CMS Updates Nursing Home Testing Guidance

Posted on September 15, 2021 by Jonathan Lips

On Sept. 10, the Center for Medicare and Medicaid Services (CMS) updated QSO-20-38-NH concerning nursing home testing to align with recently updated recommendations from the CDC.

This memo applies to nursing homes. The Minnesota Department of Health (MDH) will address these changes during this week’s COVID-19 call, and we hope to learn more about whether and how MDH will make changes to testing protocols for assisted living providers.

Testing in Response to Symptoms
No changes are recommended for when to test residents and staff who show signs or symptoms of COVID-19 infection. Residents or staff showing signs or symptoms of COVID-19 should be tested immediately regardless of vaccination status. Staff should be restricted from work, and residents should be restricted to their rooms and placed on transmission-based precautions pending evaluation for SARS-CoV-2 infection.

Routine Testing of Unvaccinated Staff
Nursing homes should now refer to the COVID-19 Data Tracker to determine the frequency of routine screening testing for unvaccinated staff. These decisions will be based on levels of community transmission as identified through the COVID-19 Data Tracker, and the use of the tracker will replace the use of CMS data on county positivity rates.

For counties with a low (blue) level of community transmission, routine testing is not recommended. Weekly testing will occur in moderate (yellow) counties and twice-weekly testing in substantial (orange) and high (red) transmission counties. Using the transmission rate guidepost instead of the county positivity rate may increase routine testing of unvaccinated staff.

Testing in Response to Outbreak
Upon identifying a single new case of COVID-19 infection in any staff or residents, testing should begin immediately. Under the revised CMS memo, facilities have the option to perform outbreak testing through two approaches.

If the facility can identify close contacts of the individual with COVID-19, they could choose to conduct focused testing based on known close contacts. Under this option, if a staff member tests positive or a new nursing home-onset case is identified among residents, the nursing home may begin an outbreak investigation in which close contacts within the nursing home are identified. Close contact means any resident who has been within 6 feet of a COVID-positive individual for a cumulative total of 15 minutes or more over a 24-hour period or any staff member who meets the definition of a higher risk exposure as outlined in Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2.

If a facility does not have the expertise, resources, or ability to identify all close contacts, they should instead investigate the outbreak according to previous guidance where the nursing home tests all residents and staff, regardless of vaccination status, at a facility-wide or group-level (e.g., unit, floor, or other specific area(s) of the facility).

Visitation Guidance
With these changes to outbreak testing procedures in nursing homes, we've received questions about how visitation is impacted. Our questions include:

• whether the county-positivity rate continues to be the metric to use for determining generally whether indoor visitation may occur for unvaccinated residents and
• whether, in an outbreak situation, visitation may resume in unaffected units based on the first round of testing that follows the contact-tracing approach, with the testing focused on individuals identified as "close contacts" and "higher risk exposures."

We are actively seeking answers to those questions and will provide any additional information during our Friday Huddle.

Please contact Jonathan Lips or Kari Everson with any questions concerning this new CMS guidance.