Iowa LTCs: Guidance on Phased Easing of Restrictions for Long-Term Care Facilities

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare

The Iowa Department of Public Health and the Iowa Department of Inspections and Appeals have released a 13-page document to address phasing of restrictions for LTC facilities.  The document carries a date of June 4, 2020.

“While public health mitigation efforts remain critically important, especially in long-term care settings where residents may be more vulnerable to virus exposure, the state acknowledges that it is equally important to consider the quality of life and dignity of the residents of long-term care facilities. Based on recent guidance from CMS, the state has collaborated with long-term care associations on how to responsibly ease restrictions in long-term care facilities while COVID-19 remains in communities across the state. This guidance is based on currently available best-practice recommendations and evidence and may be updated as additional information becomes available.”

The document speaks to 3 specific phases:

  • Phase 1 is designed for vigilant infection control during periods of heighted virus spread in the community and potential for healthcare system limitations, which may include factors such as staffing, hospital capacity, Personal Protective Equipment (PPE), and testing.
  • Facility may decide to initiate Phase 2 upon alignment with the following metrics:
    • 14 days since last positive or suspected case identified. (See Appendix A regarding testing recommendations that should be completed prior to moving to Phase 2.)
    • Adequate staffing levels.
    • Ability of local hospital to accept referrals/transfers.
    • Capable of cohorting residents with dedicated staff in the case of suspected or positive cases.
    • A downward trend in number of cases or the % positivity over the past 14 days in the county.
    • Facility shall report their Phase status to the Regional Medical Coordination Center.
    • Facilities may use discretion to be more restrictive in areas, where deemed appropriate through internal policies, even if they have moved to this Phase.
  • Facilities may decide to initiate Phase 3 upon alignment with the following metrics:
    • 14 days since last COVID-19 positive or suspected case identified.
    • Adequate staffing levels.
    • Ability of local hospital to accept referrals/transfers.
    • Capable of cohorting residents with dedicated staff in the case of suspected or positive cases.
    • A downward trend in number of cases or the % positivity over the past 14 days in the county.
    • Facility shall report their Phase status to the Regional Medical Coordination Center.
    • Facilities may use discretion to be more restrictive in certain areas, where deemed appropriate through internal policies, even if they have moved to this Phase.

The elements impacted in each phase are grouped by:

  • Visitation
  • Essential/Non-Essential Healthcare Personnel
  • Non-Medically Necessary Trips
  • Communal Dining
  • Screening
  • Universal Source Control & PPE
  • Cohorting & Dedicated Staff*
  • Group Activities
  • Salons
  • Testing
  • Phase Regression
  • Survey Activity

The * behind Cohorting & Dedicated Staff refers to this:

Many senior care communities that include assisted living programs that attached to nursing facilities or are a part of a continuing care retirement community or senior living campus have commonly shared kitchen facilities. In the current public health mitigation environment, facilities should not routinely share direct care, dietary, or environmental services staff who may have contact with residents or tenants in other segments of the senior living operations. If there are identified cases of COVID-19 in other service delivery areas of the campus, there should be no sharing of staff between those care systems.

Each of the above elements has mitigation steps associated with it.

Appendix A: Testing Guidance is a 2-page section of the guidance that speaks to QSO-20-30-NH in which  State Survey Agencies and other state officials determine how nursing facilities may begin to lift restrictions placed to mitigate the spread of COVID-19. CMS indicates in this QSO that testing will be a critical part of a facility lifting restrictions on operations.

The state agrees that it is important for all facilities to participate in baseline testing for all residents and staff prior to consideration of lifting restrictions. Baseline testing is critical to understand how the virus may exist in facilities especially among those without symptoms, so that informed decisions can be made and appropriate steps are taken for containment. Comprehensive testing of all staff and residents is encouraged as a baseline regardless of whether a case has been identified or not. At minimum facilities should meet the following testing metrics prior to moving to Phase 2 and also follow this guidance any time a single positive case is identified in a facility:

• If there were one or more positive cases previously in residents, at a minimum, all residents with shared hallways/unit or staff should have been tested. Offering testing to all residents when a positive case is recognized is advised.

• All staff, including administrative, should be offered testing regardless of contact with residents that have tested positive for COVID-19.

• Staff declining testing should be treated as having a positive or unknown COVID-19 status and appropriate PPE should be used.

For Phase 2 and 3, the state encourages testing to continue as outlined in previous guidance for residents and staff that:

• Are currently symptomatic.

• Have had close contact with an individual, either at work or in the community that has tested positive for COVID-19.

• Staff that meet either of the above two bullets and decline testing should be treated as having a positive or unknown COVID-19 status and excluded or use recommended PPE as appropriate.

Additionally, the state will be engaging in sentinel testing in facilities across the state during Phase 2 and 3. Sentinel testing will be conducted on a weekly basis with a limited number of facilities and will include a prescribed number of staff, as determined by the Iowa Department of Public Health in collaboration with a facility. Sentinel testing will be based on factors such as:

• Virus activity in the community.

• Geographic representation.

• Availability of testing in the community.

• Findings from infection control surveys.

• Reporting of testing efforts and resources by the facility.

The state will work with local public health entities and facilities to access supplies or appropriate funding for baseline testing in Phase 1 as well as case-directed and sentinel testing in Phase 2 and 3.

Facilities should report their baseline testing numbers (Phase 1) for residents and staff through their Regional Medical Coordination Centers (RMCC).

For ongoing testing efforts in Phase 2 and 3, facilities should report through their RMCC once reporting surveys are ready to accept data. Definitions for all requested data will be available as part of the RMCC reporting process.

This guidance is “specifically targeted at long-term care facilities (e.g., nursing homes). Other facilities or congregate care settings, such as assisted living or residential care facilities, may choose to follow an independently developed framework for easing restrictions. Guidance from the Centers for Disease Control (CDC) for COVID-19 mitigation strategies for assisted living congregate settings is found at:

https://www.cdc.gov/coronavirus/2019-ncov/hcp/assisted-living.html

https://www.cdc.gov/coronavirus/2019-ncov/community/shared-congregate-house/guidanceshared-congregate-housing.html

I encourage all Iowa LTC facilities to carefully review and incorporate this guidance as directed by the state of Iowa.  Keep the document handy and refer to it often as you work with staff, residents and their families.  The document does not provide contact information for questions but we all know how to reach IDIA and the IDPH.