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.

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.

Colorado Proposes Changes to General Licensure Rules Concerning Review and Approval of Quality Management Plans for Health Care Entities

The Health Facilities and Emergency Medical Services Division of the Colorado Department of Public Health and Environment (CDPHE) issued proposed amendments to its general licensure rules for health care entities on July 16, 2014.  The division plans to update its rules for the first time since the health facility quality management privilege, C.R.S. § 25-3-109, was enacted in 1988.  A rulemaking hearing is scheduled for Oct. 15, 2014.

The division is amending its regulations to strike language exempting certain health care entities from having a quality management plan, as the statute does not exempt any licensed health care entity from this requirement.  Thus, the proposed rule requires every health care entity licensed or certified by the CDPHE pursuant to C.R.S. § 25-1.5-103(1)(a) to establish a quality management program appropriate to the facility’s size and type that evaluates the quality of patient or resident care and safety.

In addition, the division is amending its rules regarding approval of quality management plans, stating that the current rule language is outdated and is being revised to align with the new health inspection process.  Thus, the proposed rule eliminates the requirement that facilities submit quality management plans for approval.  Instead, every health care entity that must have a quality management plan will be required to develop a quality management plan that shall be available to the CDPHE during the initial licensure survey and each re-licensure survey.  Significantly, the proposed regulations state that the plan for a health care entity’s quality management program shall be considered approved if the CDPHE does not cite any deficient practice related to it.  If the CDPHE finds that a quality management plan does not meet regulatory requirements, it will inform the facility of the specific reasons for disapproval and establish a reasonable date for resubmittal of a revised plan.

On a related note, the Colorado Supreme Court should issue a decision shortly under the former licensing rules.  In Simpson v. Cedar Springs Hospital, Inc., Colo. No. 2013 SA 124, a hospital challenged a trial court’s order to produce documents from its quality management meetings after the trial court found that a hospital had not implemented a quality manage­ment program approved by the CDPHE, such that its quality management materials were subject to the privilege created by C.R.S. § 25-3-109.  The trial court had rejected the hospital’s argument that the evidence that the CDPHE had licensed the hospital and renewed its license established that the hospital had an approved quality management program.

Health care facilities in Colorado should follow the CDPHE’s rulemaking as well as the Colorado Supreme Court’s decision in Simpson as they will provide important information about the scope and requirements of Colorado’s quality management privilege

Key Points to Consider When It Comes to Bed Rail Safety

In recent years, the use of bed rails has received increased scrutiny from the health care community and regulators.  There have been many reports of death and injury, such as entrapment, falls, and asphyxiation, due to bed rail use.  Between Jan. 1, 1985, and Jan. 1, 2013, the Food and Drug Administration (FDA) received 901 incident reports of patients caught, trapped, entangled, or strangled in hospital beds, including 531 deaths.

In January, the FDA, working in conjunction with the Consumer Product Safety Commission (CPSC), developed a new webpage that provides guidance about bed rail use.  The guidance addresses bed rail safety, safety concerns about bed rails, and recommendations for health care providers, consumers, and caregivers about bed rails. Among the information available is clinical guidance to assess an individual patient’s needs when using a bed rail and a bed safety entrapment kit containing information and tools that can be used to assess entrapment risk.

The Colorado Department of Public Health and Environment (CDPHE) also has information on its website to assist nursing homes with bed safety.  The CDPHE has pointed out the risks of using restraints such as bed rails.  The risk of bed rails include falls caused by climbing over the rails, becoming trapped between the bed rail and mattress, which can result in asphyxiation, and fracture from rolling into the transfer rails.

The FDA cautions that health care providers should avoid the routine use of bed rails and that bed rails should not be used as a substitute for proper monitoring, especially for people at high risk of entrapment.  Likewise, the CDPHE encourages the use of alternatives before using bed rails, such as lowered beds, futons, or waterbeds.

Nursing homes often run into conflict with family members who request bed rails.  However, nursing homes cannot use family requests to justify using bed rails.  Surveyor guidance emphasizes that the legal surrogate or representative cannot give permission to use restraints for the sake of discipline or staff convenience when the restraint is not necessary to treat the resident’s medical condition.  In other words, the facility cannot use restraints in violation of 42 C.F.R. § 483.13(a) solely based on a family member’s request or approval.