Seven Key Points From CMS’ Memo to Home Health Agencies About COVID-19

As part of the White House Coronavirus Task Force’s ongoing efforts to respond to and contain the spread of the 2019 novel coronavirus (COVID-19), on March 10, 2020, the Centers for Medicare & Medicaid Services (CMS) issued a memorandum to all Medicare and Medicaid participating home health agencies (HHAs) that addresses frequently asked questions regarding the COVID-19 outbreak. The March 10 memorandum is intended to enhance CMS’ pre-existing health and safety requirements and the recommendations set forth by the Centers for Disease Control and Prevention (CDC).

Among other things, this guidance provides HHAs with information regarding screening measures, considerations for in-home care versus hospital transfers and recommendations for family member exposure when evaluating and caring for patients with known or suspected COVID-19.

Here are seven key points from CMS’ March 10 guidance for HHAs.

1. CMS recommends that HHAs screen patients for COVID-19. As part of ongoing care, HHAs should monitor the health status of all individuals within a home-care setting (including but not limited to patients, family members, visitors, staff, etc.) for signs or symptoms of COVID-19. To identify patients who may be at risk, CMS recommends that HHAs ask each patient the following questions immediately before or upon arrival at the patient’s home: (i) whether the patient has engaged in any international travel within the past 14 days to countries with sustained community transmission of COVID-19 (see updated list); (ii) whether the patient has experienced any signs or symptoms of COVID-19, including but not limited to fever, cough and sore throat; (iii) whether the patient has had contact with someone with or under investigation for COVID-19 within the past 14 days; (iv) whether the patient has a respiratory illness; and (v) whether the patient resides in an area where community transmission is occurring. Following a screening, employees should promptly inform a HHA clinical manager as well as local public health authorities about the presence of a person under investigation for COVID-19 within a home. CMS also asks for HHAs to share with patients and their families information regarding prevention and control recommendations. CMS guidance for evaluating patients is continuing to evolve as the COVID-19 outbreak continues, so HHAs should refer to the CDC COVID-19 website for up-to-date recommendations.
   
   
2. HHAs should monitor personnel for COVID-19 symptoms. HHAs should inform all personnel that they should not report to work if they display signs and symptoms of a respiratory infection. If signs and symptoms develop while on the job, HHAs should: (i) tell employees and staff to immediately stop work, put on facemasks, and self-isolate at home; (ii) inform the HHA’s clinical manager and report the equipment and locations with which the employee/staff member recently had contact; and (iii) contact and follow local health department recommendations. CMS also recommends that HHAs refer to the CDC’s interim guidance that details when exposure may warrant restricting certain asymptomatic individuals from working.
   
   
3. CMS has directed state and federal surveyors not to cite HHAs that are unable to provide certain equipment and supplies due to shortages. Although CMS regulations require HHAs to provide the services, supplies and equipment required by an individualized plan of care, CMS has directed state and federal surveyors not to cite HHAs that are unable to provide certain supplies (e.g., personal protective equipment, respirators, and surgical masks) if the supplies cannot be obtained for reasons outside the HHA’s control. However, HHAs should proactively take steps to mitigate these supply shortages (e.g., effective handwashing) and obtain necessary supplies as soon as possible. To combat shortages, CMS encourages HHAs to notify appropriate local authorities and, in the interim, follow national guidelines to optimize the HHA’s current supply or identify the next best option for patient care.
   
   
4. HHAs should follow CDC guidelines when determining whether patients with COVID-19 should be treated at home or transferred to a hospital. CMS recognizes that, while it may be appropriate for some COVID-19 patients with mild symptoms to be treated at home, the decision to do so should take into account whether the patient can abide by isolation recommendations and whether any household members have immunocompromising conditions. In these situations, HHAs should adhere to the prevention and control practices recommended by the CDC. If a patient’s symptoms require transfer to a hospital, the HHA should inform emergency medical services and the receiving hospital of the patient’s diagnosis (or potential diagnosis) prior to the transfer. When a COVID-19 patient is discharged, necessary medical information must be provided to all service providers and healthcare transfer personnel prior to the discharge/transfer.
   
   
5. HHA personnel should follow CDC guidance regarding the use of personal protective equipment (PPE). When visiting the home of a patient suspected of COVID-19 exposure or presumed to be COVID-19 positive, CMS urges HHAs to refer to the CDC’s guidance for evaluating such persons in their homes. According to this guidance, if providers must treat patients in the home, providers should utilize PPE (e.g., gown, gloves, and eye protection). To the greatest extent possible, providers should put on PPE prior to entering the home and dispose of PPE outside the home before departing the location. Providers should also perform proper hand hygiene before putting on and after removing PPE.
   
   
6. HHAs should consult clinicians, infection prevention and control specialists, and public health officials before discontinuing transmission-based precautions for home-care patients. In making the decision to discontinue transmission-based precautions, HHAs and other providers should consider, among other things, disease severity, illness signs and symptoms, and results of laboratory testing for COVID-19 in respiratory specimens. Similarly, when considering whether to discontinue in-home isolation, CMS recommends considering the following: (i) resolution of fever without the use of antipyretic medication, (ii) improvement in illness signs and symptoms, and (iii) negative results of a COVID-19 test.
   
   
7. CMS sets forth certain protocols for coordination and investigation of HHAs with actual or suspected COVID-19 cases. If a COVID-19 confirmed or suspected case is identified during a HHA survey, the surveyor will confirm that the HHA has reported the case(s) to the appropriate individuals and agencies. The surveyor will also work with the HHA to review its current infection prevention and education practices and confirm that the agency has the most up-to-date information offered by the CDC. Again, CMS has instructed surveyors not to cite HHAs that do not have certain supplies and equipment due to shortages; however, HHAs must take proper action to mitigate these shortages and obtain necessary materials as soon as available.

As the COVID-19 situation continues to evolve, CMS encourages all HHAs and other healthcare providers to monitor the CDC’s website for up-to-date information and resources and to contact local health departments when needed. Please contact the authors for additional guidance on how other COVID-19 considerations may impact healthcare providers. McGuireWoods has published additional thought leadership related to how companies across various industries can address crucial coronavirus-related business and legal issues.