DHSS has updated its guidance to reflect recent changes to CMS’ visitation guidance and to clarify and provide examples of those considered outside health care workers, which includes hospice workers (all disciplines). The changes include:

Visitor Vaccination Status
When both the resident and all of their visitors are fully vaccinated and while alone in a resident’s room or the designated visitation room, residents and their visitor(s) can choose to have close contact (including touch) and to not wear source control. Visitors should wear source control and physically distance from other healthcare personnel and other residents/visitors that are not part of their group at all other times while in the facility.

Visitors shall be given the opportunity to disclose their vaccination status to determine if the visitor may have close contact (including touch) and not wear source control while alone in a resident’s room or the designated visitation room, however the facility may not require visitors to disclose their vaccination status or to show proof of vaccination. Visitors that decline to disclose their vaccination status should adhere to the infection control principles of COVID-19 infection prevention for unvaccinated persons.

Outside Health Care Workers
Clarified and provided examples of outside health care workers and the expectation that outside healthcare workers must be permitted to come into the facility. Health care workers who are not employees of the facility, such as hospice workers (all disciplines), Emergency Medical Services (EMS) personnel, dialysis technicians, laboratory technologists, radiology technologists, social workers, clergy, etc., but provide direct care to the facility’s residents, must be permitted to come into the facility as long as they are not subject to a work exclusion due to an exposure to COVID-19 or showing signs or symptoms of COVID-19 after being screened.

Communal Dining and Group Activities
Fully vaccinated residents can participate in communal dining and group activities without use of source control or physical distancing. If unvaccinated residents are present, all residents should use source control when not eating and unvaccinated residents should continue to remain at least 6 feet from others.

With the appointment of Acting Director of Health and Senior Services Robert J. Knodell, the Department has issued identical orders and standing orders as to what was in place prior to this transition. The only differences are the date and signatories. As Acting Director Knodell is not a physician, those medical standing orders that may only be authorized by a physician have been re-issued under the authority of the DHSS State Epidemiologist, Dr. George Turabelidze who has held an unrestricted physician license in Missouri since 1996. These updated orders cover COVID-19 vaccination and testing needs as well as Naloxone administration and are intended to mitigate any challenges associated with transition.

For purposes of administration needs, the following information is provided for the purpose of execution of the established orders in an appropriate authorized manner:

Dr. George Turabelidze
NPI Number: 1750496246

The revised orders may be found at the following links:
https://health.mo.gov/living/healthcondiseases/communicable/novel-coronavirus/statewide-orders.php
https://health.mo.gov/data/opioids/pdf/naloxone-standing-order.pdf

Johnson & Johnson’s Janssen COVID-19 vaccine administration is being paused in Missouri until further notice.

“In an abundance of caution and as per federal guidelines, we are pausing vaccination with Johnson & Johnson’s Janssen vaccine until further notice in Missouri,” said Dr. Randall Williams, director of the Department of Health and Senior Services (DHSS). “We anticipate having more information shortly to make further decisions about overall vaccine distribution in light of this new development and will continue to update citizens who have been vaccinated with the J&J vaccine after the advisory committee meets at the federal level tomorrow.”

A new standing order for this vaccine has been issued by DHSS and is effective immediately.

People who have received the J&J vaccine who develop severe headache, abdominal pain, leg pain, or shortness of breath within three weeks after vaccination should contact their health care provider. Patients with other clinical questions should contact their health care provider or call the COVID-19 hotline at 877-435-8411.

Providers are asked to keep any on-hand J&J vaccine in the appropriate storage unit and label it “quarantine-do not use” until further notice.

As the State of Missouri receives more information, it will be made available.

• Joint CDC and FDA Statement on Johnson & Johnson COVID-19 Vaccine

On 5/1/2021, the following long-term care facility waivers will either end or implementation guidance has been revised. See the implementation guidance(s) below for full details.

Effective 05/01/2021, the following regulatory waivers will end for all facilities (including Medicare/Medicaid certified):

Residential Care Facilities and Assisted Living Facilities
19 CSR 30-86.022(3) fire extinguisher inspections/maintenance
19 CSR 30-86.022(4)(A) and (C) range hood extinguishing system testing
19 CSR 30-86.022(9)(C) and (D) fire alarm system inspections/certification
19 CSR 30-86.022(11)(D),(E) and (F) and §198.074.2-4 RSMo., sprinkler system inspections/certification
19 CSR 30-86.032(13) electrical inspections
19 CSR 30-86.042(37) residential care facility documentation of the resident’s current medical status and any special orders or procedures
19 CSR 30-86.047(26) assisted living facility documentation of a physical examination prior to admission

Skilled Nursing Facility and Intermediate Care Facility (certified and state licensed only)
19 CSR 30-85.022(8) fire extinguisher inspections/maintenance
19 CSR 30-85.022(9) range hood extinguishing system testing
19 CSR 30-85.022(10)(C) fire alarm system inspections/certification
19 CSR 30-85.022(11)(A) sprinkler system inspections/certification
19 CSR 30-85.032(31)(B) electrical inspections
19 CSR 30-85.042(7) written agreements with outside resources used to provide services to the residents.
19 CSR 30-85.042(21) comprehensive orientation program within sixty (60) days of employment with nursing assistants who have not successfully completed the state-approved training program.

Adult Day Care Programs
19 CSR 30-90.050(8)(D)3.C- orders concerning treatments and medications
19 CSR 30-90.070(2)(A) annual written approval from the appropriate local fire safety officials, certifying that the facility complies with local fire codes
19 CSR 30-90.070(2)(C) fire extinguisher inspections/maintenance

Effective 05/01/2021, the following regulatory waiver implementation guidance has been amended for all facilities (including Medicare/Medicaid certified):

RCF-ALF-ICF-SNF and ADC
Tuberculosis testing: 19 CSR 30-85.042 (27), 19 CSR 30-86.042 (17) and (18), 19 CSR 30-86.047(18) and (19), and 19 CSR 30-90.040(7)

SNF
Regular visiting hours: 19 CSR 30-85.042 (11)

19 CSR 30-86.022 and 86.032 Waivers revised eff 5-1-2021
19 CSR 30-86.042 RCF waivers effective 5-1-21
19 CSR 30-86.047 ALF waivers effective 5-1-2021
19 CSR 30-85 SNF-ICF Waiver eff 5-1-2021
19 CSR 30-85.042-27 SNF-TB testing revised eff 5-1-2021
19 CSR 30-90 ADC waivers effective 5-1-2021

On March 29, 2021, the CDC issued updated guidance regarding quarantining nursing home residents. Whether a resident should be quarantined depends on factors such as vaccination status, exposure to someone with COVID-19, and length of time outside of the facility. This summary provides basic information about quarantine and indicates when quarantine is necessary. https://theconsumervoice.org/uploads/files/issues/Quarantine_summary_4-5-21_v2.pdf.

The guidance incorporates the new visitation guidance recently released by CMS as well previous guidance related to reopening, beauty and barber shop services, communal dining and group activities, and resident outings. In addition to updates to the visit guidance, several updates have been made in other areas as well, so please review carefully for the most up-to-date guidance. All prior guidance documents have been removed from the DHSS LTC COVID-19 webpage and replaced with this document.

Clarification on CMS Visit Guidance related to County Positivity Rates – CMS has provided clarification on this language in the visit document: Facilities should allow indoor visitation at all times and for all residents (regardless of vaccination status), except for a few circumstances when visitation should be limited due to a high risk of COVID-19 transmission (note: compassionate care visits should be permitted at all times). These scenarios include limiting indoor visitation for: Unvaccinated residents, if the nursing home’s COVID-19 county positivity rate is >10% and <70% of residents in the facility are fully vaccinated.

SLCR received questions regarding whether the county positivity rate of >10% referred to the actual positivity rate or to those counties designated as “red”. CMS has stated that the CDC’s county percent test positivity characterization methodology (color-coded system) may be used to determine how visitation should be implemented. Using the color-coded system, facilities in the “red” category should limit visitation for unvaccinated residents if <70% of residents in the facility are fully vaccinated.

Please note: both criteria need to be met before a facility should limit indoor visitation for unvaccinated residents – county positivity rate is >10% and <70% of residents in the facility are fully vaccinated.

March 22, 2021 marks the one year anniversary of the first known COVID positive resident identified in a long-term care facility. So much has happened in 365 days. Each of you know better than anyone else what a humbling, scary, frustrating, and grief stricken year it has been. You also know that this past year has also created deep bonds between your administrative teams, personal moments of strength that you did not know were possible, and moments of humanity and deep kindness that still make you speechless. It is a year that has reminded us of the importance of family, friends, and our health. This week is National Long-Term Care Administrator’s Week. There is no better time for all of us in the Section for Long-Term Care Regulation to share with you our appreciation of each and every one of you. We are thankful for your leadership, kindness, and support of others during the most extraordinary time of our professional lives. We are thankful for your partnership and for the partnership of our long-term care associations who worked tirelessly alongside with us. Thank you for all you have done to protect health and keep the residents of long-term care in Missouri safe.

Over the past 12 months, the State of Missouri Department of Health and Senior Services (DHSS) and the Missouri State Emergency Management Agency (SEMA) have been providing personal protective equipment (PPE) at no cost through our Strategic National Stockpile (SNS) program to healthcare providers in order to protect staff and patients during the COVID-19 pandemic. PPE supply chains have been disrupted due to many factors, but have begun to normalize. In order to determine future operations and sustainment of the Missouri DHSS PPE Request System and PPE Reserve, we are conducting a survey to assess the current state of the healthcare personal protective equipment (PPE) supply chain from the perspective of our healthcare providers.

This survey is being directed to those agencies and organizations that have been working with individual providers and individual providers. We are particularly interested in responses from smaller rural and independent facilities, clinics, and healthcare providers who have had the most difficulty obtaining PPE resources. We ask that the survey be completed by March 24, 2021.

Survey Link: https://www.surveymonkey.com/r/9YCHYVP.