CMS and CDC Update Guidance for Nursing Home Staff Testing and Work Restrictions

While attention regarding newly released guidance from the Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) on nursing home testing, visitation, and communal activities has focused on the impact on residents, the guidance also addresses testing and work restrictions for staff.¹

CMS revised an existing memorandum, QSO-20-38-NH (“Memorandum 38”), which was originally published on August 26, 2020, to address the effect of vaccination status on testing of staff for SARS-CoV-2 in various circumstances.  In tandem, the CDC updated its Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccination web page (“CDC Guidance”) to cover staff testing, work restrictions, and other matters.

Testing

Memorandum 38 and the CDC Guidance discuss the testing of vaccinated²  and unvaccinated³ staff in various circumstances.

• Testing staff with COVID-19 symptoms or signs – Staff experiencing symptoms or signs of COVID-19 must be tested immediately, regardless of vaccination status. CMS expects staff to be restricted from the facility pending the results of the testing.

• Testing staff with exposure to SARS-CoV-2 – Memorandum 38 defers to the CDC Guidance.
  • Asymptomatic staff that have had a higher risk exposure⁴  to an individual confirmed to have SARS-CoV-2 infection should have a series of two viral tests, regardless of vaccination status. The first test should be administered immediately after exposure. The second should be administered five to seven days after exposure.  Note, however, that asymptomatic staff that have had SARS-CoV-2 infection in the last 90 days do not need to be tested.

• Facility outbreak testing – Regardless of vaccination status, staff should be tested immediately and thereafter, every three to seven days until at least 14 days after testing identifies no new infections among staff or residents.

• Routine testing – Routine testing is where vaccination status affects the protocols for staff. Fully vaccinated staff need not be subject to routine testing.  Unvaccinated staff should be tested according to previously established protocols—once per week if the county positivity rate is below five percent; once per week if the county positivity rate is between five and 10 percent; and twice per week if the county positivity rate is greater than 10 percent.

Work Restrictions

Fully vaccinated, asymptomatic staff with a higher-risk exposure⁵  do not need to be restricted from work for 14 days following such exposure.  These staff members also do not need to quarantine following domestic or international travel, though CDC travel guidance requires testing in the case of international travel.

Communal Activities

Similar to its guidance with respect to communal activities for residents⁶, the CDC guidance states that fully vaccinated staff “could dine and socialize together in break rooms and conduct in-person meetings without source control [i.e., facemasks] or physical distancing.”  If unvaccinated staff are present, however, everyone must wear source control, and unvaccinated staff should be physically distanced from others.

By using the word “could” versus the more permissive term “may,” the CDC is taking an exceedingly cautious approach to such activities when a more permissive approach might provide an additional incentive for vaccine-hesitant staff to take the vaccine and thereby restore some semblance of normalcy to their daily routine.  Otherwise, the only incentive is relaxed testing and that alone may not be sufficient.

[1] This article focuses solely on staff issues.  A companion article focuses on residents.

[2] “Vaccinated” or “Fully Vaccinated” refers to a person who is two weeks following a receipt of the second dose in two-dose series, or two weeks following receipt of a single-dose vaccine.  See Memorandum 38, at page 2.

[3] “Unvaccinated” refers to a person who is not fully vaccinated or whose vaccination status is unknown.  Id. at 3.

[4] According to the CDC, higher-risk exposures generally involve exposure of the staff member’s eyes, nose, or mouth to material potentially containing SARS-CoV-2, particularly if the staff member was present in the room for an aerosol-generating procedure. 

[5] Exposure of a staff member’s eyes, nose, or mouth to material potentially containing SARS-CoV-2, particularly if the staff member was present in the room for an aerosol-generating procedure.  Examples include staff not wearing a respirator or facemask when caring for a COVID-positive resident, or a staff member not wearing eye protection when caring for a COVID-positive resident and the resident is not wearing a face-covering or facemask.  See https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html.

[6] See [companion article].