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ICF Guidance

As the Ohio Department of Developmental Disabilities (DODD) responds to coronavirus (COVID-19), please continue to exercise flexibility to ensure the health and safety of Ohioans with developmental disabilities and their families. DODD appreciates the unique role that intermediate care facilities for individuals with intellectual disabilities (ICFs) providers of service and direct support professionals (DSPs) play throughout the developmental disabilities system.

ICF providers are encouraged to ensure that a person-centered approach to services is maintained by communicating with people receiving services, their families, guardians, and DSPs to keep them updated on how they can stay safe during this state of emergency.

The following information gives recommendations and guidance on important issues for ICF providers and is effective immediately.

Emergency Response

DODD encourages ICF providers to ensure that people with developmental disabilities and DSPs are familiar with and follow recommendations from the Centers for Disease Control and Prevention (CDC) and the Ohio Department of Health (ODH).

DSPs should be familiar with the agency’s emergency response plan.

Visitation

Updated May 5

Governor DeWine announced that the Ohio Department of Health is rescinding the September 24, 2020, order that gave guidelines for indoor and outdoor visitation at intermediate care facilities. Intermediate care facilities should now follow current guidance from the Centers for Medicare and Medicaid Services (CMS) QSO-21-14-ICF to determine appropriate access to the facility and resident visitation. 

The CMS guidance requires that facilities continue to have systems in place to ensure;

  • reliable and persistent wearing of masks (face coverings)
  • diligent handwashing
  • use of other PPE such as gloves as the situations warrant
  • screening of visitors for signs and symptoms

In some cases, based on individual risk/benefit analysis discussions by the team, facilities are encouraged to maintain, and in some cases enhance, outdoor and virtual options to augment visitation. Examples include FaceTime, Skype, and Zoom.

Compassionate Care

We would like to highlight the concept of “compassionate care visits” as explained on pages 5-6 of the CMS guidance.  Compassionate care visits are intended for residents who have suffered emotional or physical decline as a result of the restricted visitation policies that were enacted as a necessity to combat the spread of COVID-19 in congregate settings. 

Compassionate care visits may include, but are not limited to, the following situations:

  1. A resident, who was living with their family before recently being admitted to an ICF/IID, is struggling with the change in environment and lack of physical family support.
  2. A resident who is grieving after a friend or family member recently passed away.
  3. A resident who needs cueing and encouragement with eating or drinking, previously provided by family and/or caregiver(s), is experiencing weight loss or dehydration.
  4. A resident who is communicating and interacting less with others, is experiencing emotional distress and/or significant changes in emotional or physical well-being.

Compassionate care visits shall be conducted using social distancing; however, if during a compassionate care visit, a visitor and ICF/IID identify a way to allow for personal contact, it should only be done following all appropriate infection prevention guidelines, and for a limited amount of time.

Through a person-centered approach, ICF/IIDs should work with residents, families, caregivers, resident representatives to identify the need, length, and frequency for compassionate care visits.

Anyone that can meet the resident’s needs such as family members, clergy, or lay persons offering religious and spiritual support shall be permitted to participate in compassionate care visits.  Facial coverings and other appropriate personal protective equipment must be supplied and used during the compassionate care visit.

Updated March 23

Compassionate Care

Recently CMS issued guidance on visitation at Intermediate Care Facilities.  That guidance is intended to assist providers to safely facilitate in person visitation and address the psychosocial needs of the residents.    Providers should be aware of this guidance and follow the requirements set forth in the guidance QSO-21-14-ICF.  

We would like to highlight the concept of “compassionate care visits” as explained on pages 5-6 of the CMS guidance.  Compassionate care visits are intended for residents who have suffered emotional or physical decline as a result of the restricted visitation policies that were enacted as a necessity to combat the spread of COVID-19 in congregate settings. 

Compassionate care visits may include, but are not limited to, the following situations:

  1. A resident, who was living with their family before recently being admitted to an ICF/IID, is struggling with the change in environment and lack of physical family support.
  2. A resident who is grieving after a friend or family member recently passed away.
  3. A resident who needs cueing and encouragement with eating or drinking, previously provided by family and/or caregiver(s), is experiencing weight loss or dehydration.
  4. A resident who is communicating and interacting less with others, is experiencing emotional distress and/or significant changes in emotional or physical well-being.

Compassionate care visits shall be conducted using social distancing; however, if during a compassionate care visit, a visitor and ICF/IID identify a way to allow for personal contact, it should only be done following all appropriate infection prevention guidelines, and for a limited amount of time.

Through a person-centered approach, ICF/IIDs should work with residents, families, caregivers, resident representatives to identify the need, length, and frequency for compassionate care visits.

Anyone that can meet the resident’s needs such as family members, clergy, or lay persons offering religious and spiritual support shall be permitted to participate in compassionate care visits.  Facial coverings and other appropriate personal protective equipment must be supplied and used during the compassionate care visit.

We are continuing to review this guidance along with our September 14, 2020 Order to Limit Access to Ohio’s Intermediate Care Facilities for Individuals with Developmental Disabilities and to Permit Visitation.    We will keep you updated as federal guidance evolves and if any changes are necessary to our existing Order.

Updated September 24

As Ohio continues to cope with COVID-19 and take steps to reopen in phases, the Ohio Department of Developmental Disabilities (DODD) recommends continued vigilance as Ohioans with developmental disabilities, families, guardians, and providers consider visits. People who are considered vulnerable may live in Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) settings and be particularly susceptible to the virus. As you consider lifting visitation restrictions, an abundance of caution and planning is advised.

Lack of in-person engagement with family and friends who live outside of the congregate setting may significantly diminish a person’s quality of life, making visits necessary to address the person’s emotional wellness despite potential physical health risks.  For these people, the provider will need to make every effort to mitigate risks to the highest degree possible. For some, their family and friends may be aged, or terminally ill, and delaying visitation may have untenable consequences.

Visits for people in congregate care settings present a significant challenge due to the number of vulnerable people living together, and the number of staff needed to ensure visits are conducted safely. The ability for facilities to understand and know where the residents have been or who has had contact with them is critical to contain the spread of infection if someone tests positive for COVID-19. To ensure the risk of spreading the virus is minimal, staff must be educated and informed of droplet precautions and must adhere to enhanced infection control precautions including:

  • reliable and persistent wearing of masks (face coverings)
  • diligent handwashing
  • use of other PPE such as gloves as the situations warrant

ICF/IID facilities may allow for indoor visitation beginning Monday, September 28, 2020 when the following conditions are met:

  • The resident’s person-centered planning team has considered all implications for the resident’s physical and mental well-being and decided visits are advisable
  • Providers have evaluated all other facility resident risk levels as a whole and determined visits are reasonable and feasible
  • Providers educate residents on the risks of the spread of COVID-19 when interacting with visitors, and the appropriate/applicable safety precautions are presented in a manner consistent with the person’s learning style
  • Providers educate families, friends, and other visitors of the risks of the spread of COVID-19 and the potential health impact for not just their loved one, but also all residents of the home
  • Providers and visitor should consider the Public Health Advisory status of the county where the facility is located and where the visitors live

The Facility has, and is implementing, visitation policies that include parameters for when and where visitation can take place, and must meet the following criteria:

  • The visitor confirms they have no household members currently in quarantine or isolation status due to COVID-19 exposure, symptoms, testing or travel to high case states
  • There are no residents in isolation or quarantine status in the distinct residential living area where the person being visited resides due to exposure to suspected or known COVID-19 cases
  • There are no personnel who have worked in the distinct residential living area where the person being visited resides within the last 14 days who have been diagnosed with COVID or been assigned quarantine status by the Local Health Department (LHD) within the past 14 days
  • The facility has enough Personal Protective Equipment (PPE) to provide for the individual, the visitor and the on-going needs of the facility personnel
  • The facility has enough resources and personnel to properly implement the visit according to the policy and state requirements for infection control practices
  • If possible, the indoor visitation will take place in a room or building that:
    • Is not currently utilized for other resident activities and has a private entrance and is not to be accessed by residents other than for visitation. If no such location exists in the facility, the visit location should be a location occupied by only the visitor and person(s) having a visitor and, support personnel, if needed, during the time of the visit
    • Is able and will have all hand-touchable surfaces cleaned between visits
    • Has ventilation that will circulate air during the visitation; circulating air should include outdoor air if possible
    • Has enough space to allow for six foot social distancing between the resident, personnel and the visitors
  • Facility should address the potential need for visitors to use a restroom
    • Access to a private restroom for visitors only is preferable, if possible
    • Any restroom to be used by visitors will be cleaned before and after use by visitors
  • Visitors must sign-in and provide contact information for potential contact tracing
  • Visitors will wash hands or use hand sanitizer upon arrival at the location and before entering the visiting location
  • Visitors will be screened for symptoms upon arrival and before visitation
  • Visitors will be required to wear a face covering during the visit. Visitor may be required to wear additional PPE (such as surgical masks) based on individual circumstances
  • The resident will preferably wear a face cover during the visit and will be assisted to not touch their face during the visit until after washing or sanitizing hands

Facilities are encouraged to maintain, and in some cases enhance, outdoor and virtual options to augment visitation. Examples include FaceTime, Skype, and Zoom.

Outings

Updated September 25

Since March 13, 2020, according to an Order issued by the Director of Health, access to intermediate care facilities (ICF) has been restricted to staff and other essential workers.   There has not been a prohibition on residents leaving the facility.  Residents of ICFs can continue to work, go to adult day and vocational habilitation programs, attend school, and engage in other activities that are important to them such as visits with families or friends outside of the ICF setting with or without staff.

When deciding how to move forward with outside activities previously enjoyed by residents, teams are guided by two principles:  continued vigilance to minimize exposure to the coronavirus and the need to restore each resident’s quality of life.  The emotional wellness of many residents is tied to the ability to visit with friends and family outside of the facility.  For these residents and their families, the team must address how to achieve this while mitigating risks to the highest degree possible.

ICFs who have not already done so should immediately initiate planning for resuming community activities.  The planning for each resident should identify the benefits to that resident and the risks to that resident and other residents.  The COVID-19 Risk/Benefit Discussion Guide has been modified for this purpose, and the Ohio Department of Developmental Disabilities (DODD) encourages teams to incorporate it into their planning.  The discussion should include opportunities to:

  1. Educate the resident and/or their guardian on the risks and benefits of engaging in the activity.
  2. Ensure the activity complies with the Centers for Disease Control (CDC) guidance and Ohio mandates. 
  3. Engage the team to make a person-centered decision.
  4. Identify alternatives activities or ways to participate to minimize risk.

DODD understands that it may take time to engage in individualized planning for each resident.  Providers should prioritize planning for those residents and families who have already requested opportunities to visit family outside the facility, engage in other community activities, go to work, etc.   The team, including the individual, and when applicable a guardian, will decide how to move forward.  As always, the plan requires the consent of the individual or guardian.

The department expects that all individualized planning will be completed within 60 days.   

There is no need to quarantine a resident upon return to the facility after an outing of any type unless the facility learns that a resident may have been exposed* to COVID-19.  In that case, the facility should quarantine that resident following the CDC guidance, local health department guidance, and the additional guidance issued by DODD including the Long-Term Services and Support Toolkit.

*Exposure is generally defined as having been less than 6 feet from a person who is symptomatic or diagnosed with COVID-19, for 15 minutes or more, and without wearing a surgical level mask.  Exposure may not be immediately known, but once known, the quarantine protocols should begin immediately.

Facilities already under quarantine or isolation must continue to follow the CDC guidance, local health department guidance, and the additional guidance issued by DODD including the Long-Term Services and Support Toolkit.

Surveys

ODH has resumed ICF annual certification surveys. If the facility is due for their licensure review, ODH will complete this at the time of the annual certification survey.

Options Counseling

Options counseling by CareStar and pre-admission counseling have resumed and may be completed virtually.

Level of Care

Level of care redeterminations remain postponed until after October 1, 2020. The need for DODD assistance with LOC redeterminations is evaluated on a monthly basis.

Notices

Thirty days’ notice of Termination of services is still required per current rules.

If a resident leaves the facility and is unable to return to the facility for a reason related to COVID-19, the facility may not issue an emergency termination of services, but may postpone the person’s return to the facility. The facility may give a 30-day termination of services notice, but must maintain the open bed for the person to return to after the quarantine period.

If an individual needs to go to another Medicaid funded facility, such as a hospital or nursing home, but there is an intent for the individual to return to the ICF after receiving necessary care, the ICF does NOT have to give a termination of services notice.  The ICF does however have to discharge the individual from the ICF by appropriately completing a discharge through DODD.  This discharge allows the Medicaid funded facility in which the person is temporarily receiving services, to be able to bill Medicaid for the services.  The individuals ICF bed must be held for the individual until they either return to the ICF, or the provider gives the 30-day termination of services notice and the 30 days have elapsed without an appeal by the individual.  This scenario may be encountered if an individual is admitted into a healthcare facility for the treatment of COVID.

Direct Support Professional Onboarding & Training

During the COVID-19 Pandemic, DODD has granted certain flexibilities to certified providers and ICFs regarding the hiring and training of Direct Support Professionals (DSPs). Effective September 1, 2021, providers will be expected to resume full compliance with all rules applicable to the hiring and training of DSPs, except for flexibilities around initial training and First Aid/CPR described below.

Full compliance includes:

  • HSD/GED/rule waiver
    • DODD will temporarily waive the requirement that DSPs must have a high school diploma or GED. This waiver will be effective from September 17, 2021, through September 30, 2022. Employees without a high school diploma or GED cannot be certified to administer medications. Read more.
  • Background checks
    • Employers will be required to initiate all applicable required Background Checks (BCII, FBI, required database checks, etc.) prior to employment.
      • Rule permits an agency to preliminarily employ a DSP for up to 60 days pending receipt of the results of the BCII check, provided the applicant has signed a Criminal
        Notification/Attestation statement prior to employment. Upon receipt of the completed background check, appropriate action must be taken if any disqualifying offenses are revealed.
    • ICFs must continue to enroll persons in Rapback within 14 days of receipt of the BCII check.
      • Previously identified issues related to Rapback enrollment have been reported as resolved.
  • Initial Training
    • DODD will continue to accept condensed initial training through December 31, 2021
      • The condensed initial training must include:
        • Training to recognize and report major unusual incidents (MUIs) and unusual incidents (UIs). The training must include at a minimum the definitions of MUIs and UIs, as well as the agency's procedures for reporting.
        • Universal precautions.
        • Training provided or arranged by the agency provider specific to the individual service plan (ISP) of each person the DSP will support.
        • Initial training must always be conducted prior to the DSP providing services.
      • Resuming January 1, 2022, initial training conducted after this date will need to comply with the Agency and Independent Certification rules and/or the Administration of Licensed Facilities rule.
  • First Aid/CPR
    • Staring September 1, 2021, all DSPs must have First Aid/CPR training prior to providing services except for those employed at Facilities subject to OAC 5123:2-3-01 (F) (1)(h-i).
    • First Aid/CPR training that does not include an in-person skills assessment will continue to be accepted through December 31, 2021.
    • Training that includes an in-person skills assessment will again be required effective January 1, 2022.
    • For DSPs who obtain CPR/First Aid training that does not include an in-person skills demonstration prior to January 1, 2022, DODD will accept this as valid training through the certificate’s expiration date. Upon renewal, the DSP will be expected to obtain training that includes the required in-person skills assessment.
  • Medication Administration Certification
    • Medication Administration Certificates that were set to expire between March 9, 2020 and April 1, 2021 were extended until July 1, 2021 by House Bill 404.
    • Any certificates set to expire during that time that have not been renewed have lapsed as of July 2, 2021.
    • All DSPs administering medication must have a current Medication Administration Certificate.
  • ICFs that share DSPs:
    • If ICFs share DSPs, each agency is required to maintain their own personnel record that demonstrates that agency’s compliance with personnel requirements
  • Compliance with all other applicable hiring and training requirements outlined in Ohio Administrative Code Chapter 5123.

ICF providers are now required to submit prior authorization of additional bed hold days as required by OAC 5123:2-7-08.ICF providers are  responsible for entering bed hold days used during the period of March 13, 2020 through July 31, 2020 prior to December 31, 2020. Additional bed hold days for this period not entered prior to December 31, 2020 will not be approved Please contact cr-icf@dodd.ohio.gov with any questions.  

DDP Assessments and Reviews Suspended for ICFs

Ohio Developmental Disabilities Profile (ODDP) certification requirements have resumed according to OAC 5123-7-33.

If an ICF is unable to certify due to a person missing an assessment, DODD will complete the certification on behalf of the ICF, excluding the person missing an ODDP assessment.

The quarterly certification and related quarterly and annual case mix scores will be updated upon an ODDP assessment completion for those people missing an assessment.

DODD will continue to assist providers with ODDP certification and allow for retroactive adjustments to the March 31, 2020 and June 30, 2020 reporting Period End Dates (RPEDs). ICFs may request adjustments to their ODDP scores for the two RPEDs with waived requirements through December 31, 2020. After December 31, 2020 all ICF ODDP scores for the March 31, 2020 and June 30, 2020 RPEDs will be considered final.

Please contact Kirstin Stewart with any questions or concerns.

DODD Waives IAF Requirements for March-June Reporting Period

DODD will waive the requirement to complete Individual Assessment Forms (IAF) for the March 31, 2020, and June 30, 2020, Reporting Period End Dates (RPEDs) due to COVID-19.

Assessments may be completed at a later date, if desired.

Please contact Ashley McKinney at ashley.mckinney@dodd.ohio.gov with any questions or concerns.

Recommended Situational Guidance from DODD and ODH

The Ohio Department of Developmental Disabilities (DODD) recognizes that the following situational actions may seem excessive or unattainable due to the lack of personal protective equipment (PPED), facility space, or for small ICFs and ICFs that do not serve elderly or medically compromised people.

However, the following is intended to serve as a guide and is highly recommended to protect the people who the department serves and those caring for them.

All staff entering the ICF should be screened for symptoms using the Entry Screening Process for Prevention of COVID-19 Transmission tool. Facility staff performing health check screenings should wear facemasks.

Health care providers (HCPs) and other facility staff with symptoms or with temperatures greater than 100.0 degrees Fahrenheit should be sent home, and HCP and other facility staff who develop symptoms or fever while in the facility should immediately go home (not to the urgent care or emergency room unless severely ill). 

Advise people who screen positive to contact their primary care physician by phone or telehealth. The HCP will determine whether the person needs to be evaluated in-person and will make referral for evaluation and treatment, as necessary.  

Respite in Licensed Residential Facilities

During the height of the COVID-19 pandemic, DODD issued communication that providers should cancel all non-emergency respite stays. At this time, DODD would like to share that this is no longer the expectation. Respite stays can be approved for non-emergency situations. If a rule waiver for a temporary increase in capacity at a licensed residential facility is required for a respite situation contact OSSAS (ossas@dodd.ohio.gov) to request such a rule waiver.

Behavioral Supports, Including Rights Restrictions

Any plans with behavioral support strategies must be developed following the behavioral supports rule, 5123-2-2-06.  HRC meetings may be held virtually.

DODD Support Teams

In this critical time, everyone will be required to work collaboratively, operate differently, and be proactive to limit the spread of COVID-19. During this state of emergency, DODD fully realizes there are on-the-ground issues that require flexibility from normal operations and additional assistance from the department.

DODD support teams are available and consist of staff ready to help county boards and providers.

DODD has set up a dedicated web page for department communications and links to helpful resources that will advise people with disabilities, their families, service providers, direct support professionals, county boards of developmental disabilities, and the community at large.

For specific questions about COVID-19 and additional information and resources, DODD urges you to use the Ohio Department of Health’s call center. Call 1-833-4-ASK-ODH (1-833-427-5634), or visit coronavirus.ohio.gov.