Many long-term care facilities (LTCFs) have received or will receive COVID-19 antigen point of care (POC) testing machines and supplies from the federal government to help facilitate timely testing of residents and facility staff. Through the distribution of the machines, LTCFs will act as the diagnosing provider and now the laboratory for the tests which requires reporting of all test results to the Missouri Department of Health and Senior Services (DHSS).

Properly submitting all test results (positive, negative, and other results) in a timely manner is important to the health and safety of the community. To expedite the reporting process, DHSS is requiring all facilities to submit test results in an electronic format with the ultimate goal of onboarding all LTCFs to electronic reporting within the next 30 days.

DHSS has assembled a team to assist you in this effort. Ryan Marsch and the DHSS Onboarding Team (ELR@health.mo.gov) will be your primary contacts as you onboard for electronic reporting of test results. Tracy Niekamp (tracy.niekamp@health.mo.gov) and Shelly Williamson (shelly.williamson@health.mo.gov) at the Division of Regulation and Licensure are also available to assist you with any questions.

Documentation and Reporting of Point of Care Test (POC) Results

By administering the POC tests, a LTCF is acting as a laboratory which is required to submit all COVID-19 test results (positive, negative, other) to DHSS for testing performed in their facility. The facility is also acting as the provider, and are required to submit case reports to DHSS.

Facilities, including K-12 schools, long-term care, and higher education institutions which administer POC tests may report all the necessary information for both the laboratory report and the case report on a single comma separated values file (CSV), which is a format-free version of a spreadsheet. A template will be provided to the facility by DHSS. Required data fields include facility information, patient demographics, lab results and basic information about symptoms.

The CSV file is then uploaded to a Secure File Transfer Protocol (SFTP) site, and is auto-ingested into the state’s disease monitoring platform, known as EpiTrax. This information is then immediately accessible to local and state health authorities.

For long-term care facilities, this means that they no longer need to complete an online CD-1 form for tests that they perform on-site, acting as a laboratory. Long-term care facilities must continue to submit an online CD-1 form to report positive COVID-19 cases that occur in their facilities if the test was performed by an external laboratory.

To successfully submit test results through SFTP, testing sites will need:

• Reporting template from DHSS
• Access to a computer/laptop with Microsoft Excel or an alternative application that can work with Excel files
• Access to the Internet
• User name and password for the secure upload site

There are three steps to onboarding to laboratory/case reporting:

Step 1: Starting Wednesday, October 7, DHSS will contact long-term care facilities in onboarding groups. Look out for an invitation email with the following resources:

• A link to a brief survey for collecting contact information on the team member assigned to submit the data in your facility. Note: Once you receive this email, please complete this survey within 24 hours. If possible, we ask that you complete this survey in advance of the invitation email at this link: https://stateofmissouri.wufoo.com/forms/ma3vqye0hqzxkj/
• This will help our team expedite this process and get you up and running as soon as possible.
  You may also find a link to this survey and additional information here: https://health.mo.gov/living/healthcondiseases/communicable/novel-coronavirus/how-to-report-lab-results.php
• A CSV Excel file to facilitate seamless reporting into EpiTrax, DHSS’ disease surveillance system
• Electronic COVID-19 Laboratory Reporting Submission Instructions to walk through submitting files via SFTP
• A second email with your SFTP credentials

Step 2: You will start to submit files via SFTP. To expedite this process, your first submission may consist of test data, as it will be for validation purposes only. DHSS will review the data for accuracy and reach out if any changes are necessary.

Step 3: Once your data is validated, you will go live for ongoing submissions. Properly formatted data ingests into EpiTrax where DHSS and local public health agencies document and track case investigation activities.

If you have questions about formatting your Excel files or how the process works, please contact ELR@health.mo.gov. There are over 1,000 facilities that may receive some type of point of care test, so be aware that there may be some delay in the onboarding process.

If you have already begun testing at your facility and need guidance for reporting while you work through the onboarding process, please contact ELR@health.mo.gov for assistance.

CLIA Requirements

Any site that performs laboratory testing must follow applicable regulatory requirements including federal, state and local mandates for testing, as well as requirements for the safety and confidentiality of personal information. Use of this authorized test is limited to Clinical Laboratory Improvement Amendment (CLIA) certified laboratories that meet the requirements to perform moderate, high or waived complexity tests and Point of Care (POC) settings operating under a CLIA Certificate of Waiver, Certificate of Compliance, or Certificate of Accreditation. If your site does not have a CLIA Certificate of Waiver or for more information about CLIA requirements, please contact the CLIA Program at DHSS by email CLIA@health.mo.gov or by telephone at 573-751-6318.

Revised guidance was released today for long-term care facilities in Missouri that choose to establish an Essential Caregiver program and/or resume general visits either inside or outside the facility. Facilities should have a policy in place to determine how contact with loved ones can occur while protecting the health of residents. Each facility will ultimately make the decision as to whether or not to adopt this guidance. Certified Skilled Nursing Facilities and Intermediate Care Facilities are required to follow the guidance provided in QSO-20-39-NH, titled Nursing Home Visitation – COVID-19.

The revised guidance is attached and can also be found at https://health.mo.gov/living/healthcondiseases/communicable/novel-coronavirus/professionals.php under the Long-Term Care Facilities link.

DHSS Visitation Guidance 9-22-20

CMS has created a process to enable states to approve requests to purchase tents for outdoor visitation and/or clear dividers (e.g. Plexiglass or similar product) to create a physical barrier to reduce the risk of transmission during in-person visits. The parameters are detailed in the instructions portion of the application template (below). This template and process will reduce the amount of time for approval of CMP funds for tents and dividers that will assist homes in facilitating visits with residents and aid in prevention of the spread of COVID-19.

The application is for nursing homes certified to participate in Title 18 and Title 19 of the Social Security Act. We encourage companies that operate more than one home to complete one application for all certified homes to the extent possible. This will reduce the number of applications and will help expedite the approval process.

Applications should be submitted to slcr@health.mo.gov. Questions regarding the application process may be sent to this address as well.

Once an application is approved, SLCR will contact each applicant to explain the payment process, which will be similar to that of the CMP application/payment process for technology.

COVID-19 In-Person Visitation Application Template – 20200918
COVID-19 In-Person Visitation Application FAQ final – 20200918

Effective August 28, 2020, the Authorized Electronic Monitoring in Long-Term Care Facilities Act became law. Due to concern for spread of COVID-19, current state and federal guidelines are in place that restrict visitation of all visitors and non-essential health care personnel to residents of long-term care facilities. Please see the Guidance for LTC Facilities Regarding Electronic Monitoring Device Placement, Discontinuance or Removal.

The Department of Health and Senior Services (DHSS) is pleased to announce the availability of Electronic COVID-19 Case Reporting. All entities currently required to complete a Communicable Disease Case Report (CD-1) should begin reporting positive COVID-19 cases via the new system*. This system will replace the paper CD-1 process and allow for more timely, appropriate, and accurate data for COVID-19 case reporting.

The new system also fulfills the requirement for residential congregate facilities to report COVID-19 cases under the Congregate Facility Reporting Order. Congregate facilities will no longer need to enter positive case information into the former system, which has been taken down.

The Electronic COVID-19 Case Reporting System can be found on DHSS’ main COVID-19 webpage: www.health.mo.gov/coronavirus. Please do not enter lab result information unless you are a reporting laboratory or you are entering on behalf of the laboratory.

Testing spreadsheets should continue to be provided by facilities to the Division of Regulation and Licensure. Testing spreadsheets can be uploaded at: https://health.mo.gov/safety/longtermcare.php.

*If your organization has already developed an electronic reporting process with DHSS, please continue to follow this process. The Electronic Reporting System is a replacement for those entities currently emailing, faxing or mailing a CD-1 form for COVID-19 case information.

In order to allow for more accurate submission of your data on the Electronic COVID 19 Case Reporting form, please note the following:
      -When you hit the “Submit” button on page 5 of the form make sure you add today’s date.
      -Make sure you choose Resident, Staff, Contracted Staff or “No” on page 2 of the form.

As of July 15^th, 192 qualifying Medicaid & CHIP eligible providers in Missouri have applied for the Medicaid & CHIP Provider Relief Fund distribution out of the 5,725 providers identified in the data that your team supplied to CMS. Of these, 93 Medicaid & CHIP providers have been paid from this distribution. To ensure that all qualifying providers are aware of the opportunity, as well as the new application deadline, we are requesting that states reach out to your medical, dental, and long-term services and supports (LTSS) providers to remind them that they can begin the application process here. 

The application deadline has been further extended to offer providers additional opportunity to apply for funding. You must act by Friday, Aug. 28, 2020 at 11:59 p.m. ET to be considered for payment from this distribution. Read more about the extension here.

To support these efforts, included below some resources that the HRSA team has released on the Provider Relief Fund to share:

• Program Overview:
  The bipartisan Coronavirus Aid, Relief, and Economic Security (CARES) Act and the Paycheck Protection Program and Health Care Enhancement Act provide $175 billion in relief funds to hospitals and other health care providers, including those on the front lines of the coronavirus response. A portion of these funds, under the Medicaid and Children’s Health Insurance Program (CHIP) Provider Distribution, provide help for providers and clinicians who treat our most vulnerable populations, including low-income and minority patients. This is allocated for eligible providers that participate in state Medicaid and CHIP Programs and that did not receive a payment from the Provider Relief Fund General Allocation. The payment to each provider will be approximately 2 percent of reported gross revenue from patient care.

• Fact Sheet
  The Health Resources & Services Administration (HRSA) released a Fact Sheet for Medicaid and CHIP Providers that is now available on the Provider Relief Fund website.

• Recorded Webcast
  A recording of the June 25 webcast is now available at https://www.hhs.gov/coronavirus/cares-act-provider-relief-fund/for-providers/index.html.

• Frequently Asked Questions (FAQs)
  In order to better address your most important concerns, HRSA has updated their FAQs to address common questions, including those submitted during the previous webcasts. The FAQs include expanded information on eligibility, application, payment process, and more.

• Application Instructions
  Medicaid and CHIP Provider Distribution Instructions and the Medicaid and CHIP Provider Distribution Application Form are available at hhs.gov/providerrelief. HRSA recommends downloading and reviewing these documents to help you complete the process through the Enhanced Provider Relief Fund Payment Portal.

• Additional Information
  For additional information, please call the Provider Support Line at (866) 569-3522; for TTY, dial 711. Hours of operation are 7 a.m. to 10 p.m. Central Time, Monday through Friday. Service staff members are available to provide real-time technical assistance, as well as service and payment support.

Many long-term care facilities have begun reporting COVID-19 data into the CDC’s NHSN Long-term Care Component. In an effort to have a more complete representation of COVID-19 data for the State of Missouri, we are asking facilities who are not yet reporting (SNF, ICF, ALF, RCF, ICF/IID) to consider reporting data through the CDC’s NHSN Module and those facilities that are currently reporting to begin sharing their data (conferring rights) with DHSS. In order to share the data you enter into the CDC’s NHSN site, you must join the “Missouri Group” within NHSN and select the option to “Confer Rights”.

Once you have completed the NHSN enrollment process and received your acceptance notification from NHSN, you can login to the NHSN site to:

1. Access the COVID-19 Module within the Long-Term Care Component
2. Join the Missouri Group (using the guidance below)
3. Confer rights to grant the state health department access to your facility’s information.

How do I join the Missouri Group and confer rights to the department?

NHSN website provides instructions – https://www.cdc.gov/nhsn/pdfs/groups-startup/JoinGroup-current.pdf.

The document is titled: NHSN Data Sharing: Joining a Group and Accepting the Confer Rights Template.

Please use the following information to join the Missouri group:
Group ID: 20503
Use password: MHIRS29

DHSS is also encouraging facilities to report each day. This will allow more accurate and timely data that could be used for increased allocation of resources for facilities that start to see increased cases, rather than responding up to a week later when outbreaks are identified.

A Frequently Asked Questions document is now available on the NHSN LTCF COVID-19 Module website. The document was developed to answer the most common questions received from facility and group users participating in the NHSN LTCF COVID-19 Module. The questions are organized by the four COVID-19 Module pathways, as well as enrollment, groups, the CMS rule, and data entry and analysis. Additionally, at the end of the document, there are examples of how to count data for reporting.

An updated list of laboratories on state contract has been placed on the DHSS website at https://health.mo.gov/living/healthcondiseases/communicable/novel-coronavirus/cares-act-funding.php under the Word document titled State and Community-Based COVID-19 Testing Qualified Vendor List.

This Qualified Vendor List has information regarding daily testing capacity, specimen types, billing, turn-around-time, etc., for the laboratories on state contract. The pricing is for work completed at the state/local government’s request, but may be honored for private entities at the lab’s discretion.

This information is being provided to assist with completing testing either for an outbreak situation or for reopening purposes. There are laboratories not listed on the qualified vendor list that conduct testing as well. There is no requirement to utilize a laboratory on this list.

The Board of Nursing Home Administrators has put forth guidance regarding 2021 license renewal changes. Please see the memo for details.