This week’s Ftag of the Week on the CMSCG Blog covers important revisions to F886 COVID-19 Testing – Residents & Staff, which we previously reviewed in our “Ftag of the Week” series around this same time last year. (You can view the original regulatory requirements in Part 1 and Part 2 of our Ftag of the Week posts for F886). The updates to F886 has been released in several versions of the Centers for Medicare & Medicaid Services (CMS) QSO Memo, “Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements,” and this latest version of the regulatory requirements for COVID-19 testing in nursing homes are part of the recently updated QSO-20-38-NH with a revision date of 9/10/2021.
F886 – Updated Definitions
The revisions to F886 now include definitions for:
- “Close contact” – This update states that close contact refers to someone who has been within 6 feet of a COVID-19 positive person for a cumulative total of 15 minutes or more over a 24-hour period.
- “Fully Vaccinated” vs. “Unvaccinated” – The definitions guide the reader to the CDC definition of fully vaccinated, and note that an unvaccinated person is someone who does not fit the definition of being fully vaccinated, including individuals with unknown vaccination status.
- “Level of Community Transmission” – This definition states that this term refers to the facility’s county level of COVID-19 transmission based on the CDC’s COVID-19 data tracker with county transmission rates.
- Higher–Risk Exposure” – A higher risk exposure is now defined as exposure of an individual’s eyes, nose or mouth to material that potentially contains SARS-CoV-2, particularly in the case where aerosol-generating procedures are being completed and the individual is in the same room. It is noted that higher-risk exposures can occur when staff members do not wear appropriate PPE when interacting with an individual or performing care.
The definitions of “close contact” and “higher-risk exposure” align with the CDC’s September 10, 2021 update to its Infection Control: Severe acute respiratory syndrome coronavirus (SARS-CoV-2) webpage which includes updated testing intervals for individuals who have had higher-risk exposures and close contact.
Testing Updates
The updated QSO Memo follows Interim Guidance from the CDC that was updated on September 10, 2021, “Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes,” which includes updates to outbreak response. The updated guidance promotes the use of contact tracing during outbreak investigations, as well as provides alternatives for outbreak responses. This means that when a single new positive case of COVID-19 is identified in any resident or staff member, the facility should begin an outbreak investigation immediately, using one of two approaches (contact tracing or broad-based testing).
The Testing Trigger Summary Table has been updated to the following:
- If a symptomatic individual is identified, both staff and residents with signs or symptoms of COVID-19 must be tested, regardless of vaccination status.
- If there is a newly-identified COVID-19 positive staff member or resident in a facility that can identify close contacts:
- All staff that had a higher risk exposure to the COVID-19 positive individual should be tested, regardless of vaccination status.
- All residents who had close contact with the COVID-19 positive individual should be tested, regardless of vaccination status.
- If there is a newly-identified COVID-19 positive staff member or resident in a facility that is unable to identify close contacts:
- Staff should be tested at either a facility-wide level, or at a group-level if staff have been assigned to a specific area where the new case occurred, such as the same unit or floor. Staff must be tested regardless of vaccination status.
- Residents should also be tested at either on a facility-wide basis, or on a group-level, such as residents on the same unit or floor. This testing must occur regardless of resident vaccination status.
So, as you can see, there is more flexibility given to facilities with strong contact tracing capabilities in place. If a facility cannot identify close contacts of the individual who tested positive, then facility-wide testing must be conducted just as in prior guidance.
Routine Testing
The criteria for routine testing has also been updated. The guidance now states that routine testing for residents is “not generally recommended.” For staff, the following guidance should be followed:
- Routine testing of unvaccinated staff should be based on the extent of the virus in the community.
- Fully vaccinated staff do not need to be tested routinely.
- The CDC COVID-19 Integrated County View should be used to determine community transmission level, which is the trigger for staff testing frequency.
Facilities should monitor their level of community transmission every other week and adjust the frequency of performing staff testing accordingly. If the level of community transmission increases, the facility should begin testing its staff at the expected frequency as soon as the criteria for the higher level is met. Conversely, if the community transmission decreases, the facility is still expected to test staff at the higher level frequency until the level of community transmission has remained at the lower level for at least two weeks before the testing frequency can be reduced. So, to reduce testing frequency, if a facility is in a “substantial” level of transmission county and the county drops into the “moderate” level, the facility needs to watch the community transmission level for two weeks to ensure it stays at the “moderate” level before it can reduce the testing to what is required for the “moderate” level.
While many facilities have chosen to go above and beyond the required minimum testing as part of their own policies, this is now the minimum expectation for testing:
- Low community transmission means that routine testing of unvaccinated staff is not recommended.
- For Moderate community transmission, unvaccinated staff should be tested 1x/week.
- For Substantial or High levels of COVID-19 Community Transmission, unvaccinated staff should be tested a minimum of 2x/week.
Other Key Points about Staff Testing
Since F886 was updated to align with current CDC guidance, there are several other important items to note.
First, as of September 10, 2021, the CDC updated its “Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2.” Providers should view this guidance, as well as the previously mentioned guidance, for preventing the spread of SARS-CoV-2 in nursing homes when testing staff who have had a higher-risk exposure to COVID-19 when the facility is not in outbreak status.
Second, as mentioned, facilities now have the ability to conduct focused testing based on known close contacts of an individual with COVID-19. This is only feasible if the facility has the capabilities to identify all close contacts. If this is not possible, then the expectation is to complete an outbreak investigation at either the facility-wide scale or at the group level, such as a floor or unit. It is noted that facilities may need to test more broadly if:
- Directed to do so by public health authorities having jurisdiction
- All potential close contacts are unable to be identified
- All potential close contacts are too numerous to manage
- Contact tracing fails to stop an outbreak
Third, for staff who test positive for COVID-19, repeat testing is not recommended to end work restrictions. The facility should follow this CDC guidance.
To read the full revisions to F886, view the updated CMS QSO Memo (Ref: QSO-20-38-NH) here.