FAQs: Post-Acute Care

What are the requirements for testing skilled-nursing facility (SNF) residents?  

SNFs are required to include a plan for resident and staff testing as one of the elements in a facility-specific COVID-19 mitigation plan. CDPH has issued recommendations for ongoing baseline, surveillance, and response-driven testing for SNFs to prevent spread of infection. (7/22)

At my acute care hospital, we have several Medicare patients who need continued care at a skilled nursing level, but there are no local SNFs willing to admit patients, due to the public health emergency. Is there a way we can continue to provide the necessary care and get reimbursed? 

Yes. On May 20, The Centers for Medicare & Medicaid Services issued a blanket waiver to allow acute care hospitals, excluding inpatient psychiatric hospitals and long-term care hospitals, to establish swing beds to provide skilled nursing care for hospitalized patients who don’t need continued acute care but cannot transition to a SNF during the COVID-19 public health emergency. Hospitals establishing swing bed SNF services will receive reimbursement via the SNF prospective payment system. Noridian, the Medicare administrative contractor for most California hospitals, has provided additional provider education and outreach on this matter.  (5/28)

Our hospital has a patient who no longer needs acute care. We gave her the “Important Message from Medicare,” and she has not appealed the discharge decision. However, she refuses to consent to the skilled-nursing facility placement we secured. What can we do?

During the COVID-19 pandemic, many statutes and regulations regarding discharge planning and consent for transfer have been waived. Read more

What personal protective equipment (PPE) should be provided to employees working in SNFs?

Cal/OSHA’s Aerosol Transmissible Disease Standard applies to SNFs and specifies what PPE is appropriate in a variety of circumstances.  Cal/OSHA has developed specific guidance for SNFs and has indicated it intends to focus more attention on these workplaces. 

Do SNFs have to report cases to COVID-19?

Yes, SNFs are required to report communicable diseases, health care-associated infections, and potential outbreaks to state and local health departments. CDPH has released All Facilities Letter 20-43 requesting that SNFs provide, via an online survey, a daily report of staffing levels, the number of COVID-19 residents — including confirmed positive and suspected residents — equipment availability, and other facility needs.  Additionally, beginning July 20, SNFs are required to submit the results of required COVID-19 surveillance or response driven testing data to the CDPH on a weekly basis.  (7/22)

What should I do if I become aware of an unsafe situation in a skilled-nursing facility? 

Contact the District Office for the CDPH Licensing and Certification Program. Contact information for district offices is located here. (4/20)  

What is the impact of recent CMS waivers on discharge planning and patient determination of their post-acute care destination?

CMS has waived certain aspects of the discharge planning process, most notably the requirement that hospitals provide a patient in need of post-acute care services a complete list of certified providers in their area, and the requirement to use and share data on quality and resource use measures. (4/20)

Is there a waiver for the inpatient rehabilitation facility “3-hour rule?”    

Yes. During the COVID-19 public health emergency, the Coronavirus Aid, Relief, and Economic Security Act waives the provision generally required for payment — that patients of an inpatient rehabilitation facility receive at least 15 hours of therapy per week. 

Can patients with COVID-19 be discharged to SNFs?

Yes, as long the appropriate level of transmission-based precautions can be maintained. The Centers for Disease Control and Prevention (CDC) has provided interim guidance on discontinuing transmission-based precautions and disposition of patients with COVID-19 in health care settings. If a patient is being discharged to a SNF and transmission-based precautions are still required, they should go to a facility that is able to adhere to infection prevention and control recommendations for the care of COVID-19 patients. Preferably, the patient would be placed in a location designated to care for COVID-19 residents.

CDPH has also issued interim guidance for transfer and continuity of care of residents with suspected or confirmed COVID-19 infection, including admission of COVID-19-positive residents following hospitalization who still need transmission-based precautions. Unless otherwise directed, hospital personnel must consult with their local health department when discharging a COVID-19-positive patient from the hospital to a SNF.  (7/22)

Can patients under investigation (PUIs) be discharged to a SNF?

No. CDPH guidance states that PUIs with test results pending should not be transferred to SNFs until the results are available. Investigated patients with negative test results may be transferred from hospitals to SNFs following usual procedures.

Can SNFs require testing for all admissions from the hospital?

Recent CDPH  guidance recommends that all SNF residents be tested prior to admission or readmission. If the transferring hospital does not test the patient, the SNF must test and quarantine upon admission. While CDPH guidance states that hospitals are not required to perform COVID-19 testing on patients solely for discharge considerations, acute care hospitals may choose to, in order to facilitate care coordination and SNF admission. (6/11)

Should SNFs send residents to the hospital emergency department for testing?

No. If clinically stable, residents with suspected or confirmed COVID-19 should remain at the SNF with appropriate infection prevention and control measures. According to CDPH, residents with suspected or confirmed COVID-19 should be transferred to hospital emergency departments only when clinically indicated.

Can SNFs require that a new admission receive negative tests prior to admission?    

No.  Test results on asymptomatic individuals for the purposes of SNF discharge do not necessarily have to be available at the time of SNF transfer, since all newly admitted residents will be placed in the SNFs quarantine/observation area for 14 days since the date of their last potential exposure.  For SARS-CoV-2 positive individuals, facilities should use the symptoms or time-based strategy for discontinuing isolation and transition-based precautions.  Additional information can be found in AFL 20-87.

Multiple SNFs in my regions are closed to admissions, so I am unable to find a placement for my patients who need a SNF

CDPH has asked that hospitals of SNFs that encounter difficulty in transitioning new or returning resident from an acute care hospital to a SNF based on a COVID-19-related admission hold contact their local health department or the healthcare associated infections program of CDPH for review of the admission and decision and suggestions for next steps.   Additional information can be found in AFL 20-87

Has CMS expanded the availability of respiratory-related devices and oxygen services during this public health emergency?

Yes, in CMS’ recent interim final rule, the agency removed coverage restrictions that limited access to respiratory-related devices and oxygen services to Medicare beneficiaries with certain clinical characteristics. During the public health emergency, Medicare will cover equipment such as non-invasive ventilators multi-function ventilators, respiratory assist devices, continuous positive airway pressure devices – as well as oxygen services – for any medical reason as determined by a clinician.  (4/7)

What federal waivers are available for inpatient rehabilitation facilities, skilled-nursing facilities, home health agencies and hospices, and long-term care hospitals?

Federal legislative and regulatory action has included several important provisions affecting inpatient rehabilitation facilities, home health agencies and hospices, SNFs, and long-term care hospitals. As the crisis continues and additional areas emerge, additional waivers may be forthcoming. To read more about each type of facility, see: (4/7)