American Health Care Association Issues Public Comment on Centers for Medicare & Medicaid Services Rule

WASHINGTON, Oct. 31 -- Erin Prendergast, senior manager for quality improvement at the American Health Care Association, has issued a public comment on the Centers for Medicare and Medicaid Services rule entitled "Medicare and Medicaid Programs, Clinical Laboratory Improvement Amendments, and Patient Protection and Affordable Care Act:Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency". The comment was written and posted on Oct. 29, 2020:

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The American Health Care Association and National Center for Assisted Living (AHCA/NCAL) represent more than 14,000 non-profit and proprietary skilled nursing facilities, assisted living communities, sub-acute centers, and homes for individuals with intellectual and developmental disabilities (ID/DD). By delivering solutions for quality care, AHCA/NCAL aims to improve the lives of the millions of frail, elderly, and individuals with disabilities who receive long term or post-acute care in our member facilities each day.

AHCA appreciates the opportunity to comment on the interim final rule: "Medicare and Medicaid Programs, Clinical Laboratory Improvement Amendments (CLIA), and Patient Protection and Affordable Care Act; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency."

The COVID-19 pandemic has created and continues to create unprecedented challenges for our entire health care and public health system and AHCA welcomes the opportunity to find solutions to protect and preserve the quality of care for long term care residents, patients, staff, and providers. We support, the intent and purpose of routine testing in section J and offer considerations for testing criteria. However, we are concerned with section A. New Enforcement Requirement for LTC Facilities, and strongly oppose section D. Quality Reporting: Updates to the Extraordinary Circumstances Exceptions (ECE) Granted for Four Value-Based Purchasing Programs in Response to the PHE for COVID-19, and Update to the Performance Period for the FY 2022 SNF VBP Program.

The following are responses to specific questions or solicitations for comments posed by CMS in the IFC and comments on specific provisions of the rule including, when appropriate, recommended modifications. Thank you in advance for your consideration of the issues we raise and our associated recommendations.

Sincerely,

Erin Prendergast, MPH

Senior Manager, Quality Improvement

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Responses to Specific Questions Posed by CMS or Solicitation for Comments in the Preamble

On page 54852 it states, "We recognize that there may be additional factors that may be useful in developing parameters for COVID-19 testing. As a result, we are soliciting comments on other factors the Secretary should consider for LTC facility resident and staff testing for COVID-19."

AHCA Comment: AHCA applauds CMS for basing test frequency on the prevalence of COVID-19 in the local community. Independent research/1 has shown that the rate of COVID-19 in the community in which the nursing home is located, is the determining factor in outbreaks. Controlling the spread of COVID-19 will not be possible until wide-spread rapid testing is possible for all residents/patients, staff, others such as visitors and state personnel. Given that testing is a key step to manage and minimize outbreaks, AHCA also supports the routine testing of all staff, at a frequency appropriate to the prevalence COVID-19 in the community, and more frequent testing when cases are identified. As we learn more about the relationship between community rates and COVID-19, and the test performance of different testing platforms, the frequency for testing will likely need to be adjusted. AHCA applauds CMS for establishing testing guidelines that are flexible and can be modified as more evidence and information becomes available. For example, CMS has already modified the criteria for testing frequency for counties with a very low testing rate and modified the data collection period to minimize the impact of small sample sizes.

AHCA Recommendation: We would encourage CMS to take the following factors into consideration as the test frequency criteria continues to evolve.

* Evaluate efficacy of/need for twice weekly routine test frequency: As of Sept 29, over 400 counties are operating under a twice weekly test requirement. Twice weekly testing may not yield additional information compared to weekly testing to prevent spread. In addition, it is extremely expensive and burdensome, and stresses nationwide testing capacity. To our knowledge, little evidence is available that supports a twice weekly routine testing frequency as being more advantageous than a weekly test frequency. AHCA would support a twice weekly test frequency if evidence were available to show significant gains at this test frequency. CDC guidance indicates that facilities with active outbreaks should test every three days for the first two weeks and then every seven days until resolution of that outbreak./2

From this recommendation, it seems that a twice weekly testing strategy may not be necessary when not dealing with an active outbreak. A facility managing an outbreak may actually test less than a facility without COVID-19 in the community but under a twice weekly test strategy.

* Provide flexible pathways for testing contractors, consultants, etc.: The test frequency guidance requires routine testing of staff, which includes "employees, consultants, contractors, volunteers, and caregivers who provide care and services to residents on behalf of the facility, and students in the facility's nurse aide training programs or from affiliated academic institutions." CMS further indicates that facilities should prioritize individuals at the facility on a regular basis and with contact with residents and staff. The rationale behind this is sound; COVID-19 does not discriminate based on job title. However, this puts a disproportionate burden on SNF providers when testing requirements for other provider/employer types would be more effective especially in light of the requirement for a physician order which is almost impossible to obtain for vendors and consultants entering the building. A more effective strategy of requiring their employers to provide testing should be implemented. Nursing facilities commonly rely on external staff to provide care and services to residents, and residents commonly have external professionals supporting their care. From a practical standpoint, requiring providers to enforce test requirements on non-staff poses a significant challenge. Especially challenging for providers when they must test twice weekly, there is a hardship on the provider to ensure "contracted staff" are tested. We would strongly encourage CMS to impress testing requirements upon other professional groups under their jurisdiction, such as EMS, laboratory services, transportation, hospice and state employees. We also encourage CMS to exercise flexibility in their approach to enforcement of this policy, recognizing that providers may not be able to test or match the frequency required for testing non-staff.

* Understand the impact of race and ethnicity: The secretary may want to consider the demographics of residents in the nursing home, or in the county where the nursing home resides, as there have been large disparities in COVID-19 rates by different races and ethnicities. Race and ethnicity have been shown to be a stronger predictor of COVID-19 cases in nursing homes.

* Develop guidance for outbreak testing: CMS' testing strategy requires frequent testing (every 3-7 days) in response to an outbreak. There continues to be confusion on what prompts outbreak testing. For example, it is not clear whether a staff person with a family member who has a confirmed case of COVID-19 would be a cause for outbreak testing in a facility. We recommend that CMS with the CDC continue to develop guidance to assist providers in determining when to initiate outbreak testing.

We also recommend testing of Ombudsmen and Surveyors as a critical component to preventing outbreaks. It is unclear why ombudsman and state and federal survey inspectors are not subject to the same testing frequency. All the reasons supporting testing of contractors, consultants, volunteers, etc. apply to these two categories of individuals as well. Individuals are at risk of contracting COVID-19 in the community in which they live and work. The job duties of these individuals require traveling from building to building and other health care settings, increasing their potential exposure to COVID-19. The argument that ombudsman and surveyors wear PPE and follow transmission-based precautions does not eliminate the need for their testing to prevent the spread of COVID-19. This is posing a serious risk to residents that can be easily mitigated by requiring these individuals to be tested on a regular basis.

On page 54863 it requests, "We solicit comments on our cost estimates, as well as any additional costs associated with acquiring reagents, test kits, or anything else we may not have considered. Best practices for catching and eliminating these outbreaks, as well as availability of the tools necessary to do so, is a quickly changing landscape."

AHCA Comment: AHCA estimates that there are 1.6 million full time staff and 1.3 million residents in US nursing homes. This does not include contractors, consultants, and other vendors who are reflected in the testing requirement. The direct cost of testing all staff in a nursing home just once with a PCR test would be 160 million dollars and residents would be 130 million. This does not cover other direct costs and indirect costs.

However, the cost of complying with this regulation goes well beyond the direct cost of the test charged by the commercial labs or the cost of test kits for rapid antigen point of care (POC). There are also increased direct costs in PPE as Occupational Safety and Health Administration (OHSA) considers collecting test specimens a high-risk activity, which recommends gloves, a gown, a face shields or goggles, and a respirator. Indirect costs also need to be considered. Due to international shortages of PPE including n-95 masks, providers have reported that they may get different types of n-95 masks in shipments which then require fit-testing staff again. This can be costly as not all providers have been able to secure fit-testing kits and have to pay contractors to conduct these OSHA required tests. There can be additional costs around workplace controls such as engineering and administrative controls that OSHA has recommended. These include installation of high-efficiency air filters, installing physical barriers, cohorting, etc. We have heard from members that running the point of care antigen tests, plus meeting all the reporting requirements, in areas with weekly or twice weekly test frequency, requires at least one full time person to conduct the tests for an average size facility of 85-125 beds. In addition, a full-time employee is needed for PCR test collection, tracking and coordination. It is also increasing burden on staff in other areas, such as for ordering supplies and housekeeping for keeping the testing area clean.

CMS and HHS have been extremely supportive in providing rapid antigen POC test devices to nursing homes, along with a new initiative to provide Abbott test kits. This has been incredibly helpful and important in our fight against COVID-19. Unfortunately, these testing requirements are so extensive that most nursing homes will exhaust those supplies after just a few weeks of testing. This is already happening for nursing homes in counties with high test frequency. We would recommend CMS continue to prioritize and distribute test supplies to nursing homes across the country. We also recommend that CMS continue to recognize providers good faith efforts to meet the intent and purpose of these requirements.

CMS also requested, "... public comments regarding our policy to revise the FY 2022 SNF VBP Program performance period to April 1, 2019 through December 31, 2019 and July 1, 2020 through September 30, 2020."

AHCA Comment: AHCA appreciates the recognition by CMS that due to the significant disruption in care delivery created during the COVID-19 pandemic, the Agency granted Extraordinary Circumstances Exceptions (ECE) SNFs to reduce the data collection and reporting burden on SNFs so they could direct their full resources to patient care during the early months of the pandemic. The ECE relieved these providers and facilities of their obligation to report data for the fourth quarter calendar year (CY) 2019, first quarter CY 2020 and second quarter CY 2020. We also appreciate that CMS has considered revising the FY 2022 SNF VBP Program performance period in an attempt to mitigate concerned about the national comparability of these data due to the geographic differences of COVID-19 incidence rates and hospitalizations, along with different impacts resulting from different state and local laws and policy changes implemented in response to COVID-19.

However, AHCA strongly opposes the policy described in this IFC "...to revise the FY 2022 SNF VBP Program performance period to April 1, 2019 through December 31, 2019 and July 1, 2020 through September 30, 2020." While we recognize the well-intended rationale given the earlier projections of the course of COVID-19 infection rates diminishing during the third quarter of CY 2020, the reality is that the spread of COVID-19 has grown nationally and new hot spots have developed in many parts of the country not significantly impacted during the first six months of CY 2020, and the impact is expected to extend into CY 2021. Due to the fact that it now clearly unrealistic that CMS will be able to obtain any reliable hospital readmission data that satisfies the rigorous measure requirements for at least three of the four FY 2020 reporting quarters for the SNF VBP hospital readmission measure, we instead strongly recommend that CMS not score facilities for FY 2020 performance or make associated payment adjustments for the FY 2022 SNF VBP program, and resume the program in subsequent years once reliable performance data consistent with measure specifications is available.

General Comments

A. New Enforcement Requirement for LTC Facilities

In the IFC, CMS states "We will determine if noncompliance exists through a retrospective review each week to identify the facilities that failed to take the necessary and timely actions to report to CDC. Noncompliance with this requirement for each weekly reporting cycle will be cited at a scope of widespread, and a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy, which constitutes a level ''F'' deficiency."

AHCA Comment: AHCA questions what the intent is of an automatic citation at a scope and severity of F level. It is unclear how the potential for harm, that is widespread, happens if a facility fails to report aggregate data to NHSN. This is especially true if the failure to report occurs in infrequent or single instances that are often due to an error or technical issue. It does not impact patient care and does not increase or lower the risk of harm. This is especially true when the causes and reasons for failure to report are not captured. We would argue that the failure to report should be more appropriately assigned a scope and severity of C unless more individual reviews of the reasons for failure to report and the consequences associated with patient care for why a facility failed to report are collected and included in the citation.

On page 54824, CMS writes "We are enforcing the new reporting requirements through the imposition of CMPs for each time a facility fails to report the required data to the CDC NHSN system. We believe that CMPs are an appropriate enforcement remedy that will facilitate a swift return to compliance with the new reporting requirement. Sections 1819(h)(2)(B)(ii)(I) and 1919(h)(3)(C)(ii)(I) of the Act limit the amount of a CMP to $10,000 for each day of noncompliance. We have determined that a minimum $1,000 initial CMP, with a $500 incremental increase, is within the authorized CMP range and an appropriate amount to deter noncompliance with this requirement." AHCA Comment: AHCA recognizes the importance of effective disease surveillance, transparency, and shared action to mitigate the impact of COVID-19 on nursing home residents/patients, their loved ones, the staff who care for them, and the communities that support and surround them. During this time, it is necessary to bring a process improvement mindset that puts the focus on residents and staff, not enforcement and punishment. The challenges for nursing homes with COVID-19 are extensive including staffing and resource shortages, communication strains internally and externally, system pressures on practices, evolving knowledge of the virus itself and how to manage it, morale and emotional well-being of staff and residents due to the impact of the virus, and more. The survey process needs to be supportive to nursing home providers as that is where residents are living, and where care is provided. The collective goal of local, state, federal agencies as well as other stakeholders should be to build up all who are in the nursing home (residents, all staff including direct care, clinical and non-clinical, leadership) to enable them to meet and overcome the challenges inherent in the presence of COVID-19.

AHCA finds this approach concerning to providers who are making good faith efforts to comply with the new CMS requirements. An automatic fine with a minimum of $1,000 goes against the goal to collect data to support providers during the pandemic. Providers who do not exhibit any attempt to submit data and repeatedly do not meet this requirement should be held accountable. However, to penalize a provider with an increasing monetary penalty and F-level citation every time they miss a single weekly reporting deadline, will not serve to improve resident health and safety. Instead, it diverts vital resources to focus on survey, enforcement, and appeals of citations.

AHCA Recommendation: CMS should utilize a warning letter to providers who fail to report before issuing a citation. This warning letter should permit facilities to submit any missing data in a timely manner for the sake of obtaining the most accurate surveillance data. This approach is supportive to providers during this demanding time and aligns with the goal of effective disease surveillance and transparency. Citations and penalties for failure to report to NHSN as required should be reserved for providers that continually fail to report and have not made a good faith effort to do so.

AHCA recognizes the importance of effective and accurate national disease surveillance during the COVID-19 pandemic. However, CMS's current approach for long term care facilities is creating unnecessary burden and confusion due to disparate local, state, and federal surveillance efforts. We would recommend streamlining reporting and create more consistent definitions of key data elements to provide more reliable data. This can be accomplished through a single portal and allow states and localities to submit disease surveillance data they are already collecting through existing systems into NHSN on behalf of providers. CMS should also survey states' definitions of key data elements and better align common data definitions and reporting specifications through NHSN. These collaborative actions will help support compliance with reporting as well as collecting accurate data on national scale.

In the IFR, it is explained that "After each CMP is imposed, CMS will place the facility back into compliance, without requiring a Plan of Correction (POC) in accordance with Sec. 488.408(f). A facility may still submit a POC if it chooses to do so; however, because compliance will be imposed each week and facilities will be assessed an increased CMP amount for each subsequent failure to report, a POC will not be necessary. Facilities are offered an opportunity for Independent Informal Dispute Resolution under Sec. 488.431." AHCA Comment: AHCA is supportive of the removal of a POC in responding to a CMP if providers are still guaranteed the option of an IIDR. The opportunity for an IIDR is important to maintain as it is supportive of good faith efforts and allows providers who experience technical difficulties and other factors that are beyond a provider's control. Not requiring a POC will help streamline and make this process timely. AHCA would recommend CMS to implement a template for an IIDR that would minimize paperwork and expedite the reviews.

D. Quality Reporting: Updates to the Extraordinary Circumstances Exceptions (ECE) Granted for Four Value-Based Purchasing Programs in Response to the PHE for COVID-19, and Update to the Performance Period for the FY 2022 SNF VBP Program

As part of the CMS response to the COVID-19 pandemic, on March 22, 2020, Agency granted Extraordinary Circumstances Exceptions (ECE) SNFs to reduce the data collection and reporting burden on SNFs so they could direct their full resources to patient care during the early months of the pandemic. The ECE relieved these providers and facilities of their obligation to report data for the fourth quarter calendar year (CY) 2019, first quarter CY 2020 and second quarter CY 2020.

In this IFC, CMS is updating the performance period for the FY 2022 SNF VBP Program because the Agency is concerned that using qualifying claims from the two quarters that are not excepted under the ECE for COVID-19 (October 1, 2019 through December 31, 2019 (Q4 2019), and July 1, 2020 through September 30, 2020 (Q3 2020)) for all SNFs nationwide to calculate the SNF Readmission Measure (SNFRM) for the FY 2022 Program will not yield measure scores that reliably reflect SNF quality of care as determined by hospital readmission rates. The new performance period will be April 1, 2019 through December 31, 2019 and July 1, 2020 through September 30, 2020. Per the IFC, the FY 2022 Program performance standards included in the FY 2020 final rule (84 FR 38822 through 38823) will remain as finalized.

CMS also announced that they reserve the right to not score facilities or make associated payment adjustments for the FY 2022 Program if due to ongoing COVID-19 issues, there are additional ECEs or a significant number of individual facility ECEs submitted that the Agency does not have sufficient SNF VBP program data to reliability measure national performance. In the interest of time and transparency, CMS may provide sub regulatory advance notice of an intent to suspend proactive application of SNF VBP program penalties or payment adjustments for FY 2022 if unable to do so under the SNF PPS proposed rulemaking process.

AHCA Comment: AHCA appreciates the recognition by CMS that due to the significant disruption in care delivery created during the COVID-19 pandemic, the Agency granted Extraordinary Circumstances Exceptions (ECE) SNFs to reduce the data collection and reporting burden on SNFs so they could direct their full resources to patient care during the early months of the pandemic. We also appreciate that CMS has considered revising the FY 2022 SNF VBP Program performance period in an attempt to mitigate concerned about the national comparability of these data due to the geographic differences of COVID-19 incidence rates and hospitalizations, along with different impacts resulting from different state and local laws and policy changes implemented in response to COVID-19.

However, AHCA strongly opposes the policy described in this IFC "...to revise the FY 2022 SNF VBP Program performance period to April 1, 2019 through December 31, 2019 and July 1, 2020 through September 30, 2020."

While we recognize the well-intended rationale of seeking more stable data given the earlier projections of the course of COVID-19 infection rates diminishing during the third quarter of CY 2020, the reality is that the spread of COVID-19 has instead grown nationally through Q3 of CY 2020 and that new hot spots have developed in many parts of the country not significantly impacted during the first six months of CY 2020, and the impact is expected to extend into CY 2021. This means that the Q3 2020 hospital readmission data will also be extremely unstable so that the only plausible useful data from FY 2020 would be from Q1.

In addition, we do not believe that retroactively including two quarters of claims data from FY 2019 as a substitute for performance during Q2-3 of FY 2020 is appropriate for several reasons.

* First, we do not believe in general that it is appropriate to make prospective performance payment adjustments (positive or negative) based on overlapping time periods because a provider has already been subject to payment adjustments for the prior reporting periods and should not continue to be penalized for rewarded for prior performance already accounted for.

* Second, the use of CY 2019 Q3-4 data as a substitute for FY 2020 Q2-3 performance penalizes providers that have improved performance in FY 2020 and will result in payment adjustments in FY 2022 based on performance that occurred more than two years earlier.

* Third, while CMS cites an example of historically using overlapping data in the SNF VBP program for the FY 2020 SNF VBP Program when the reporting period was changed from CY to FY, we do not accept that that situation is applicable here because the intent of the measure is to capture the most recent 12-month performance data available that would be reflective of the performance year, and the cited historical precedent was a result of a permanent change in the measure itself. In this case, CMS is not permanently changing the measure performance period like in the FY 2020 SNF VBP Program but is instead attempting to apply a 6-month data proxy to substitute for FY 2020 performance even though CMS has acknowledged concern that most if not all of the CY 2020 performance data is likely to be unstable and not useable. It does not make sense to base the FY 22 SNF VBP Program payment adjustments on 6 months of data that is not from the specified performance period, combined with 6 months of unstable FY 2020 data.

Due to the fact that it now clearly unrealistic that CMS will be able to obtain any reliable hospital readmission data that satisfies the rigorous measure requirements for at least three of the four reporting quarters for the SNF VBP hospital readmission measure, we instead strongly recommend that CMS not score facilities for FY 2020 performance or make associated payment adjustments for the FY 2022 SNF VBP program, and resume the program in subsequent years once reliable performance data consistent with measure specifications is available.

F. Limits on COVID-19 and Related Testing without an Order and Expansion of Testing Order Authority

This rule proposes to allow one COVID-19 test to be reimbursed without a clinician's order, but subsequent tests require a physician's order for reimbursement. "The order of a physician or other practitioner is not required for one otherwise covered diagnostic laboratory test for COVID-19 and for one otherwise covered diagnostic laboratory test each for influenza virus or similar respiratory condition needed to obtain a final COVID-19 diagnosis, when performed in conjunction with a COVID-19 diagnostic laboratory test in order to discount influenza virus or related diagnosis." AHCA Comment: We support this change and would encourage CMS to accept standing orders in the nursing home setting since other CMS regulations require testing of all residents when they develop any symptoms consistent with COVID-19 or during an outbreak, defined as any one positive test in a resident or staff member. In an outbreak investigation CMS is requiring repeat testing of all residents until no tests are positive for all residents and staff over a 14-day period. Requiring individual orders for each repeat test will slow down the outbreak investigation and jeopardize compliance with CMS and CDC guidance on testing to prevent the spread of the virus.

In addition, AHCA urges CMS to not mandate a physician order under CLIA regulations prior to obtaining the test done by the facility with a point of care testing device. This requirement for a physician order will impede testing of visitors, staff and other individuals that need timely testing that can be accomplished with a POC testing device. While we understand the need for a physician order to support Medicare reimbursement, we do not believe a physician order should be mandated for CLIA waived testing if the facility is not billing Medicare.

J. Requirement for Long-Term Care (LTC) Facilities to Test Facility Residents and Staff for COVID-19

AHCA supports CMS' requirements for routine testing in nursing homes. As stated above, research and experience has shown that asymptomatic spread can have a deadly impact on nursing homes. Frequent and routine testing is a key way to identify and minimize outbreaks. We also appreciate CMS' intention to keep the language in the rule broad to allow providers to shift strategies as new evidence, guidance and information becomes available.

We know from experience that testing in nursing homes is extremely burdensome and expensive, and building an effective, systematic testing process is a complex task. Many important questions have arisen from CMS' and CDC' testing guidance, some of which do not have clear answers. For example, questions remain over handling discordant (conflicting) test results, including how to report discordant results and whether they trigger an outbreak investigation. There continues to be confusion over what to do (continue to test or discontinue all together) when providers cannot receive results back within the time frame indicated by CMS (48-hours). Many states also have guidance that is different from CMS, and even CDC guidance. For example, some states are requiring testing at a different frequency than CMS, some states are requiring facilities to confirm antigen test results differently than CDC's algorithm dictates and some states are not allowing the use of antigen testing at all. This causes confusion for providers and makes building an effective, systematic testing process even more difficult.

AHCA supports the intent and purpose behind these testing requirements and will continue to reinforce this in their guidance and support to providers. Providers will continue to implement their best efforts and exercise clinical judgement to meet the intent of the guidance for testing of residents and staff. For this to be effective, CMS must also recognize providers' good faith efforts to comply with the intent of the regulations. CMS should direct surveyors to recognize good faith efforts (which may include thoughtful rationale and documentation by nursing home) to comply with testing requirements, rather than immediately moving to citation.

AHCA Recommendation: AHCA strongly encourages CMS to support providers in meeting these requirements through partnership and support from state survey offices. For example, state agencies and surveyors can help connect providers with state and local health departments on opportunities to gain access to faster testing results rather than penalizing the provider for not meeting precise timeframes. As another example, they could provide feedback to providers in developing policies and procedures around issues such as refusal of testing.

At Sec. 483.80, CMS directs providers "When necessary, such as in emergencies due to testing supply shortages, contact state and local health departments to assist in testing efforts, such as obtaining testing supplies or processing test results."

AHCA Recommendation: AHCA would encourage CMS to coordinate with state partners to ensure nursing homes are prioritized for testing supplies, availability, resources and other support. Throughout the PHE, states have provided a varying degree of support to nursing facilities. State prioritization of nursing homes is key to combating this virus and developing a robust and effective testing program.

We continue to reinforce that ombudsman, state and federal survey inspectors should be subject to the same testing frequency. COVID-19 does not discriminate based on job title. All the reasons supporting testing of contractors, consultants, volunteers, etc. apply to these two categories of individuals. They are at risk of contracting COVID-19 in the community they live and work and are traveling from building to building and other health care settings with exposure to COVID-19.

AHCA Recommendation: For the safety of residents, the testing requirements should apply to state and federal surveyors. This is posing a risk to residents that can be easily mitigated by requiring these individuals to be tested on a regular basis.

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Footnotes:

1/ Provider Magazine, 5/11/20, "Characteristics of U.S. Nursing Homes with COVID -19 Cases", 6/2/2020, McKnight's Long Term Care News, 5/11/20 and Testimony to United States Senate Special Committee on Aging, 5/21/20

2/ Clinical Questions about COVID-19: Questions and Answers. (n.d.) from https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html

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The rule can be viewed at: https://www.regulations.gov/document?D=CMS-2020-0097-0001

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