Please see the guidance in regards to Waivers for Nursing Home Administrators and Residential Care/Assisted Living Administrators.

As COVID-19 rapidly spreads across the country, more long-term care communities will have residents develop COVID-19. When a resident develops COVID-19 in your facility, there are steps you can implement that may be able to limit the spread.

Please see the guidance for details.

Background:
On March 25, 2020, the Centers for Medicare and Medicaid Services notified MO HealthNet Division of their approval of a Federal Section 1135 Waiver request to suspend pre-admission screening and annual resident review (PASRR) Section 1919(e)(7) of the Act allows Level I and Level II assessments to be waived for 30 days. All new admissions can be treated like exempted hospital discharges. After 30 days, new admissions with mental illness (MI) or intellectual disability (ID) should receive a Resident Review as soon as resources become available.

Effective April 2, 2020 and until April 25, 2020, certified Skilled Nursing Facilities and Intermediate Care Facilities may follow the process outlined below for new admissions into Medicaid-certified beds.

For an applicant that may require a Level II evaluation (have a qualifying mental illness (MI) or intellectual disability (ID) diagnosis):

• The applicant may enter the Skilled Nursing Facility (SNF) prior to completion of a Level II PASRR evaluation or Special Admission Category.
• The Hospital (or other individual completing the paperwork) will send the completed DA 124 C form to the SNF prior to discharge. The SNF should review the client’s information to ensure the Level of Care points (24) would meet prior to admission and ensure they have enough information to determine if they can meet the medical and behavioral needs of the individual.
• The SNF will submit the entire DA 124 application (DA 124 A/B, DA 124 C and any other supporting documentation) with a Special Admission Category form indicating “Waiver due to COVID-19” to COMRU@health.mo.gov. The SNF should indicate if the client plans to reside at the SNF after 30 days.
• DHSS recommends that SNFs submit the complete DA 124 application to COMRU within 14 days of admission to the SNF.
• Once received, COMRU will determine if the applicant meets Level of Care and refer applicants requiring a Level II PASRR screening to DMH.
• After 30 days, new admissions with mental illness (MI) or intellectual disability (ID) will receive a Resident Review as soon as resources become available.

For completed applications already submitted to COMRU for processing:

• The applicant may enter the Skilled Nursing Facility (SNF) prior to completion of a Level II PASRR evaluation or Special Admission Category.
• COMRU will process all pending Level II PASRR applications as Special Admission Category #5 indicating “Waiver due to COVID -19”.
• Upon discharge, the hospital or other submitter will notify COMRU via email of the following information:  the client’s name, DCN or SSN#, and the receiving SNF information (Name, Telephone number and fax number).
• The hospital/submitter will ensure a copy of the DA 124 application (DA 124 A/B form and DA 124 C form) are sent to the accepting SNF prior to discharge.

This information should be added to the DA 124 application in process and sent to DMH. For the DA 124 applications that were already referred for Level II PASRR screening, DHSS will notify DMH and Bock & Associates via email of the individuals change in location.

Questions regarding this process can be directed to COMRU@health.mo.gov. The DA 124 application (DA 124 A/B form, DA 124 C form and Special Admission Category Referral form) can be accessed at https://health.mo.gov/seniors/nursinghomes/pasrr.php.

Please see the DHSS Health Update: Criteria to Guide Evaluation Evaluation and Lab Testing for COVID-19.

Please see the documents below for information.

• Centers for Medicare and Medicaid Services (CMS) COVID-19 Emergency Declaration Health Care Providers Fact Sheet (dated 3-13-2020)
• Medicare Fee for Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19) Released March 16, 2020

This is guidance from SLCR; it is not a mandate but rather provides facilities with an avenue to protect the health and safety of residents.

It is appropriate for facilities to ask residents not to leave the facility, unless for a necessary medical reason that cannot be addressed in the facility. For those insistent on taking residents out of the facility, SLCR recommends the following:

• Only legally authorized persons may remove a resident from the facility. This may be a durable power of attorney for healthcare (if the DPOA has been enacted), a legal guardian or the resident themselves.
• Before a resident leaves, the facility should follow the discharge regulations to the extent possible so that the resident receives appropriate care while away from the facility.
• Upon leaving the facility, the resident, their legal representative and all those required by regulation should be given a written emergency discharge notice. It is imperative that the notice contain the required elements stated in regulation, including the reason for discharge (as permitted in regulation) and the location to which the resident is being discharged.
• Those taking the resident out of the facility are to be informed that the resident will not be permitted to return until the restrictions currently in place are lifted. When appropriate, residents may be required to obtain clearance from their medical provider which may include proof of a negative COVID-19 screening.

For residents, primarily in RCFs and ALFs, who leave the facility on a frequent basis, the facility will need to determine at what point those outings pose a risk to the health and safety of the residents in the facility. This includes, but is not limited to, the location the resident is going, whether there are positive COVID-19 cases in the community, whether there is community transmission of the virus, etc. This guidance does not require facilities to issue an emergency discharge notice every time a resident leaves a facility. The resident and their legal guardian, when applicable, should discourage outings, attempt to meet the needs of residents without them leaving the facility, clearly communicate the expectations to residents (including any screening required upon return) and work together should the need arise to give an emergency discharge notice.  

Please see Department of Health and Senior Services guidance regarding visitation restrictions in all long term care facilities including residential care facilities, assisted living facilities, intermediate care facilities, skilled nursing facilities, and intermediate care facilities for persons with intellectual disabilities.

This guidance along with similar guidance from the Centers for Medicare and Medicaid Services should be implemented immediately.

These documents will also be posted to the Department’s COVID-19 website at https://health.mo.gov/living/healthcondiseases/communicable/novel-coronavirus/ under the Health Care Professionals tab.

All COVID-19 information and resources on the DHSS website for long-term care facilities should be used by all levels of care, including Skilled Nursing, Intermediate Care, Assisted Living, and Residential Care Facilities. Adult Day Care programs will also benefit from reading the information and applying proper infection control practices.

Please see the Health Alert from DHSS for more information.

This video includes information from the Department of Health and Senior Services regarding guidance and education surrounding COVID-19. The focus is on the basics of COVID-19 (symptoms, who is at most risk), the types of coronavirus, how long term care communities can prepare and testing protocols.

The LTCF Video is available at https://youtu.be/u-OZNQ3A-fs.

Please note information is changing rapidly so please check the Department’s COVID-19 website frequently for updated information.