The Centers for Medicare and Medicaid Services (CMS) recently issued recommendations regarding reopening facilities to provide non-emergent, non-COVID-19 health care. CMS recognizes that as states and localities begin to stabilize—particularly for many areas that have a low, or relatively low and stable incidence of COVID-19—there is a need to restart care that is currently being postponed.
The CMS recommendations indicate that non-COVID-19 care may be offered to patients as clinically appropriate within states, localities or facilities that have necessary resources to provide such care, and the ability to respond to a surge in COVID-19 cases, if necessary.
Coordinate With Public Health Officials
In general, prior to beginning the non-emergent, non-COVID-19 services, providers should—in coordination with state and local public health officials—evaluate the incidence and trends of COVID-19 in the area. In addition, they should evaluate the necessity of the care based on clinical needs, prioritizing surgical/procedural care and high-complexity chronic disease management. Providers should remain up-to-date on trends of COVID-19 in the area to avoid scheduling non-COVID 19 services if a surge of COVID-19 infections occurs in the provider's area.
NCC Zones
Providers are encouraged to establish "Non-COVID-19 Care Zones" (NCC zones) for care of patients not infected with COVID-19. All patients should be screened for symptoms of COVID-19 prior to entering the NCC, including through administration of temperature checks. These areas should be separate from the other facilities to the degree possible. Staff who are working in these NCC Zones should be limited to working in NCC Zones and not rotate into "COVID-19 Care Zones." These two separate areas should be clearly designated.
Within NCC Zone facilities, administrative and engineering controls should be established to facilitate social distancing, such as minimizing time in waiting areas, spacing chairs at least six feet apart, and maintaining low patient volumes. Visitors should also be prohibited. But if they are necessary for the aspect of patient care, they should be prescreened in the same way as patients. Visitors may be considered necessary, for example, if they will be providing care at home for the patient, or if they are needed for transporting the patient.
Screening and Testing
Staff should be routinely screened, as should all others who work in the facilities. Those providing services should be screened for symptoms of COVID-19 and if symptomatic, they should be tested and quarantined.
With regard to testing capability, all patients must be screened for potential symptoms of COVID-19 prior to entering the NCC Zone facility, and staff must be routinely screened for potential symptoms, as noted above. When adequate testing capability is noted, patients should be screened by laboratory testing before care, and staff working in the facility should be regularly screened by laboratory tests as well.
Equipment
In addition, CMS recommends that health care providers and staff wear surgical face masks at all times. Procedures on the mucus membranes, including the respiratory tract, with a higher risk of aerosol transmission should be performed with great caution, and staff should utilize appropriate respiratory protection, such as N95 masks and face shields. Patients should wear a cloth face covering that can be bought or made at home, if they do not already possess a surgical mask, and every effort should be used to conserve personal protective equipment (PPE).
Sanitation Protocols
In regard to sanitation protocols, the facility should establish a plan for thorough cleaning and disinfection prior to using spaces, or facilities for patients with non-COVID-19 care needs. Any equipment, such as anesthesia machines used for COVID-19 patients, should be thoroughly decontaminated following Centers for Disease Control and Prevention (CDC) guidelines.
The above are general recommendations from CMS with respect to re-establishing non-emergent care.
Practical Considerations
In addition to the general recommendations from CMS, practical considerations must be included in developing a plan to re-establish non-emergent care. We recommend the following considerations be involved in plans to re-open:
- Patient Interactions:
- Meet with patients through telehealth technology whenever possible.
- Take extra care to document all pandemic circumstances in a patient's electronic health record (EHR).
- Financial:
- Notify your professional liability carrier about your plan to reopen, including changes made to practice to ensure that all coverage is reinstated if it was suspended.
- Consult with accountants and financial advisors regarding loans, advance payment and other financial programs.
- Ensure that tax preparation status is compliant.
- Review changes to billing procedures and billing codes for health insurance plans, ensure that staff is aware of these changes, and ensure that they are loaded onto the provider's billing system.
- Confirm that your billing practices remain compliant with changes to billing procedures and billing codes, and the status of waivers and executive orders.
- Employee and Contractor:
- Confirm that employees with their own liability coverage have not let their coverage lapse.
- Confirm that all employees with professional licenses or certifications have not let them lapse.
- Update employment contracts as needed.
- Require staff, prior to their return, to participate in a brief training specifically focusing on data security as a reminder to guard against hacking attempts to avoid a breach.
- Review vendor contracts for cleaning and ensure that cleaning-related contract provisions comply with CDC guidance for disinfection.
- Miscellaneous:
- Ensure that information technology (IT) systems are fully functional and that your EHR system and facility remained secure with no breaches during closure by running a scan on all electronic systems.
- Run tests on the fire and security alarm systems prior to opening the facility to ensure that they are functioning normally. Notify your central station monitoring company prior to the tests.
- Ensure that exit signs, smoke detectors, sprinklers and fire extinguishers are in good working condition according to local fire codes.
- If utilities were shut off at the time of closure, make sure that: no mold or bacteria has grown, water is safe to consume, ventilation systems continue to operate properly, and all equipment is working properly.
- Evaluate how sterile instruments were stored prior to closure and determine whether another sterilization cycle is necessary prior to use.
- Ensure that outdated or improperly stored supplies and medications (including samples) are discarded.
