Final Nursing Home Commission Report Yields Many Recommendations, Even More Action Items

The independent, 25-member Coronavirus Commission on Safety and Quality in Nursing Homes (Commission) convened earlier this year by the Centers for Medicare and Medicaid Services (CMS) to study lessons learned from the early days of the pandemic and make recommendations going forward to improve infection prevention and control, and enhance resident care and quality of life, issued its final report on September 16.

The Commission, which represented providers and provider organizations, consumer organizations, academicians, state officials, Ombudsman representatives and others, made 27 principal recommendations to CMS spanning 10 themes:

• Testing and Screening
  • Develop and execute a national strategy for rapid response testing tailored to community prevalence of infections.
• Equipment and Personal Protective Equipment (PPE)
  • Establish a collaborative process to ensure that nursing homes are able to procure and maintain a three-month supply of PPE.
  • Working with other federal agencies, provide specific guidance on the use, decontamination, and reuse of PPE.
  • Provide guidance to clinical and nonclinical staff on the proper use of PPE.
• Cohorting
  • Update cohorting guidance to balance both resident and staff psychological safety and well-being with infection prevention and control objectives.
  • Update guidance and reimbursement policy to address differences in resources across nursing homes in such areas as physical plant, infrastructure, and staffing.
• Visitation
  • In recognition that visitation is critical for residents, provide evidence-based guidance on in-person visitation prior to federal Phase 3 reopening
    • Note: CMS issued such guidance on September 17.
  • Update guidance for implementing virtual visitation.
  • Provide resources to help staff assess and improve resident mental health and psychosocial well-being.
  • Review and consolidate visitation directives, guidance, and resources into a single source.
• Communication
  • Expand guidance on communications among staff, residents, and families.
• Workforce Ecosystem: Stopgaps for Resident Safety
  • Mobilize resources to support a fatigued staff and assess minimum care standards.
  • Provide guidance to allow workers to continue to work in multiple facilities while adhering to infection prevention and control practices.
  • Support 24/7 RN staffing in the event of a positive test for the SARS-CoV-2 virus within the facility.
  • Identify and leverage certified infection preventionists.
  • Require facilities to hire infection preventionists with educator capabilities.
• Workforce System: Strategic Reinforcement
  • Increase recruitment efforts for CNAs; issue guidance to allow on-the-job training, testing, and certification of CNAs; and create a national CNA registry.
  • Professionalize infection prevention positions.
  • Overhaul the workforce ecosystem for long-term care.
  • Convene a long-term care workforce commission regarding modernization of the workforce ecosystem.
• Technical Assistance and Quality Improvement
  • Identify and establish funding mechanisms for collaborative, on-site support during and after a public health emergency.
• Facilities
  • Share with facilities short-term, low cost design enhancements to address pandemic-related risks.
  • Establish a collaborative national forum to identify and share best practices for using existing physical spaces.
  • Establish long-term priorities and seek appropriate funding streams for nursing homes to redesign and/or strengthen facilities against infectious diseases.
• Nursing Home Data
  • Standardize COVID-19 data elements, improve data collection, and identify supportive actions in response to nursing home reporting.
  • Create an intuitive and interactive technical infrastructure for reporting that streamlines the process; consolidate dissemination of regulatory materials and communications.

While many of the recommendations presently are being implemented, the Commission included over 100 action steps that provide much greater detail regarding the principal recommendations.  Some of the more noteworthy action items include the following:

• Provide funding for technology-based solutions, such as phone and web-based applications, to streamline daily screening processes and free up staff so they can focus on resident care.
• Ability for CMS to exercise its enforcement authority to ensure compliance and accountability for procurement of recommended supplies of PPE, i.e., three-month supply on hand at all times.
• Establish national training requirements for infection control and use of PPE for all health care personnel and others having direct or indirect contact with residents.
• Provide advance written notice to residents and resident representatives about facility cohorting protocols, including intra-facility and inter-facility transfers, and provide notification of intent to isolate or transfer a resident when symptoms emerge that necessitate such action.
• Modify the Resident Assessment Instrument/Minimum Data Set coding instructions to eliminate the possibility of a higher reimbursement rate for residents isolated or quarantined in a room alone than that paid for residents cohorted with a group.
• Develop a mental health supplemental assessment for residents exhibiting a change in mental health status.
• Require an individualized communication plan as part of each resident’s care plan, including preferred mode and frequency of communications, and action steps for missed communications.
• Issue requirements for minimum care standards that specify hours of care per resident per day during normal and emergency operations.
• Identify federal relief funds to provide paid quarantine-leave options for direct care providers who test positive for SARS-CoV-2.
• Develop regulations requiring integration of multi-employer staffing assignment patterns into emergency planning.
• Leverage federal relief funds, and coordinate the use of regional health system resources to provide 24/7 RN staff augmentation.
• Modify RN, LPN, and CNA clinical training standards for certification and licensure, and include a clinical rotation in a long-term care setting.
• Work with the CDC to supplement guidance for the manipulation of HVAC systems that can reduce the risk of transmission of SARS-CoV-2 by supporting infection control (e.g., creating negative pressure or replacing filters), adding air purification equipment and setting HVAC system performance standards.
• Encourage nursing homes to assign residents to single-occupancy rooms in facilities that can accommodate this approach without detrimental reduction in census, and examine changes in reimbursement that would promote such an approach.
• Develop interoperability and communication standards to integrate nursing home data with that from other health organizations, and incentivize nursing homes to adopt health information technology to support health information exchange and access to electronic health records across settings.

The Trump Administration released a response to the Commission’s report.  The response details actions already taken to address many of the Commission’s recommendations and telegraphs future rulemaking and other changes the Administration intends to take.  Specifically, the response notes that CMS intends to address the recommendation to professionalize infection prevention positions in future rulemaking and, as part of the agency’s long-term strategy to seek input on the best approach for convening a long-term care workforce commission.  The response also stated that CMS is presently working on designing a website for making critical information available to various stakeholders, including providers and residents.

It remains to be seen what will become of the Commission’s recommendations and action items in the long run, particularly with the possibility of a change in administration in the months following the November election.  While many of the recommendations and action items have been or are capable of being implemented before the election, others will be much more difficult, if for no other reason than they call for changes that are likely to require notice and comment rulemaking to implement.  Moreover, some of the recommendations and action items place significant burdens on providers at a time when they are still struggling with their immediate response to the pandemic.  One thing is certain, however; the Commission’s report lays the groundwork for nursing homes, as well as federal and state agencies, to be more nimble in their response to future pandemics.