CMS Issues Guidance to States on Reopening Nursing Homes: Universal Testing Needed to Lift Visitation Ban

The Centers for Medicare & Medicaid Services (CMS) released guidelines on reopening nursing homes on Monday, with parameters around testing requirements and visitation — while emphasizing that nursing facilities will be among the last institutions that can safely reopen as the U.S. takes tentative steps toward moving out of COVID-19-induced lockdowns.

CMS announced that states have flexibility on deciding how the criteria in the guidelines should be implemented, given the variety in how the COVID-19 pandemic is affecting different communities.

For instance, states can require that all facilities in certain regions meet the reopening benchmarks, or make the call on a building-by-building basis.


However, the agency adamantly recommended that nursing homes secure COVID-19 testing for all residents and staff before advancing through the three planned phases of reopening, or relaxing any restrictions.

“CMS recommends nursing homes do not advance through any of the stages of reopening or relax any restrictions until all residents and staff have received a baseline test to establish that there are no known cases of COVID-19 in the facility,” CMS administrator Seema Verma said on a call with reporters held Monday evening. “In addition to the baseline test, we are calling on nursing homes to screen all staff daily and test them weekly. Further testing of residents may be necessary upon identification of coronavirus symptoms.”

The factors CMS listed to inform the relaxation of restrictions on skilled nursing facilities include:

  1. A community’s case status
  2. A nursing home’s case status
  3. Adequate staffing
  4. Local hospital capacity
  5. Universal source control — i.e. residents and visitors wearing face masks or face coverings
  6. Access to adequate testing
  7. Access to sufficient personal protective equipment (PPE)

“Due to the elevated risk COVID-19 poses to nursing home residents, we recommend additional criteria for advancing through phases of reopening nursing homes than is recommended in the broader administration’s Opening Up America Again framework,” CMS wrote.

These additional criteria include states surveying SNFs that “experienced a significant COVID-19 outbreak prior to reopening” to make sure the facility is preventing transmission.

In essence, a nursing home’s opening needs to lag behind the general community’s reopening by 14 days, according to the guidance.

Adequate testing plans for SNFs — a long-standing pain point in the COVID-19 pandemic — should consider several factors. These include:

  1. The capacity to give all facility residents a single baseline COVID-19 test, as well as the capacity to test all residents when an individual is identified with symptoms of COVID-19 or when a staff member tests COVID-19-positive.
  2. The capacity to provide all nursing home staff, including volunteers and vendors in the facility on a weekly basis, with a baseline test and to retest all staff every week –—though the weekly testing could be adjusted based on COVID-19 circulation in the community.
  3. Written screening protocols for staff, residents, and all those who enter a facility.
  4. An arrangement with laboratories to process tests.
  5. A procedure for residents or staff that decline tests or cannot be tested.

SNFs across the country have reported challenges related to the capacity to both secure testing and get results back; in New York, operators have expressed concerns about the ability to scale up testing amid new mandates, while laboratories in the state reported being overwhelmed.

PruittHealth, which operates primarily in the Southeast of the U.S., had to scramble to secure adequate testing for residents, and at least as of the end of April, did not have the capacity to test staff despite being able to scale up its testing resources considerably.

And the president and CEO of one of the largest nursing home operators in the U.S. said that while the SNF testing situation is improving, there’s still a lot of ground to make up, given that most SNFs don’t have their own labs and supplies for the tests have been short.

“You have a supply issue, and a logistical issue, and a capacity issue — all of which are improving, but by no means do we have the resources we need to test, to really identify where the virus exists and prevent the spread,” George Hager, the president and CEO of the Kennett Square, Pa.-based Genesis HealthCare (NYSE: GEN) told SNN on May 5.

The testing methods might vary by what is available in a community, whether that includes a local hospital lab using high-throughput testing, working with state labs, or mobile efforts with a point-of-care test from Abbott — which has separately drawn scrutiny over the accuracy of its results.

But at the federal level, CMS is comfortable with the testing capacity across the country, Verma said.

“We feel that there is sufficient testing capacity available in all states, and so these recommendations and guidelines were put together with that in mind,” the administrator said Monday.

LeadingAge, an association which represents non-profit senior housing and care providers, disagreed strongly with Verma’s assertions, stating that the guidance from CMS “is not grounded in the everyday realities.”

“We need funding to make both of those possible for the brave people who care for vulnerable older adults day in and day out,” LeadingAge president and CEO Katie Smith Sloan said in a statement provided to SNN. “Our members pay between $200,000 and $250,000 per week to test staff just twice a week. That’s $1 million a month. Nursing homes need help from federal or state governments to cover these necessary costs. Today’s guidance delivers none of that.”

The American Health Care Association (AHCA), which represents 14,000 nursing homes and assisted living communities across the U.S., expressed support for the new guidance and appreciation for the focus on testing in a statement attributed to president and CEO Mark Parkinson. But it also emphasized the need for support and funding for long-term care.

“Moving forward, it is vital that all long term care facilities receive additional support and funding from state governments to conduct expanded testing,” Parkinson said in the statement. “We encourage governors to use the $11 billion that has been allocated to states for expanding testing in our nursing homes, assisted living communities and other long term care facilities.”