Developing and maintaining written plans that balance access to care, staffing shortages and infection control.

Background:

COVID-19 has highlighted some risks involved in resident care, particularly in skilled nursing facilities and other congregate living settings. There are several competing priorities, and it is difficult to balance access to care, health care provider (HCP) safety, staffing shortages, resident safety and infection control. Maintaining appropriate staffing in health care facilities, while adhering to state and federal regulatory requirements and evidence-based infection control and prevention standards, is essential to providing a safe work environment for HCP and for safe resident care. It is required that each health care facility maintains a robust plan for infection control that includes contingencies for balancing safety, staffing and compliance. This document is meant to provide guidance and support for facilities in developing and maintaining these complicated plans and the necessary balance of competing priorities.

State and Federal Guidance and Regulation:

Centers for Medicare and Medicaid Services (CMS) regulations require nursing homes to establish an infection prevention and control program (IPCP) that includes a system for preventing, identifying, reporting, investigating and controlling infections and communicable diseases for all residents, staff, volunteers, visitors and other individuals providing services under a contractual arrangement based upon a facility-wide assessment and following accepted national standards. The implementation of this plan may be impacted by staffing shortages. Those impacts and the decisions made to address them should be documented by facilities to ensure that efforts to meet the regulations are clear in any future regulatory activity.

While these plans are required, it is recognized that during a public health emergency nursing homes may need to deviate from conventional standards of care to maintain access to care while also working to protect staff and residents. As such, accepted national infection control and prevention standards, such as those of the Centers for Disease Control and Prevention (CDC), do allow for strategies to mitigate HCP staffing shortages, including that “CDC guidance for SARS- CoV-2 infection may be adapted by state and local health departments to respond to rapidly changing local circumstances.” The Nevada Crisis Standards of Care (last updated on 11/08/2021) also recognizes this by allowing additional guidance as issued in technical bulletins from the Nevada Department of Health and Human Services.

The CDC’s “Strategies to Mitigate Healthcare Personnel Staffing Shortages” notes:

Health care facilities (in collaboration with risk management) should inform patients and HCP when the facility is operating under crisis standards, specify the changes in practice that should be expected, and describe the actions that will be taken to protect patients and HCP from exposure to SARS-CoV-2 if HCP with suspected or confirmed SARS-CoV-2 infection are requested to work to fulfill critical staffing needs.

Steps for facilities:

1. Given the COVID-19 pandemic and the need to balance access to care, state and federal regulation, and safety, the following steps should be taken:
   • Ensure the facility has a written Infection Prevention and Control program (IPCP).
   • Incorporate the facility COVID-19 infection prevention and control program into the facility’s Emergency Operation Plans (EOP). Document the use of contingency plans designed to respond to staffing shortages and other challenges.
   • Document the specific measures that trigger contingency plans to be implemented. Examples include:
     • Identifying additional resources to carry out its contingency plan; for example, additional personal protective equipment (PPE) to safely care for residents when moving from one cohorted unit to another and additional time required by staff to carry out the contingency plan.
     • Identifying risk mitigation methods when a facility chooses to utilize staff in different cohorts such as bundling care and planning the order of care to minimize the need to go back and forth between cohorts whenever possible.
     • Identifying which conventional strategies can still be maintained.Following nationally recognized evidenced-based infection control and prevention practices when carrying out the contingency plan.
     • Clearly documenting the contingency plan, the interventions being implemented, the reasons why conventional standards of care cannot be met and identifying parameters to help determine when a nursing home can safely return to utilizing conventional standards of care.
     • Outlining steps necessary to end the contingency plan, including time points of when measures taken because of urgent needs will be evaluated and reversed if safe for HCP and residents.
   • Notify the Nevada Bureau of Health Care Quality and Compliance (HCQC) infection preventionist and Office of Public Health Investigations and Epidemiology (OPHIE) staff when contingency plans are implemented and for further mitigation efforts under crisis standards.

Example of Putting the Plan into Action: Nursing Home Staff Shortages and Dedication of Staff to Specific Cohorted Units

The nursing home has conducted and documented a facility-wide assessment pursuant to CFR §483.70(e) and has determined that the staffing shortage is/will negatively impact resident care. The nursing home is actively recruiting staff but remains understaffed.

After consultation with the facility’s medical director, director of nursing and infection preventionist, the facility determines that it is safer for residents to forego the conventional standard of care, based on the CDC’s “Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes,” which notes:

Identify HCP who will be assigned to work only on the COVID-19 care unit when it is in use. At a minimum this should include the primary nursing assistants (NAs) and nurses assigned to care for these residents. If possible, HCP should avoid working on both the COVID-19 care unit and other units during the same shift.

In addition, the nursing home is utilizing this technical bulletin to supplement the guidance in the Nevada Crisis Standards of Care, which notes: “Implement protocols for cohorting ill residents with dedicated HCP.” The nursing home has determined, based on its assessment, that it is safer to allow staff to work across units to have sufficient staff available to care for residents, rather than following the conventional standard of care of dedicating staff to each individual cohorted unit. The nursing home implements strategies sequentially (conventional strategies to contingency strategies prior to moving to crisis strategies) and uses the assessment to develop a contingency plan to allow direct care staff to be assigned to more than one cohorted care unit.

The IPCP must address resident room assignment (e.g., single/private room versus cohorted) as appropriate and/or available, based on a case-by-case analysis of the risk factors for increased likelihood of transmission.

The nursing home has documented its plan to safely carry out the contingency plan, using evidence-based nationally recognized infection control and prevention standards.

Definitions: (as used in this specific document)

• Conventional standards of care provide care in accordance with evidence-based nationally recognized infection control and prevention practices without having to rely on contingency or crisis standards.
• Contingency standards of care include measures that may be used temporarily during periods of limited resources, such as staffing and PPE shortages. Contingency capacity strategies should only be implemented after considering and implementing conventional capacity strategies. There may be uncertainty as to whether future supply will be adequate and therefore, contingency capacity strategies may be needed. Contingency plans do not make substantial changes to the conventional care being provided.
• Crisis standards of care result in substantial changes to the conventional care being provided.

Note: Implementation of all standards of care must be done in accordance with federal and state regulations, mandates and guidance.

Questions: State health officials are available to assist nursing homes with consultation and education related to evidence-based infection control and prevention practices to ensure the safety of staff and residents. For assistance, contact:

Bureau of Health Care Quality and Compliance:

• Las Vegas: 702-486-6515
• Carson City: 775-684-1030

Office of Public Health Investigations and Epidemiology:

Email COVID-19 questions to outbreak@health.nv.gov. For updated guidance, please review the DPBH Technical Bulletin website and the Nevada Health Response website regularly.