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Guidance: Intermediate Care Facilities

Update for requesting prior authorization for bed hold days during the COVID-19 state of emergency in Ohio. 5/18/2020 Click here to view

Attention Intermediate Care Facilities Providers:

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.

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) related to social distancing and personal hygiene.

DODD encourages ICF providers to take all steps necessary to follow guidelines for social distancing, including limiting the delivery of services in community settings when appropriate.

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

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.

With respect to visitation in ICFs, the Ohio Director of Health issued an order that requires the following: (Note: ICFs are included in “Homes.”)

  1. Restrict access to all Homes only to those personnel who are absolutely necessary for the operation of the Homes. People who are "absolutely necessary for the operations of the Homes" include, but may not be limited to, home staff, contracted and emergency healthcare providers, contractors conducting critical on-site maintenance, and governmental representatives and regulators and their contractors. No visitors of residents shall be admitted to any Home, except for end-of-life situations.
  2. Restrict access to all Homes only to those personnel who have been screened for COVID-19 each time they enter Homes. Screening guidance is available from the U.S. Centers for Disease Control and Prevention and Centers for Medicare and Medicaid Services, as well as from the Ohio Department of Health. Screening should include questions about exposure to COVID-19 and assessing visitors and personnel for cough, shortness of breath, and body temperatures of 100.0 degrees and higher. This order does not apply in exigent circumstances, to emergency medical services, first responders, and similarly situated individuals.
  3. Restrict access to all Homes to as few points of entry as is possible, with the Ohio Department of Health recommending one point of entry. This does not apply to emergency ingress or egress of facilities.
  4. Restrict access to all Homes only to those persons who produce legal federal- or state-issued identification, other satisfactory identification, or are a known person, and provide the Homes with business telephone numbers and addresses. It is the responsibility of the Homes to log such information, maintaining it for at least six months.
  5. Allow residents to discharge from Homes at any time and in accordance with applicable state and federal law, understanding that residents that then return to the Homes while this Order is in effect are subject to the directives above.

DODD recognizes that these requirements may seem excessive for small ICFs and ICFs that do not serve elderly or medically compromised people, but they currently are required for all ICFs.

The department anticipates that the Centers for Medicare and Medicaid Services (CMS) soon may issue ICF-specific guidelines for COVID-19, at which time DODD will amend this guidance to reflect CMS direction. Until that time, DODD recommends that ICFs study and use the current CDC guidelines for long-term care facilities. Please check this link frequently, as the CDC guidelines are often updated.

The guidelines cover

  • education of residents and families,
  • infection control supplies,
  • screening of staff for potential infection,
  • visitors,
  • managing residents with respiratory infection,
  • additional measures to reduce potential for spread within the facility,
  • and additional measures if there are COVID-19 cases in the facility or surrounding community.

Surveys

ODH is currently following CMS guidance to continue annual and complaint surveys. Governor Mike DeWine is working diligently to waive the requirement for annual surveys, and DODD has requested ODH to suspend licensure surveys.

As of the close of business March 13, DODD’s Office of System Support and Standards (OSSAS) suspended regularly scheduled compliance reviews and regulatory work [Plan of Correction (POC) and Plan of Correction - Verification (POC-V)] in response to COVID-19. If an ICF has a review in process, DODD or a county board reviewer will contact them with guidance.

Initial and three-year Ohio Developmental Disabilities Profile (ODDP) reviews are on hold through the state of emergency.

Options Counseling

Options counseling by CareStar and pre-admission counseling has been postponed until further notice.

Level of Care

Level of care redeterminations are postponed until after June 1, 2020.

Service Plans and Service Delivery

All Human Rights Committee (HRC) and service plan meetings should be conducted using conference calling or other technology when possible and appropriate. If meetings cannot be held as required, the reason it did not take place should be clearly documented.

ICFs do not need HRC consent for restrictions that occur due to the mandates from the governor, ODH, DODD, and CMS due to COVID-19.

ICF providers are encouraged to update service plans as needed using conference calling or other technology to hold team meetings. If a guardian is unavailable to approve a person’s service plan, ICF providers may continue services per the existing service plan through June 1, 2020. If a service plan is to be continued without a guardian’s approval, there must be an addendum to the plan indicating that it is continuing as written until consent for the plan can be obtained from the guardian.

ODH and DODD will be reviewing each case specific to the person and their service plan. All health and safety requirements for the person in the service plan must be met. If a requirement cannot be met, the ICF provider should clearly document why the requirement was not met, such as a dentist appointment not being an emergency appointment because the person was not experiencing any symptoms. Governor DeWine’s order issuing a state of emergency sets the expectation for people not to schedule or attend non-emergency appointments.

DODD supports a provider’s ability to prioritize medical appointments, follow-ups, and consultations based on the needs of the person and after consultation with the appropriate medical professional. When possible, telehealth options, such as 24/7 nurse phone lines, should be explored.

ICF providers may operate over their licensed capacity with team approval when necessary to respond to the emergency. A rule waiver should be requested and will be granted expeditiously by DODD. The ICF may exceed licensed capacity while waiver approval is pending.

An ICF provider may lock doors to limit entry into the building, but must still ensure that there are at least two means of egress from each floor of the building.

Discharge Notices

Thirty days’ notice of discharge is still required per current rules. It is also required that each ICF provider has an emergency response plan that includes shelter-in-place and quarantine areas.

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 discharge, but may postpone the person’s return to the facility. In this event, the facility may give a 30-day discharge notice, but must maintain the open bed for the person to return to after the quarantine period.

Under CDC guidelines, ICFs may be able to treat an infected person or a person under investigation for COVID-19 at the facility if the ICF can implement appropriate infection control precautions per the guidelines (isolation, use of personal protective equipment, etc.). ICFs are not required to discharge a COVID-19 positive person and may allow them to return after hospitalization, subject to appropriate precautions.

Direct Support Professional Training

DODD is asking day program providers and ICF providers to collaborate in order to subcontract employees from day programs to help cover shifts needed by the ICF provider. If active treatment cannot be provided, this should be documented on an individual basis. ICFs should try to be creative and complete goals and activities.

If an ICF provider has not met a specific non-emergency training requirement, they should document the reason. Training must continue to meet each person’s needs, health, and safety.

DODD encourages providers to explore alternative service delivery methods. People receiving services, guardians, and teams must be consulted and approve these alternatives.

ICF providers may explore the availability of an alternative workforce, such as college students or people without high school diplomas or GEDs. The staff person may be placed in a direct support position immediately. A rule waiver should be requested and will be granted expeditiously by DODD. The person may provide direct support while the waiver request is pending.

If ICF providers need to share staff, a statement can be accepted from a DSP’s primary employer stating that they have required training and background checks in order for them to work for a different agency. These employees must still receive person-specific training (including crisis intervention, if necessary) and site emergency response training.

ICF providers must ensure that newly hired or reassigned staff have condensed training to recognize and report major unusual incidents (MUIs) and unusual incidents (UIs), as well as universal precautions. The training must include, at minimum, the definitions of MUIs and UIs and the agency’s procedures for reporting.

DODD encourages ICF providers to utilize all staff in the provision of direct services. This includes management and clerical staff, as examples. The training expectations for this staff is the same as described in this section.

An ICF provider who chooses to utilize non-traditional staff in direct support positions must initiate appropriate background checks, driver’s abstract (if driving), and the required registry checks, but may place the staff person on the schedule immediately. RAPBACK is not required unless the staff person maintains a direct support position after June 1, 2020.

Online CPR/first aid classes will be accepted. CPR/first aid certification as required by rule must be obtained if the staff person maintains a direct support position after June 1, 2020.

DSPs without current CPR/first aid may provide direct supports as long as they are working with a nurse or at least one other staff person who has current CPR/first aid certification.

Even with the relaxed training requirements described above, the medication administration training requirements have not changed. All staff who are responsible for administering medication must have medication administration training. Providers whose certifications are expired for no more than 180 days may continue to administer medications and get renewal of certifications during that extension. (Note: This requirement was updated March 18, 2020.)

Cost Reports

Updated March 27*

ICF providers will automatically be granted an extension to submit their Medicaid year-end cost reports, making all reports due April 28, 2020. With questions, contact Ashley McKinney at ashley.mckinney@dodd.ohio.gov.

Bed Hold Days

DODD will waive the requirement for prior authorization of additional bed hold days as required by OAC 5123:2-7-08, effective March 13, 2020, until further notice. ICF providers will be responsible for entering bed hold days used during this period prior to year-end. Please contact cr-icf@dodd.ohio.gov with any questions.  

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.