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Phase 3 of Reopening Nursing Homes – How? When?

The Centers for Medicare & Medicaid Services (CMS) released recommendations for how to safely reopen nursing homes in the US in a May 18, 2020 QSO Memo (Ref: QSO-20-30-NH). Nursing homes, as it has been widely covered in the media, are not really allowed to “fully” reopen until Phase 3 of Opening Up America Again. The recommendations from CMS are cross-walked to the framework provided by the Trump Administration for reopening the country safely. So, what is in Phase 3 of the reopening nursing homes guidance? Is everything right back to where we were pre-COVID infiltrating our facilities? No, not quite.

Phase 3 – Reopening Nursing Homes

There are multiple criteria that must be met before nursing homes can enter this final reopening phase. The first of these requires that the community that the nursing home is in has met the Phase 3 entry criteria for Opening Up America Again. This requires that communities do not experience rebound cases during Phase 2 and can successfully move to next phase. Referral hospitals must also have bed capacity in ICU and wards.

Nursing homes, per CMS recommendations, will have lagged behind the opening dates for the general state/region/community for prior phases. Here’s what needs to happen at the nursing homes once the community is ready for Phase 3:

  • No new nursing home-onset COVID-19 cases in the facility for 28 days (14 days for Phase 1 + 14 days for Phase 2).
  • The facility has adequate supplies of Personal Protective Equipment (PPE) as well as essential cleaning and disinfection supplies.
  • The facility is not experiencing staffing shortages.
  • Adequate access to COVID-19 testing is available to the facility.

Phase 3 – What to Expect

  • Screening:
    • All  individuals entering the facility should be screened, and all staff must be screened at the beginning of each shift. This includes:
      • Temperature checks
      • All outside personnel entering the facility must wear a cloth face covering or facemask
      • Questionnaire about symptoms and potential exposure
      • Sign/symptom observation
      • Resident Screening – 100% of residents must be screened daily, at a minimum. This includes temperature checks and questions about/observation for signs/ symptoms of COVID-19
  • Testing:
    • All staff should be tested weekly.
    • All residents should be tested upon identification of an individual with symptoms consistent with COVID-19 or if staff have tested positive. Weekly testing occurs until all residents test negative.
  • Visitation – Visitation will be allowed again – with a few caveats. Visitation will be allowed with screening, ensuring social distancing is maintained, and hand hygiene is being performed. Visitors must wear a cloth face covering/ facemask for the entire visit. What else?
  • Personnel/Contractors – Non-essential healthcare personnel/contractors are allowed to enter the facility again, also with a caveat. The facility needs to have a plan in place for determining which non-essential personnel are determined to be necessary. Facilities must also ensure that these non-essential personnel and contractors are screened and take additional precautions like other visitors. They must maintain social distance, perform hand hygiene and wear a cloth face covering/ facemask.
  • Volunteers  – Volunteers will be allowed entry into the facility, but must be screened and take additional precautions. These precautions are the same for other visitors and non-essential personnel – maintaining social distance, performing hand hygiene and wearing a cloth face covering or facemask.
  • Dining – Communal dining should be limited to COVID-19 negative or asymptomatic residents only, but residents will be allowed to eat in the same room so long as the room has been set up for social distancing appropriately. This means limiting the number of people at a table and spacing tables by at least 6 feet.
  • Group Activities – Group activities should be allowed for COVID-19 negative or asymptomatic residents only, and can include outings. The number of participants in an activity should be limited to no more than the number of people where social distancing can be maintained among residents. Everyone should perform appropriate hand hygiene and wear a cloth face covering or facemask.
  • MedicallyNecessary Trips Outside the Facility – Residents who need to take medically-necessary trips outside of the facility should wear a mask and the facility must share the resident’s COVID-19 status with the transportation provider and provider that the resident has the appointment with.
  • Cohorting/Dedicated Space – The facility needs to have dedicated space for cohorting and managing care for residents who are COVID-19 positive and have a plan in place for managing new admissions/readmissions with unknown COVID-19 status as well as residents who develop symptoms.

What to Expect on Survey

Since “normal” nursing home operations will be in place in Phase 3 of the reopening, normal survey operations will be in place as well. Specifically, the following surveys will be performed:

  • All Complaint and Revisit surveys necessary to identify and resolve any noncompliance with health and safety requirements
  • Standard surveys (Recertification) and revisits – Prioritization for these is as follows:
    • Facilities with a significant number of COVID-19 positive cases
    • Special Focus Facilities
    • Special Focus Facility Candidates
    • Facilities that are overdue for a standard survey (greater than 15 months since last standard survey) and have a history of noncompliance (S/S: of Actual Harm or higher) in these areas:
      • Abuse or neglect
      • Infection Control
      • Violations of transfer or discharge requirements
      • Sufficient staffing
      • Staffing competency issues
      • Other quality of care issues including pressure ulcers, falls, and other high risk areas
  • Focused Infection Control Surveys
  • Survey activity based on state priorities

It may be awhile until nursing homes are able to reach Phase 3, given constraints with testing availability, PPE availability, and staffing issues. Providers should prepare not only for COVID-19 Focused Surveys and Infection Control-related concerns in the near term, but for the full depth of survey capabilities as more states open and move through the phases.


For additional information, please view the following CMSCG Blog posts:

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