP proceeds are to be reported. Since a loan is not revenue, I believe that only the forgiven portion of a PPP loan would apply as revenue for purposes of this calculation. - Federal Emergency Management Agency (FEMA) Coronavirus Aid, Relief, and Economic Securities (CARES) Act relief
- CARES Act testing
- Local, state, or tribal government assistance
- Business insurance payouts for business interruption coverage, etc.
- Other assistance from other federal programs which would include Economic Injury Disaster Loan (EIDL) grants. It would not include any receipts that are subject to repayment obligations such as EIDL loans or accelerated advance payments.
All of the foregoing items will be added together to produce 2020 revenue for purposes of the PRF calculation.
The end result
The bottom line is that providers cannot rely on PRF payments to create an advantage in 2020 over the operating results achieved in 2019, and this could operate to require some to repay larger than expected sums to the government. Let’s take a look at a simple example of how this will work:
Agency A received a total of $3 million in reimbursement from all sources in 2019. About 80% of Agency A’s revenue came from the Medicare program with the remainder coming from other pay sources. After deduction of routine business expenses including bad debts, the agency posted net income of $150,000. Agency A is owned by passive investors who are not actively engaged in the business.
In 2020, Agency A had a significant loss of patient referrals and patient willingness to accept in-person visits, due to COVID-19 concerns. Agency A took steps to limit in–person visits to only those that were absolutely necessary to receive full reimbursement for services, with other services and contacts with patients and their caregivers occurring remotely. Agency A experienced a 20% decline in revenue between March and October that amounted to $350,000. Agency A received $150,000 from the Provider Relief Fund and with that and careful attention to its costs, manages to essentially break even at the end of 2020 with just $40,000 of net income.
Agency A, as of the end of 2020, would compare its $150,000 of net income in 2019 to $40,000 in 2020 after inclusion of the PRF funds it received. Thus, it has a year-over-year change of $110,000 which is $40,000 less than the funds it received. Unless Agency A is able to perform the same set of calculations for the first six months of 2021 to use up more of the funding, it will owe $40,000 back to the government.
My best advice is to do the math now and see where your agency comes out. Adjustments may need to be made.
Updated Provider Relief Fund guidance for nursing home infection control distributions
On September 18, HHS added new FAQs to its guidance concerning the Provider Relief Fund payments to nursing homes for increased infection control. There are four new questions. You can find the entirety of the text here.
How will nursing homes qualify for funds under the quality incentive payment program as part of this distribution?
Nursing homes will not have to apply to receive a share of this incentive payment allocation. HHS will be measuring nursing home performance and distributing payments based on required nursing home data submissions.
To be eligible to receive an incentive payment, a facility must have an active certification as a nursing home or skilled nursing facility (SNF) and must also receive Medicare reimbursement. To be eligible, facilities must also report data to Certification and Survey Provider Enhanced Reports (CASPER), which will be used to establish eligibility and collect necessary provider data to inform payment.
Additionally, nursing homes must meet two criteria in order to be eligible for payment. First, a facility must demonstrate a rate of COVID-19 infections that is below the rate of infection in the county in which they are located. Second, facilities must also have a COVID-19 death rate that falls below a nationally established performance threshold for mortality among nursing home residents infected with COVID-19.
Are there different permissible uses of funds received as quality incentive payments compared to those for the funds distributed previously under the $2.5 billion Nursing Home Infection Control Distribution?
No. The same Terms and Conditions and restrictions on use of funds apply to the quality incentive payments received by nursing homes as under the Nursing Home Infection Control Distribution. Quality incentive payments may only be used for the infection control expenses. These include costs associated with administering COVID-19 testing for both staff and residents; reporting COVID-19 test results to local, state, or federal governments; hiring staff to provide patient care or administrative support; incurring expenses to improve infection control, including activities such as implementing infection control “mentorship” programs with subject matter experts, or changes made to physical facilities; and providing additional services to residents, such as technology that permits residents to connect with their families if the families are not able to visit in person.
What is the timeline for distributing quality incentive payments under this distribution?
The incentive payment program is scheduled to be divided into four performance periods (September, October, November, December), lasting a month each with $400 million available to nursing homes in each period.
All nursing homes or SNFs meeting the payment qualifications will be eligible for each of the four performance periods. Nursing homes will be assessed based on a full month’s worth of data submissions, which will then undergo additional HHS review and auditing before payments are issued the following month. These four individual performance periods would be followed by an aggregate performance period that would measure performance across the entire four–month period from September to December. The aggregate performance period would have an available incentive pool of at least $400 million.
How will facilities be assessed for purposes of issuing incentive payments?
Facilities will have their performance measured on two outcomes. First, facilities will be evaluated based on their overall COVID-19 infection rate among residents. Second, facilities will be evaluated based on their performance for COVID-19 mortality among residents.
Performance measurements for each facility will be evaluated based on the population-wide rate of COVID-19 infection in the geographic area in which a facility is located. The goal is to appropriately evaluate facility performance by measuring the baseline level of infection in the community in which a facility is located.
In order to measure facility COVID-19 infection and mortality rates, the incentive program will make use of data from the National Healthcare Safety Network (NHSN) Long-term Care Facility Component COVID-19 Module. Within the NHSN module, the program will incorporate weekly reported data on COVID infections, COVID mortality, and the total count of occupied beds.
In addition, admissions of COVID-19-positive patients will be considered in order to focus accountability on infections acquired among existing residents. Using this weekly information, each facility will receive measurements of their COVID-19 infections per resident and COVID–19 deaths per resident in each performance month. There will be an additional measurement of the baseline level of COVID-19 infection in the general community in which a facility is located. In order to measure the baseline infection rate, the program will make use of weekly updates of data included in CDC’s Community Profile Reports (CPRs). Data from the CPRs includes county-level information on total confirmed and/or suspected COVID infections per capita, which will be used to measure the baseline infection rate for all eligible facilities located in that county.
Economic Injury Disaster Loans vs. Paycheck Protection Program Loans
The last set of Small Business Administration (SBA) FAQs that were released in early September clarified how the EIDL grants would work in conjunction with PPP loans and forgiveness. Here is the takeaway:
Remember that the EIDL grants were originally set at $10,000 and then changed to $1,000 per employee. So, if a provider received an EIDL grant (different from the loan which is entirely repayable) that amount will offset the amount of the PPP loan that can be forgiven. For example:
- Agency A has 20 full time employees. It applied for and received an EIDL grant in the amount of $10,000 (which is the limit). Agency A also applied for and received a PPP loan in the amount of $40,000. No matter how Agency A applied the PPP loan proceeds, only $30,000 of the PPP loan can be forgiven and $10,000 will be treated as a loan that must be repaid.
In addition, the SBA has already advanced over $188 billion to small businesses that “suffered substantial economic injury” due to COVID-19. That is generally defined as a significant decrease in income from operations or working capital with the result that the business is unable to fully meet its obligations in the normal course of its business.
EIDL proceeds can be used to cover payroll, provide paid sick leave, satisfy rent or mortgage obligations, repay revenue obligations that cannot be met due to revenue losses, or cover increased costs to obtain materials due to interrupted supply chains. These proceeds should not be used for payments of dividends or bonuses, payments to owners other than those directly related to the performance of services for the benefit of the business, repayment of shareholder loans, to acquire assets, refinance long-term debt, or payment of government obligations for the length of time that the loan is outstanding.
Clinical highlights
New CDC guidance on virus transmission
On Monday, October 5, the CDC issued an update to previous guidance about how COVID-19 spreads. The updated guidance notes that COVID-19 spreads easily from person to person, most commonly during close contact, but occasionally it can be spread by airborne transmission. Here is what the newest guidance states with respect to airborne transmission:
Some infections can be spread by exposure to virus in small droplets and particles that can linger in the air for minutes to hours. These viruses may be able to infect people who are further than 6 feet away from the person who is infected or after that person has left the space.
This kind of spread is referred to as airborne transmission and is an important way that infections like tuberculosis, measles, and chicken pox are spread.
There is evidence that under certain conditions, people with COVID-19 seem to have infected others who were more than 6 feet away. These transmissions occurred within enclosed spaces that had inadequate ventilation. Sometimes the infected person was breathing heavily, for example while singing or exercising.
Under these circumstances, scientists believe that the amount of infectious smaller droplet and particles produced by the people with COVID-19 became concentrated enough to spread the virus to other people. The people who were infected were in the same space during the same time or shortly after the person with COVID-19 had left.
Available data indicate that it is much more common for the virus that causes COVID-19 to spread through close contact with a person who has COVID-19 than through airborne transmission.
The guidance goes on, as it has previously, to state that the virus spreads less commonly through contact with contaminated surfaces and rarely spreads between people and animals.
The guidance can be found here.
Article shares experiences of NYC home care staff during COVID-19
In a recent article published on the JAMA Network, Experiences of Home Health Care Workers in New York City During the Coronavirus Disease 2019 Pandemic: A Qualitative Analysis, authors Madeline R. Sterling, MD, MPH, MS; Emily Tseng, MS; and others describes the reactions of 33 home care workers, affiliated with 24 different agencies, to questions about how they have fared while caring for home care patients during the pandemic. It’s a revealing article and worth our consideration. There were five distinct themes based on the interviews that were conducted:
- Theme 1 – On the frontlines, but invisible. Participants in the study reported that they were aware that they were considered essential workers. “As such, they continued to work and care for their patients despite social distancing policies that would otherwise keep people 6 feet apart.” Most patients had several chronic conditions and were at a high risk for COVID-19, and most of the staff members admitted taking significant measures to take precautions while in patient homes and clean carefully as they were leaving. But despite their efforts, many “described feeling invisible to the health care community and society.”
“We’re definitely a forgotten field . . . You hear people clapping and thanking doctors and nurses, even the hospital cleaning staff . . . I’m not doing this because I want praise; I love what I do. But it would be nice for people to show us gratitude.”
- Theme 2 – Risk for transmission of COVID-19 to patients and themselves. Participants believed that providing care to patients placed them in a unique position. But they worried about their patients becoming ill and about transmitting the virus to them. To protect patients from exposure, some went to the grocery store or pharmacy to pick up items for patients, which increased their own risk for contracting the virus — sometimes they volunteered and other times they were asked to do so. Many cared for patients at the same time that others were in the home. This added to their fear of transmitting COVID-19 to patients and to one another.
“He needs to stay inside the house, so he tells me, ‘I need you to go there, go here.’ I really don’t want to, but I can’t say no. I’m the aide – I’m supposed to do this.”
- Theme 3 – Agency support was not always consistent. There were variances among agencies with respect to teaching workers about COVID-19 and providing PPE. Some agencies adapted quickly while others did not.
“I’m worried about getting infected because I don’t have the right equipment. The agency has not really been providing for their workers . . .”
- Theme 4 – Reliance on others for support. Many who did not get adequate information from their agency leadership turned to social media or news reports to get information.
“We talk to each other. We need to protect ourselves for the clients, if [we] want to keep working.”
- Theme 5 – Workers were forced to make tough trade-offs between protecting their own health and their finances. “Owing to these challenges, participants described constantly navigating hard choices. For example, when patients contracted COVID-19, workers had to decide whether to continue caring for them . . . workers also weighed whether they should remove themselves from cases they perceived to be risky. Taken together they tried balancing the risks of work with their own health and financial well-being.
“I see a fire. Am I going to walk right into that fire? . . . If I have the backup, the proper gear, yes, I’m going to be there on the front lines to help that person.”
This article is worth a read. The providers who were interviewed were home health aides and personal care workers — people who are often overlooked when the kudos go out. Maybe it’s time that we changed that and, as the quote suggests, show gratitude.
SNF infection control quality measure
In mid-September, CMS began a new public comment period on a proposal for a new quality measure aimed at infection control. The measure — entitled Skilled Nursing Facility Healthcare-Associated Infections (HAIs) Requiring Hospitalizations — will track the number of SNF stays that result in facility-acquired infections. The method would involve identifying the primary diagnosis for each resident’s prior hospital claim during a window that starts with the fourth day of the SNF stay through the third day, following the patient’s discharge from the facility. SNF and subsequent diagnoses would be used to establish the presence of the HAI. As with most other quality measures, this metric would be risk–adjusted and is a component of the Meaningful Measures for SNFs.
The program goal would be to identify SNFs with higher HAIs, most of which are considered preventable because they are outcomes of care or related to structures of care. According to CMS, “In other words, these infections typically result from inadequate management of patients following medical intervention, such as surgery or device implantation, or poor adherence to hygiene protocol and antibiotic stewardship guidelines.” The measure is intended to provide additional information about the quality of care provided in SNFs by comparing their HAI rates related to resistant staph or other infections associated with devices — such as indwelling catheters, trach tubes, and central or peripheral lines. Chronic infections and some community–acquired infections would not be included in the measure. The comment period goes through October 14 and comments can be emailed to [email protected].
Hospice election statement and addendum
The new hospice election statement and addendum requirements are now in effect as of October 1. Recently the National Association for Home Care & Hospice (NAHC) confirmed its conversations with representatives of CMS regarding how the new requirements will be enforced. Here are the takeaways:
- While the election statement modifications and addendum, if requested, are conditions of payment, Medicare contractors will only impose financial penalties when the addendum has been requested but there is no evidence in the record that it was provided.
- Medicare contractors will be looking at the addendums that were provided to ensure that they are signed by the patient or their representative.
- Medicare contractors will not, however, be enforcing the time limits for providing the addendum once it has been requested.
- CMS provided guidance to NAHC to indicate that hospice teams should endeavor to explain to patients or their representatives that the signature on the addendum is nothing more than an acknowledgement of receipt. If the patient or representative still refuses to sign the document, the hospice should record the specifics in a note included in the medical record.
- If the record shows that the addendum was requested but not provided, the penalty will extend to non-coverage of services.
Administrative highlights
Department of Labor establishes temporary rule covering the definition of “health care provider”
Readers will remember back in August when I reported on a decision that was handed down in the Southern District of New York concerning the definition of “health care provider.” The decision was made by the Department of Labor (DOL) related to passage of the Families First Coronavirus Response Act (FFCRA). At the time, I interviewed Robert Markette of Hall, Render, Killian, Heath and Lyman about whether the ruling in New York would impact agencies outside of that court’s limited jurisdiction, and he generally declined to make the leap and say that it would apply to all. Nonetheless, the DOL took the court’s opinion to heart and issued a revision to the rule. Here is the essence of the issue at hand and how the new DOL rule affects the court’s ruling for those of us outside of New York.
The court opined that the DOL overstepped its bounds as it defined the term “health care provider” for purposes of deciding whether an exemption from extended family and/or sick leave applied to certain people employed by healthcare organizations. In essence, the DOL said that anyone working for a healthcare organization would fit the definition. This is what the court overturned as too broad a characterization of “health care provider.” The new DOL rule changes that and applies to the employee and their set of responsibilities related to the delivery of healthcare services.
Generally, those who are performing diagnostic, preventive treatment or “integrated” services that combine all three elements are considered healthcare providers. This includes nurses, nursing assistants (CNAs), technicians, therapists, social workers, and any other employee under the supervision, order, or direction of or providing direct assistance to a healthcare provider. According to the analysis done by NAHC, it also appears “likely that home health aides, home care aides, and personal care attendants are exempt” provided they work under orders from or supervised by a physician or a non-physician practitioner, nurse, or therapist. So, anyone providing care to a patient under a Plan of Care that is covered by Medicare or Medicaid is likely going to be exempt.
According to NAHC, what is “much less clear is whether a home care aide or personal care attendant not subject to a healthcare professional’s order or supervision qualifies for the exemption. In such circumstances, it appears necessary to demonstrate that the employee is integrated into the provision of health care services overall.”
In closing
It’s amazing to me — in the worst possible way — that we have come to the point of passing 200,000 deaths related to COVID-19, with predictions that the numbers could nearly double by year’s end. And in what is now the seventh straight month of curtailed activity for us all — no matter where we live or what we do for a living — it is more important than ever to recognize the sacrifices that many like you are making to keep us going in ways that, little by little, get us a tiny bit closer to what used to pass for “normal.”
So, as we close off yet another (lengthy!) issue of the WellSky COVID-19 Briefing, let me say once more how much I appreciate my relationship to those of you who do the heavy lifting by providing excellent patient care or making that care possible through your support of your colleagues in the field. As suggested by the JAMA article on home care, you may not be in the spotlight, but your contributions are still amazing and very much valued. Until next month, hang in there — and be safe.