DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop C2-21-16

Baltimore, Maryland 21244-1850

Center for Clinical Standards and Quality/Quality, Safety & Oversight Group

Ref: QSO-20-16-Hospice

DATE: March 9, 2020

TO: State Survey Agency Directors

FROM: Director

Quality, Safety & Oversight Group

SUBJECT: Guidance for Infection Control and Prevention Concerning Coronavirus Disease 2019 (COVID-19) by Hospice Agencies

Memorandum Summary

CMS is committed to protecting American patients by ensuring health care facilities have up-to-date information to adequately respond to COVID-19 concerns.

• Coordination with the Centers for Disease Control and Prevention (CDC) and local public health departments – We encourage all Hospice Agencies to monitor the CDC website for updated information and resources and contact their local health department when needed (CDC Resources for Health Care Facilities: https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/index.html).

• Hospice Guidance and Actions – CMS regulations and guidance support Hospice Agencies taking appropriate action to address potential and confirmed COVID cases and mitigate transmission including screening, treatment, and transfer to higher level care (when appropriate). This guidance applies to both Medicare and Medicaid providers.

Background

The Centers for Medicare & Medicaid Services (CMS) is committed to the protection of patients and residents of healthcare facilities or homecare settings from the spread of infectious disease. This memorandum responds to questions we have received and provides important guidance for Hospice Agencies in addressing the COVID-19 outbreak and minimizing transmission to other individuals.

Guidance

Hospice Agencies should regularly monitor the CDC website (see links below) for information and contact their local health department when needed (https://www.cdc.gov/coronavirus/2019-ncov/whats-new-all.html). Also, hospice agencies should be monitoring the health status of patients, residents, visitors, volunteers, and staff under their care setting for signs or symptoms of

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COVID-19. Per CDC, prompt detection, triage and isolation of potentially infectious patients are essential to prevent unnecessary exposures among patients, healthcare personnel, and visitors at the facility. For exposed staff, hospice agencies should consider frequent monitoring for potential symptoms of COVID-19 as needed throughout the day.

In addition to the overarching regulations and guidance, we have provided the following information (Frequently Asked Questions) about some specific areas related to COVID-19:

Guidance for Addressing COVID-19 in Hospices (In-patient units, nursing facilities, assisted living, hospitals and home settings)

Which patients are at risk for severe disease from COVID-19?

Based upon CDC data, older adults, those with underlying chronic or life-limiting medical conditions such as hospice patients are presumed to be at greater risk of poor outcomes when infected with novel coronavirus.

Refer to the CDC guidance for people at higher risk: https://www.cdc.gov/coronavirus/2019- ncov/specific-groups/high-risk-complications.html

How should providers screen visitors and patients for COVID-19 in a Hospice that provides short-term inpatient care directly or in an inpatient unit of another facility?

Hospices should identify volunteers, visitors and patients at risk for having COVID-19 infection before or immediately upon arrival to the inpatient unit. They should be asked about the following:

1. International travel within the last 14 days to countries with sustained community transmission. For updated information on affected countries visit: https://www.cdc.gov/coronavirus/2019-ncov/travelers/index.html

2. Signs or symptoms of a respiratory infection, such as a fever, cough, and sore throat.

3. In the last 14 days, has had contact with someone with or under investigation for COVID- 19, or are ill with respiratory illness.

4. Residing in a community where community-based spread of COVID-19 is occurring.

For patients with respiratory symptoms, implement respiratory hygiene and cough etiquette (i.e., placing a facemask over the patient’s nose and mouth) and isolate the patient in a private room with the door closed. If the patient cannot be immediately moved to an private location, ensure they are not allowed to wait among other patients who reside in the inpatient unit. Identify a separate, well-ventilated space that allows patients to be separated by 6 or more feet, with easy access to respiratory hygiene supplies.

Medicare requires Hospice Agencies to provide appropriate medical supplies for respiratory hygiene and cough etiquette, including 60%-95% alcohol-based hand sanitizer (ABHS), tissues, no touch receptacles for disposal, facemasks, and tissues at healthcare facility entrances.

Inform infection prevention and control services, local and state public health authorities, and other healthcare facility staff as appropriate about the presence of a person under investigation

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.

(PUI) for COVID-19. For hospice patients with symptoms, determination about whether or notto conduct diagnostic testing versus presuming apositive COVID-19diagnosis(based on his/hersymptoms and exposure)should be a decision amongthe patient, patient representative, hospiceagency and state andlocal public health authority. Additional guidance forevaluating patients in

U.S. for COVID-19 infection can be found on theCDCCOVID-19 website.

How shouldhospice programsmonitor or restrict health care staffor hospice volunteers?

The same screening performed for patientsand visitors should be performed forhospicestaffand volunteers.

•Health care providers (HCP)and volunteerswho have signs and symptoms of a respiratoryinfection should not report towork.

•Anyonethat develop signs and symptoms of arespiratory infection while on-the-job,should:

oImmediately stop work, put on a facemask, and self-isolate at home;

oInform the hospice’s infection control manager/team to include information on individuals, equipment, and locations the person came in contact with; and

oContact and follow the local health department recommendations for next steps (e.g., testing, locations for treatment).

•Refer to the CDCguidance for exposures that might warrant restrictingasymptomatichealthcare personnelor volunteersfrom reportingto work (https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html).

Hospices should contacttheir local health department for questions, and frequently review theCDC website dedicated to COVID-19 for health care professionals(https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html).

When a hospice patientis in an inpatient unit, what are recommended infection preventionand control practices, including considerations for patient placement,when evaluating and care for a patientwith known or suspected COVID-19?

Recommendations for patient placement and other detailed infection prevention and controlrecommendations are available in the https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html.

Consider, whereappropriate allowing certain types of volunteer activities to be performed viaphoneor otherelectronic devicesto minimize risk of exposure in the eventof a suspected orpositive COVID-19 case.

Dohospice patients with known or suspected COVID-19 infection require hospitalization?

Hospice patientsand/or their familiesshould carefullydiscuss care options withthehospice teamto ensure thegoals and wishes of hospice patient are respected consistent with patient rightsrequirements. Patients can be managed at home ifthe patient is stable, the environmental exposure to COVID-19to others in the household can be minimized, and if there are appropriateinfection control precautions made and PPE available.

Patients whose symptoms are exacerbated by COVID-19and cannot beadequatelymanaged in the home setting, shouldbe transferred toa hospice inpatient unit. More information is availablehere:https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-home-care.html.

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When is it safe to discontinue Transmission-based Precautions inpatient hospice patients with COVID-19?

The decision to discontinue Transmission-Based Precautions for hospitalized patients with COVID-19 should be made on a case-by-case basis in consultation with clinicians, infection prevention and control specialists, and public health officials. This decision should consider disease severity, illness signs and symptoms, and results of laboratory testing for COVID-19 in respiratory specimens.

Currently, negative RT-PCR results from at least 2 consecutive sets of nasopharyngeal and throat swabs collected at least 24 hours apart are needed before discontinuing Transmission-Based Precautions. A total of four negative specimens are needed to meet this requirement.

More detailed information about criteria to discontinue Transmission-Based Precautions are available here: https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-hospitalized-patients.html.

When is it safe to discontinue in-home isolation for in home hospice patients with COVID-19?

The decision should be made on a case-by-case basis in consultation with clinicians and public health officials. This decision should consider disease severity, illness signs and symptoms, and results of laboratory testing for COVID-19 in respiratory specimens

Guidance for discontinuation of in-home isolation precautions is the same as that to discontinue Transmission-Based Precautions for hospitalized patients with COVID-19. For more information, see: https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-in-home-patients.html

Considerations to discontinue in-home isolation include all of the following:

o Resolution of fever, without use of antipyretic medication

o Improvement in illness signs and symptoms

o Negative results of an FDA Emergency Use Authorized molecular assay for COVID-19 from at least two consecutive sets of paired nasopharyngeal and throat swabs specimens collected ≥24 hours apart (total of four negative specimens—two nasopharyngeal and two throat). See Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Patients Under Investigation (PUIs) for 2019 Novel Coronavirus (2019-nCoV) for specimen collection guidance.

Can hospices restrict visitation of patients (in-patient unit provided directly by the hospice)?

Medicare regulations require a hospice to focus on preventing and controlling infections. Hospices may have policies regarding the visitation rights of patients and may wish to set clinical restrictions on visitation subject to patient’s rights. If the inpatient hospice is not provided by the hospice itself (such as a hospital), that provider may have established additional visitation restrictions associated with that setting to address COVID-19 transmission concerns.

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What are the considerations when caring for a hospice patient in their home?

For hospice patients with known or suspected COVID-19 who remain in their homes, there are a number of infection prevention and control practices that should be followed. The CDC advises the patient to stay home except to get medical care, separate yourself from other people and animals in the home as much as possible (in a separate room with the door closed), call ahead before visiting your doctor, and wear a facemask in the presence of others when out of the patient room.

For everyone in the home, CDC advises covering coughs and sneezes followed by washing your hands or using an alcohol-based hand rub, not sharing personal items (dishes, eating utensils, bedding) with individuals with known or suspected COVID-19, cleaning all “high-touch” surfaces everyday, and monitoring your symptoms. Please see: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-prevent-spread.html

CMS regulations also require that hospice agencies provide the types of necessary supplies and equipment required by the individualized plan of care. For a patient with COVID-19, this would include supplies for respiratory hygiene and cough etiquette, including 60%-95% alcohol-based hand sanitizer (ABHS). However, given supply shortages, State and Federal surveyors should not cite hospice agencies for not providing certain supplies (e.g., personal protective equipment (PPE) such as gowns, N95 respirators, surgical masks and alcohol-based hand rubs (ABHR)) if they are having difficulty obtaining these supplies for reasons outside of their control. However, we do expect providers/suppliers to take actions to mitigate any resource shortages and show they are taking all appropriate steps to obtain the necessary supplies as soon as possible.

What Personal Protective Equipment should hospice staff routinely use when visiting the home of a patient suspected of COVID-19 exposure or confirmed exposure?

If care provided to symptomatic patients who are confirmed or presumed to be COVID-19 positive is anticipated, then Hospice Agencies should refer to the CDC Interim Infection Prevention and Control Recommendations for Patients with Confirmed Coronavirus Disease 2019 (COVID-19) or Persons Under Investigation for COVID-19 in Healthcare Settings: https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control- recommendations.html

Health care professionals who enter the room of a patient with known or suspected COVID-19 should adhere to Standard Precautions and use a facemask or respirator, gown, gloves, and eye protection. When available, respirators (instead of facemasks) are preferred; they should be prioritized for situations where respiratory protection is most important and the care of patients with pathogens requiring Airborne Precautions (e.g., tuberculosis, measles, varicella).

What are the considerations for discharge to a subsequent care location for hospice patients with COVID-19?

The decision should be made based on the clinical condition of the patient including careful consultation with the patient, patient representatives and/or their family, and understanding their individual needs and goals of care. If Transmission-Based Precautions must be continued in the subsequent setting, the receiving facility must be able to implement all recommended infection prevention and control recommendations. Be sure the transportation team is aware that the patient has confirmed COVID-19.

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Although COVID-19 patients with mild symptoms may be managed at home, the decision to discharge to home should consider the patient’s ability to adhere to isolation recommendations, as well as the potential risk of secondary transmission to household members with immunocompromising conditions. More information is available here: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-home-care.html.

If hospice care is provided in a nursing home, we have advised nursing homes that hospice workers should be allowed entry provided that hospice staff is following the appropriate CDC guidelines for Transmission-Based Precautions, and using PPE properly.

Important CDC Resources:

CDC Resources for Health Care Facilities:

• CDC Resources for Health Care Facilities: https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/index.html

• CDC Updates: https://www.cdc.gov/coronavirus/2019-ncov/whats-new-all.html

• CDC FAQ for COVID-19: https://www.cdc.gov/coronavirus/2019-ncov/infection-control/infection-prevention-control-faq.html

• Strategies for Optimizing the Supply of N95 Respirators: https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Frespirator-supply-strategies.html

CDC Updates:

https://www.cdc.gov/coronavirus/2019-ncov/whats-new-all.html

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FDA Resources:

• Emergency Use Authorizations: https://www.fda.gov/medical-devices/emergency-situations-medical-devices/emergency-use-authorizations

CMS Resources:

Hospice Infection Control and Prevention regulations and guidance: 42 CFR 418.60, Infection Control, Appendix M of the State Operations Manual, Infection Prevention and Control. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_m_hospice.pdf.

Contact: Questions about this memorandum should be addressed to [email protected]. Questions about COVID-19 guidance/screening criteria should be addressed to the State Epidemiologist or other responsible state or local public health officials in your state.

Effective Date: Immediately. This policy should be communicated with all survey and certification staff, their managers and the State/Regional Office training coordinators immediately.

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/s/

David R. Wright

cc: Survey and Operations Group Management

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