Colorado Issues New COVID-19 Directives & Guidance to ALRs

On March 23, 2020, the Colorado Department of Public Health & Environment (CDPHE) issued further Directives and Guidelines applicable to Assisted Living Residences (ALRs).

CDPHE Letter Regarding ALR Visitation Requirements:

  1. Home health and hospice workers operating under physician’s orders may be essential visitors, as considered on a case-by-case basis with the resident’s physician.
  2. All visitors permitted after screening must perform hand hygiene, use Personal Protective Equipment (PPE), and restrict their visit to the resident’s room or other designated location.
  3. Essential visitors entering under compassionate care situations or as vendors must be screened and then also limited to a specific room.

CDPHE Directives and Guidelines also highlight the following:

  1. If a resident has a suspected COVID-19 case:  Consider telehealth or nurseline options instead of calling EMS.  In Colorado, telehealth is covered by all insurance plans.  Services are available here.
  2. For people experiencing COVID-19  symptoms:  Not everyone with symptoms needs to be immediately tested, but if the resident has mild symptoms, isolate the resident and avoid unnecessary contact until he/she: (1) has had no fever for at least 72 hours; (2) other symptoms have improved; and (3) at least 7 days have elapsed since the symptoms first appeared.   Increased precautions and directives are provided for residents with more serious or sever symptoms.
  3. Communities who are aware of a resident with COVID-19:  Report the case to the county public health agency.  Log other individuals who interacted with the afflicted resident and be able to report all staff who had interactions. 
  4. Resident Rights:  There is a right to personal and community engagement and residences may not restrict a resident from leaving unless living in a locked and secure environment.  However, strongly encourage residents to stay-in-place and screen returning residents.  Gordon & Rees attorneys advise that for those Communities in Denver, residents must be educated about and comply with the Stay at Home Order issued on March 23, 2020 and revised on March 24, 2020.
  5. Infection Control Practices:  Re-train all staff on infection control policies and reinforce hygiene directives.
  6. Stimulating Self-Isolating Residents:  Consider alternate communication methods with technology and provide other activities.  Make routine, safe-distance checks on isolated residents.

Visit our COVID-19 Hub for ongoing updates.

Denver Ordered to Stay Home, Certain Healthcare Operations Excluded

On March 23, 2020, Denver Public Health Administrator Robert McDonald issued a Stay at Home Order.  The Order requires all individuals in the City and County of Denver to stay at home, except for limited essential activities, including “Healthcare Operations.”  Individuals are permitted to leave their homes to both work at and obtain services from these Healthcare Operations.

The Order provides the following list of examples of Healthcare Operation, but notes the term will be construed broadly to avoid any impacts to the delivery of healthcare.  Finally, health clubs, fitness and exercise gyms, and similar facilities are not included in the exemption.

Healthcare Operations:

  • Hospitals, clinics, and walk-in health facilities;
  • Medical and dental care, excluding elective procedures;
  • Research and laboratory services;
  • Medical wholesale and distribution;
  • Home health care companies, workers, and aides;
  • Pharmacies;
  • Pharmaceutical and biotechnology companies;
  • Behavioral health care providers;
  • Nursing homes, residential health care, or congregate care facilities;
  • Medical supplies and equipment manufacturers and providers, or any related and/or ancillary healthcare services;
  • Veterinary care, livestock services, and all healthcare services provided to animals; and
  • Animal shelters and pet boarding services.

Visit our COVID-19 Hub for ongoing updates.

CMS Updates Guidance for Visitation in Nursing Homes

On Friday, March 13, 2020, Centers for Medicare & Medicaid Services (CMS) again revised its guidance for infection control and prevention of COVID-19 in nursing homes – this time to include guidance for visitation.

The new guidance applies to all facilities nationwide and calls for a restriction on visitation of all visitors and non-essential health care personnel. If a state issues a more restrictive ban, a surveyor cannot cite the facility for noncompliance with visitation requirements when complying with heightened state orders. Facilities should notify all potential visitors to defer visitation through signage posted at entrances/exits, letters, emails, phone calls, recorded messages, and other means by which the facility normally communicates.

Exceptions to the Restriction

1. Cases of compassionate care or end-of-life

These visits are to be evaluated on a case-by-case basis. Before a visitor is permitted into the facility, they must undergo careful screening for symptoms of respiratory illness including fever, cough, shortness of breath, or sore throat. If the potential visitor has any of these symptoms, they should not be allowed in the facility at any time.

If the visitor is permitted, facilities must require the visitor to frequently perform hand hygiene and use personal protective equipment, including a facemask. The visit should be limited to a specific room. This could either be the resident’s own room or another room designated by the facility.

2. Health care workers

Health care workers are permitted into facilities given they meet the criteria outlined by the CDC here.

3. Surveyors

Surveyors must be allowed to enter, unless they are exhibiting symptoms of respiratory illness.

Monitoring after Visitation

Facilities should advise any individual who is allowed in the facility to monitor themselves for symptoms of respiratory infection for at least 14 days and, if symptoms occur, to:

  • self-isolate at home;
  • contact their healthcare provider; and
  • immediately notify the facility with details of their visit such as the date of visit, who they were in contact with, and the locations within the facility they visited.

Facilities should the immediately screen the individuals of reported contact and take appropriate actions.

Additional Updated Guidance

CMS added some general additional guidance for infection control, such as:

1. Canceling communal dining and group activities;

2. Implementing active screening of residents and staff for symptoms of respiratory illness;

3. Reminding residents of proper hand hygiene and social distancing;

4. Screening staff for and documenting symptoms of respiratory illness at the beginning of each shift;

5. If staff work at multiple facilities, actively screen and restrict appropriately so illness is not spread between facilities; and

6. Restricting access to the Ombudsman program per the guidelines above, but allowing review on a case-by-case basis.

See CMS Guidance for Infection Control and Prevention of COVID-19 in Nursing Homes (REVISED).

Colorado State Health Department Issues Orders Restricting Visitors in Skilled Nursing, Assisted Living, and Intermediate Care Facilities

On March 12, 2020, The Colorado Department Public Health and Environment (CDPHE) issued emergency orders to prevent further spread of COVID-19. The order requires all Colorado licensed or certified skilled nursing facilities, intermediate care facilities and assisted living residences to implement the following restrictions and requirements regarding visitors to these facilities:

Screening, limiting and restricting visitors

1. Follow the revised CMS guidelines on restricting visitorson restricting visitors, even though the facility (e.g., ALRs) may not be subject to CMS certification. Gordon & Rees has concurrently published a bulletin on these guidelines here.

2. Restrict visitation of non-essential individuals. Facilities should post signage with the essential individual visitor policy. Essential visitors include vendors providing necessary supplies or services and individuals necessary for a resident’s physical and mental health.

3. Before allowing entry, screen all essential individuals before they enter the facility. Facilities should limit the number of essential individuals who enter the building. Facilities are required to document all screenings with this CDPHE form. These forms must be retained indefinitely and must be provided to CDPHE when requested.

4. After entry, facilities should implement limits within the facility. This includes:

  • Using personal protective equipment, including a gown, gloves, and a mask;
  • Limiting movement to the resident’s room;
  • Limiting surfaces touched;
  • Limiting physical contact; and
  • Limiting the number of visitors to only two essential visitors per resident at a time.

Gordon & Rees counsel have confirmed with State authorities that the Order does not give facilities discretion to require some, but not all, essential individuals entering the building to wear PPE. Even though resident interaction may be limited for certain visitors, the Order still requires PPE for all visitors entering the facility. The Colorado Department of Public Health & Environment has indicated that, when PPE is not available, facilities should contact their local/county health departments to determine if there is PPE available for distribution.

Gordon & Rees counsel also recommend requiring outside home health, hospice and or therapy contractors to supply their own PPE when entering the facility.

5. If there is a suspected, presumptive, or confirmed case of COVID-19 the facility must:

a. Contact and notify the county public health agency and CDPHE;

b. Identify and maintain a log of visitors and staff who interacted with the infected individual and their environment; and

c. Restrict visitation to and all group activities within the facility.

Provide alternative means of communication

Facilities must provide residents and family with alternate means of communication, phone calls, Facetime, email, etc., when restricting visitation. A staff member should be assigned as a primary contact for each resident. This person should be the contact point for incoming calls as well as provide regular updates via outbound calls. Facilities should set a phone line recording, updated daily, concerning the facility operation and visitation status.

Revise polices concerning third parties

Facilities should also review their interactions with third parties and revise related policies to ensure the best practices are in place to prevent transmission of COVID-19.

Gordon & Rees counsel are continually monitoring the rapidly evolving nature of State and Federal guidance. We are here to assist with the development of compliant policies, while understanding the continuing need to promote patient care and operational objectives during these difficult times.

See Notice of Public Health Order 20-20.

CDC COCA Issues Update on COVID-19 for Clinicians & Healthcare Facilities

On March 5, 2020, the CDC Clinician Outreach and Communication Activity (COCA), a resource for emergency health professionals, hosted a call updating clinicians on preparing for COVID-19, or coronavirus. Healthcare settings, including skilled nursing and long-term care facilities, are some of the areas of greatest concern. Below is a summary of COCA’s best practices when addressing COVID-19 in a healthcare setting:

1) Identifying persons under investigation

As of yesterday, the criteria for evaluation of persons under investigation was expanded to a wider group of symptomatic patients. Clinicians should look to possible symptoms of COVID-19, such as fever, cough, and difficulty breathing, in determining if the patient should then be tested. Influenza should also be considered during testing and co-infection is possible. Testing of healthcare personnel should be considered if they have been exposed to an individual with a suspected case of COVID-19 or they exhibit even mild symptoms of COVID-19.

2) Applying infection prevention and control measures

While the CDC has learned a lot about COVID-19, there is still a great deal that is unknown. The best way to protect residents, visitors, and staff is to rely on the infection control measures already in place. This includes standard precautions, such as washing hands and disinfecting surfaces. Facilities should also take an aggressive approach to diagnosing individuals showing signs of any respiratory infection and place them in isolation where possible.

3) Assessing risks for exposures

It is currently optional, not mandatory, for facilities to verify absence of fever and respiratory symptoms when healthcare personnel report to work. Risk exposure should focus on source control, use of personal protective equipment (PPE), and the degree of contact with the resident. Healthcare providers are also advised to inform their employers if they have travel or community related exposure.

4) Optimizing the use of personal protective equipment supplies

The CDC anticipates an increased demand for N95 masks. Facilities should optimize the use of these masks by, for example, limiting them to use in symptomatic residents and using expired masks during training. The FDA has also issued an emergency use authorization for the use of certain other masks in healthcare settings. See Letter of Authorization and NIOSH-approved FFRs.

5) Managing and caring for patients (inpatient and at home)

If a resident is either a person under investigation or a confirmed case, provide supplies and a garbage bin outside the door of the resident’s room. Post signage on the door clearly describing the infection control precautions to be taken. A facility may also limit exposure by designating and training certain individuals, or a team, to care for persons under investigation or confirmed cases.

Stay Updated:

Looking for information related to a specific state? Contact the authors for more information.

See also: CDC Issues Update on COVID-19 Response: Precautions in Healthcare Facilities (March 4, 2020)