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COVID-19: Nursing Homes

A medical professional hold the hand of an older adult in a wheelchair

This guidance is for Wisconsin nursing homes and intermediate care facilities for individuals with intellectual disabilities (ICF/IID). Nursing homes and ICF/IIDs care for residents who are elderly and/or who have chronic medical conditions that place them at higher risk of developing severe complications from COVID-19.

This guidance is based on information from the Centers for Medicare & Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC), and the Department of Health Services (DHS) in accordance with Wis. Stat. chs. 50 and 252, Wis. Admin. Code chs. DHS 132, DHS 134, and DHS 145. It is designed to assist facilities to improve their infection prevention and control practices, to prevent the transmission of COVID-19, and keep residents and the health care personnel (HCP) who care for them safe from infection.

CMS and CDC continue to provide guidance for nursing homes and other long-term care facilities. Facilities are encouraged to routinely check the CMS and CDC websites for additional guidance.

Admissions

Facilities should admit any individuals that they would normally admit to their facility, including individuals from hospitals where a case of COVID-19 was or is present. Facilities should follow the CDC guidance for infection controlwhen COVID-19 is identified or suspected in a resident.

Newly admitted or readmitted residents who are not up to date with all recommended COVID-19 vaccine doses should still be quarantined for evidence of COVID-19.

For more information on managing new admissions visit CDC’s Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes

Admissions During a COVID-19 Outbreak

When a suspected or confirmed case of COVID-19 is identified in a facility, the facility may temporary halt admissions to the facility, at least until the extent of transmission can be clarified and interventions can be implemented. See Preventing and Controlling Respiratory Illness Outbreaks in Long-Term Care Facilities for more information.

While COVID-19 remains a threat in Wisconsin, a facility may determine that they can safely admit a resident if certain considerations are taken into account. Facility leadership should carefully review CDC’s Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes and consult with the local public health officer when possible.

Discharges and Transfers

If a resident has been exposed and is being discharged, the resident requires quarantine at the receiving facility. Therefore, you must inform the facility that is accepting the resident. If the facility is unable to meet transmission-based precautions and quarantine for the appropriate length of time, then the resident cannot be transferred.

The strategies used to limit the spread of COVID-19 are especially difficult for residents with dementia. Due to their decreased cognitive ability, residents with dementia will require additional assistance adhering to quarantine and isolation. In particular, residents with dementia may have an impaired ability to follow or remember these instructions and may require additional assistance and reminders from staff:

  • Refraining from touching face
  • Handwashing
  • Wearing a mask
  • Refraining from placing things in their mouth
  • Social distancing - staying in a particular area
  • Other interventions requiring individual follow-through or accountability

On May 6, 2020, CMS issued Interim Final Rule Updating Requirements for Notification of Confirmed and Suspected COVID-19 Cases Among Residents and Staff in Nursing Homes Memo, QSO-20-29-NH (PDF). This requires nursing homes to report COVID-19 facility data to the CDC and also to residents and their families/representatives. The memo states that failure to report in accordance with 42 CFR § 483.80(g) can result in an enforcement action. Data from the CDC National Healthcare Safety Network (NHSN) is available for viewing by facilities, stakeholders, or the public. The COVID-19 public use file is available at COVID-19 Nursing Home Data. The memo includes updated COVID-19 focus survey forms and regulatory tags.

Pursuant to Wis. Admin. Code ch. DHS 145 the local health department should be notified about residents or staff with suspected or confirmed COVID-19, residents with severe respiratory infection resulting in hospitalization or death, or three (3) or more residents or staff with new-onset respiratory symptoms within 72 hours of each other.

Nursing homes should screen everyone entering the facility, regardless of their vaccination status. The screening includes all staff, visitors, hospice, clergy, external health care personnel (HCP), surveyors, and all vendors.

Anyone who meets any of the following three criteria should not enter the facility:

  • Tested positive for SARS-CoV-2 with a viral test
  • Has symptoms of COVID-19, or
  • Had a known exposure to someone with COVID-19 (or a higher-risk exposure for HCP).

Visitors who have met community criteria to discontinue isolation or quarantine should not visit the facility until they have met the same criteria used to discontinue isolation and quarantine for residents.

Staff who have a fever or any COVID-19 symptoms prior to or during their shift should be excluded from work. Decisions about when staff can return to work should be made using Criteria for Return to Work for Healthcare Personnel with SARS-CoV-2 Infection.

Do you need outbreak support? Contact your regional infection preventionist.

Infection control assessment and response

CDC's COVID-19 Infection Control Assessment and Response (ICAR) tool was developed to help facilities take steps to assess and improve their preparedness for responding to COVID-19. The ICAR tool should be used as one tool to develop a comprehensive COVID-19 response plan.

Facilities can request an ICAR evaluation by the Healthcare-Associated Infections (HAI) Prevention Program Regional Infection Preventionists (IPs) which involves a more detailed phone-based or on-site infection control assessment of elements for COVID-19 readiness. The Regional IPs are also available to:

  • Answer infection prevention questions on a variety of topics (for example, appropriate PPE use, environmental infection control, bloodborne pathogens, multidrug-resistant organisms, quarantine and isolation).
  • Participate in outbreak and infection control breach technical assistance.
  • Provide infection prevention and control education.

See highlights and common recommendations the IPs make during ICAR calls or visits on the HAI Infection Prevention Education webpage.

Guidance

For current guidance, information on mitigation strategies, and infection prevention best practices review CDC's Infection Control Guidance for Healthcare Personnel During the COVID-19 Pandemic and Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes.Educate residents, staff, and visitors about COVID-19, current precautions being taken in the facility, and actions they should take to protect themselves.

Maintaining appropriate staffing is essential to providing a safe work environment for facility staff and safe resident care. Facilities must be prepared for potential staffing shortages and have plans and processes in place to mitigate them. Facilities should also communicate with staff about actions the facility is taking to address shortages and maintain resident and staff safety, and provide resources to assist staff with anxiety and stress.

Develop a contingency staffing plan

Develop a contingency staffing plan that identifies the minimum staffing needs and prioritizes critical services based on residents' needs.

  • Assign a person to conduct a daily assessment of staffing status and needs during a COVID-19 outbreak.
  • Contract with staffing agencies, local hospitals, and clinics to fill roles as appropriate.
  • Explore all state-specific emergency waivers or changes to licensure requirements or renewals that may allow for hiring and staffing flexibility.
Strategies to lesson staffing shortages

As a facility deviates from their standard recruitment, hiring, and training practices, there may be higher risks to the staff and residents. Facilities should carefully review their emergency plans and cautiously move from one staffing strategy to the next, balancing risk and benefits with each decision.

For more information on implementing strategies to mitigate staffing shortages, see CDC’s Strategies to Mitigate Healthcare Personnel Staffing Shortages and Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure.

Wisconsin Emergency Assistance Volunteer Registry (WEAVR)

Facilities may reach out for assistance from the Wisconsin Emergency Assistance Volunteer Registry (WEAVR). WEAVR is a web-based online registration system for Wisconsin's health professional volunteers willing to serve in an emergency. WEAVR facilitates health and medical response through identification, credentialing and deployment of volunteers. Facilities who may be in need of WEAVR support should work with local public health and emergency management to identify needs and available resources. Facilities can submit their request directly to dhsweavrmail@dhs.wisconsin.gov. We ask that you copy your local public health agency on the submission.

Information from facilities that would expedite this process includes:

  • Contact information at the facility.
  • A brief description of the situation at the facility.
  • The skill set(s)/profession(s) that are needed.
  • The duration of time you will need the volunteers for.
  • A brief description of duties.
  • Information on whether you will compensate people or are looking for volunteers.
  • The date you need people to start.

Additional resources and training to help nursing homes hire and retain the best possible workforce can be found on the WisCaregiver Careers webpage.

EMResource Bed Tracking System

The Department of Health Services (DHS), Division of Quality Assurance (DQA) and Division of Public Health (DPH) asks all nursing homes, hospitals, EMS providers, and other eligible entities to use the EMResource Bed Tracking System during the COVID-19 pandemic and into the future.

The EMResource Bed Tracking System tracks bed availability, identifies the number of patients pending post-acute discharges, and provides a real-time picture of bed capacity in both hospitals and nursing homes across the state. The system, expanded in March 2021 to include a nursing home dashboard, has the ability to save hospitals and nursing homes many hours of searching for beds by phone and email. Forty percent of nursing homes are signed up and actively report in the system. DHS requests the remaining 60% to enroll in EMResource and consistently report into the bed tracker dashboard.

Please register with EMResource. If you have questions or would like more information about the program, contact DHS.

When staff with COVID-19 are identified (regardless of whether the staff member is showing symptoms or not), they should be excluded from work until they have met the criteria set by CDC Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2. Exceptions to this recommended practice will increase the risk of COVID-19 transmission to residents of long-term care facilities, but may be necessary in a crisis situation.

On March 10, 2022, the Centers for Medicare & Medicaid Services (CMS) revised CMS Memo QSO-20-39-NHto state that visitation is now allowed for all residents at all times. However, outdoor visitation is preferred when a resident and/or visitor are not up-to date with all recommended COVID-19 vaccine doses. CMS and CDC continue to emphasize the importance of adhering to the core principles of COVID-19 infection prevention.

Residents and their loved ones may contact providers with questions about visits. Facilities should ensure residents, and their loved ones, have access to the Ombudsman Program at the Board on Aging and Long-Term Care at 800-815-0015.

Facilities should consider approaches to decrease the number of different staff interacting with each resident as well as the number of interactions among those staff and residents.

  • Nursing homes should use separate staffing teams for COVID-19 positive residents, to the best of their abilities.
  • To the extent possible, facilities should consider making consistent assignments throughout the facility, regardless of COVID-19 status. This may include the assignment of staff to specific residents. When feasible, staff should not work across floors, units, or wings.
  • Consistent staff assignments also serve to enhance staff's ability to detect emerging condition changes among residents, which staff with less familiarity may not notice.

Facilities should designate units or wings dedicated to residents with known or suspected COVID-19, ensuring that they are separate from other residents.

  • COVID-19 units and wings must have capacity to maintain strict infection control practices and testing protocols, according to current regulations and guidance.
    • Capacity includes the ability to manage higher intensity residents (including ventilator management).
  • When possible, facilities should use consistent assignments or have separate staffing teams for COVID-19 units and wings.

CMS testing requirements

See CMS Memo QSO-20-38-NH Revisedfor facility testing requirements for residents and staff. CMS Memo 21-14-ICF/IID & PRTF Revised has guidance for visitation and testing specific to ICF/IIDs and references some guidance that differs from CDC.

Considerations for use of COVID-19 antigen testing in nursing homes
  • Antigen tests are available with rapid turn around time critical to the identification of COVID-19 infection and rapid implementation of infection prevention and control strategies.
  • These tests can augment other testing efforts, especially in settings where reverse transcription polymerase chain reaction (RT-PCR) testing capacity is limited or testing results are delayed (for example, more than 48 hours).
  • In general, POC antigen tests have a lower sensitivity, but similar specificity, for detecting COVID-19 compared to RT-PCR tests.
  • Antigen tests are especially useful for testing symptomatic individuals, such as symptomatic staff, and can inform decision-making.
Interpreting antigen testing

The CDC developed considerations for using antigen testing in long term care facilities to help interpret antigen test results in nursing homes. A flow chart for interpreting results is also available.

Implement a plan for testing

Testing only provides information for a given point in time. Residents and staff with negative test results can become infected in the future. Nursing homes and ICFs/IID should implement a plan for testing as a way to continue to identify infections early and stop transmission. A facility's plan for testing, including expanded screening testing of staff, should be based on the level of COVID-19 transmission in the community. The plan should include a procedure for addressing residents or staff who decline or are unable to be tested.

Testing priorities: symptomatic testing, outbreak testing and routine testing
Process to obtain testing supplies and lab support

Wisconsin has contracted with several labs to support both routine staff testing and outbreak testing. Submit all orders for both routine and outbreak testing via the state testing portal.

If you have questions regarding testing, please email wicovidtest@wisconsin.gov.

On November 4, 2021, the CMS announced new emergency rules that require all health care providers and suppliers that participate in a federally certified Medicare and Medicaid program under Medicare Conditions of Participation (COP), Conditions of Coverage or Requirements for Participation to develop a plan/process to vaccinate all staff against COVID-19.

The federal emergency rule does not apply to providers that are certified through the Wisconsin Medicaid program but are not federally certified under the Medicare and Medicaid program under Medicare Conditions of Participation (COP), Conditions of Coverage or Requirements for Participation.

The Division of Quality Assurance hosted a COVID-19 Health Care Staff Vaccination Rule webinar on November 23, 2021. During the webinar, DQA staff provided information about the federal COVID-19 health care staff vaccination rule and answered questions. Learn more by viewing the following webinar recordings:

CMS has provided additional information in a FAQ document: CMS Omnibus COVID-19 Health Care Staff Vaccination Interim Final Rule. Learn more by viewing the CMS Omnibus COVID-19 Health Care Staff Vaccination Rule presentation in video or slide format.

For information on staying up to date with your COVID-19 vaccines, visit CDC’s webpage.

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Last revised March 22, 2023