Order of the Secretary of Health for Testing of Residents and Staff in Long-Term Care Facilities Frequently Asked Questions
Updated: July 31, 2020
Why did the Secretary of Health issue this Order?
The Secretary of Health issued this Order to assist in protecting the safety of residents and staff in Long-Term Care Facilities (LTCFs) across the Commonwealth. Many facilities across the Commonwealth are already conducting universal testing per the Department of Health (DOH) plans published on May 12 and May 29, 2020. For facilities that have not begun testing already, this Order mandates testing beginning July 1, 2020 because doing so protects vulnerable populations and frontline workers.
In addition, the Secretary of Health issued this Order to increase facility readiness. Facilities need to prepare for a potential second surge in the future and developing capacity to do this in advance of a surge will help everyone to be better prepared.
Why did the Secretary of Health issue this Order for only some facilities licensed by the Department of Human Services (DHS)?
Secretaries Levine and Miller determined which facilities should be required to test residents and staff. Personal Care Homes (PCHs), Assisted Living Residences (ALRs), and Intermediate Care Facilities (ICFs) licensed by DHS are all subject to the requirements herein, which are reflective of the same requirements established for Skilled Nursing Facilities (SNFs). Many residents living in PCHs, ALRs, and ICFs are among the most vulnerable populations due to underlying health conditions. Testing for COVID-19 can help make sure that staff infected with COVID-19 stay home, and that infection control measures (such as appropriate use of PPE, infection control expertise support, and cohorting) are utilized when appropriate.
Not all DHS-licensed facilities were included in the Order because 1) other DHS-licensed facility types do not have as many residents who are either elderly or have preexisting conditions, 2) many DHS-licensed facilities are not residential facilities, and 3) many other DHS-licensed facilities are structured as small homes with only a few people in each home, leading to different infection control considerations. DHS staff are working closely with licensed providers to monitor conditions at all DHS-licensed facilities, including those not encompassed within the scope of this order, and providers can request additional support if necessary.
What is the timeline for testing? How long does a facility have to initiate or complete the tests?
A facility has until August 31, 2020 to complete the initial baseline testing, including testing of all staff and residents. A facility that has tested all staff and residents in the 14 days prior to the issuance of this Order (since June 12, 2020) should count that testing as meeting the initial baseline testing requirement, as long as the testing is appropriately captured in the data collection survey specified in the Requirements for Testing issued on June 26, 2020. There is no requirement for when a facility must begin testing, but testing must be completed by the August 31, 2020.
Our facility completed a baseline test of all staff beginning June 8, 2020 and ending June 14, 2020. Is this close enough to meet the intent of the Order, or does another round of testing need to be done?
To comply with the Order, all staff and residents must have a test completed since June 12, 2020. Any staff or resident that was tested prior to that date will need a retest before August 31, 2020. The best practice would be to retest everyone. There are no exceptions or waivers. Please consult the Requirements for Testing for how to handle staff or residents who refuse testing.
Are staff who refuse testing allowed to work?
The facility’s human resources department should develop a policy to address these staff based on their risk of exposure, community spread, and staffing needs. Documenting and maintaining the refusal, level of risk, and response should be a component of the policy. In facilities with residents who are exposed to or have COVID19 (Yellow and Red Zones per PA-HAN-509), staff persons refusing to be tested should not care for unexposed residents (Green Zones).
If a facility has completed universal testing, and it has been more than 14 days since the last case in staff or residents, does the facility need to continue testing?
The Order of the Secretary does not require continued testing. However, continued testing is recommended contingent upon the availability of testing supplies and personal protective equipment (PPE). PCHs, ALRs, and ICFs should continue to test residents and staff if any become symptomatic and follow guidelines in PA-HAN-509 for any new cases of COVID-19.
My facility is following PA-HAN 501, but now we cannot meet minimum staffing requirements. What should we do?
Staff who are symptomatic should be excluded from work and isolated until they meet return to work criteria as specified in PA-HAN-509. Asymptomatic staff who test positive but remail asymptomatic should be excluded from work and isolated for 10 days from the date of their first positive test, if they have not developed symptoms. A facility should consider a plan to augment staff, such as contacting staffing agencies, prior to receiving testing results. If there are no longer enough staff to provide safe patient care, and other contingency capacity strategies have been exhausted (see CDC strategies), a facility and employer may need to implement crisis capacity strategies to continue to provide patient care. The decision to follow contingency or crisis standards rests with the facility, but these decisions and actions must be detailed in and consistent with their emergency preparedness plan. Under crisis capacity standards, asymptomatic positive staff may be permitted to work in certain roles. Please follow guidance in PA-HAN-501. A facility in staffing crisis may also need to reach out to partners, such as their local Healthcare Coalition or, beginning in July, their Regional Response Health Collaborative Program (RRHCP), to discuss additional options. If contingency or crisis capacity strategies are implemented, the facility should notify their licensing program office. The facility continues to be obligated to comply with licensing standards.
How is “staff” defined in connection with the Order? Please provide clarification on what staff need to be tested and whether that includes such individuals as health care personnel not employed by the facility such as hospice and emergency medical services (EMS) personnel.
Individuals employed by the facility or who work in the facility three or more days per week (regardless of their role) are considered “staff” for purposes of the Order. Therefore, direct care personnel and all others employed by the facility who work in the facility must be tested. This includes, but is not limited to, the Director of Nursing, Assistant Director of Nursing, administrative assistants, housekeeping, and dietary staff.
Contracted staff (such as therapists or PRN staff) who enter the facility to work three or more days per week are considered staff for purposes of the Order and must be tested. A facility may require the contract staff employer to arrange for testing, or the contracted staff may independently obtain a test. Test results must be obtained and maintained by the facility.
Testing is not required for personnel who attend to health care needs of the residents but are not employed by the facility and do not enter the facility to work three or more days per week. This includes, but is not limited to, EMS personnel, phlebotomists, technicians, physicians, certified registered nurse practitioners, physician assistants, and hospice caregivers – if they are not employed by the facility. These individuals should, however, be screened each time before entering the facility. If they do not pass screening, they should not enter the facility.
Does the facility have to test its own staff and send specimens to a commercial laboratory (as it would for patients), or can the facility either use an occupational testing vendor or require its staff to be tested?
The facility can determine the most appropriate approach for testing all staff before August 31, 2020. However, the facility should impose a deadline for staff to get tested and a range of dates that are acceptable, concurrent with the testing occurring in the facility. The facility is responsible for compiling the results and taking appropriate action based on those results. Action is most effective when results are received at or around the same time. An approach that tests a different subset of the staff or residents weekly until all have been tested does not align with the intention of the Order. Any laboratory the facility uses must have a current Pennsylvania laboratory permit and be approved to perform COVID-19 testing. A facility may verify licensure and approval by emailing RA-DHPACLIA@pa.gov.
If there are residents or staff who have a prior positive test result, do they need to be re-tested?
No, a resident or staff person with a history of a positive test result for SARS-CoV-2 does not need to be re-tested.
If a resident was tested prior to discharge from the hospital (which occurred after June 12, 2020), does that resident need to be tested again?
How do we report the test results for different days but for the same facility?
If the test result upon discharge was negative, the resident must be tested again at time universal testing occurs. If the test result upon discharge was positive, the resident does not need to be tested again to comply with the Order.
Facilities should complete the survey only once, so wait until all results are back. In the survey, for the field “On what date was Universal Testing completed in your facility?” enter the last date testing was done. Then enter a note in the survey with the range of dates used.
What if I am unable to cohort patients or create the red, yellow, green zones as outlined in PA-HAN-509 due to lack of empty beds or space?
While some of these facility types will not be able to cohort as effectively as SNFs, PA-HAN-509 lays out a series of alternatives to separating the facilities into three zones. Please reference the section titled "Potential Cohorting Modifications for LTCFs" in PA-HAN-509 for recommendations on how a facility that cannot move patients around their facility can implement appropriate infection control measures. For technical assistance with the implementation of infection prevention and control measures, please reach out to your licensing program office. If you are a facility licensed by the Office of Long Term Living (OLTL), contact RAfirstname.lastname@example.org. If you are a facility licensed by the Office of Developmental Programs (ODP), contact RA-PWODPEMRGNCYRSPRQ@pa.gov. RRHCPs will be available to assist facilities beginning in July.
What is the penalty if I do not follow the Secretary's Order? Will I receive a deficiency or fine?
The Governor and the Secretary believe that facilities intend and are attempting to care for their residents appropriately. If, however, it appears that a facility willfully refuses to test as required in the Secretary's Order or is negligent in complying with the Order, DOH has the option to fine the facility
under the Disease Preventions and Control Law. Facilities are strongly urged to request help when necessary and take every step necessary to comply with the Secretary's Order.
Question: Will we be penalized if baseline results are not returned by the August 31, 2020 deadline?
Answer: Facilities will not be penalized if baseline results are not returned by August 31, 2020 due to current lab capacities. Baseline testing should occur prior to August 31, 2020 and reported as specified.
How can facilities get assistance with swabbing residents and staff?
Facilities should rely primarily on in-house clinical expertise (e.g., the Medical Director, RNs, LPNs) to conduct testing if available. ICFs are required to have physician services available to the facility 24/7, for example. If a facility does not have those team members on staff or contract or because they are out sick, RRHCPs will be able to assist with ordering, conducting, and reporting the results of the testing beginning in July. Also, DOH is bringing on additional resources to assist with swabbing. A facility in need of assistance should reach out to their licensing program office, and send an email to ra-dhCOVIDtesting@pa.gov to request assistance with testing from DHS and DOH.
Who will help facilities with follow-up testing?
Facilities should have plans in place to implement follow-up testing if residents or staff within the facility test positive, as outlined in PA-HAN-509. Facilities can coordinate with commercial vendors, including staffing support to conduct the tests, and commercial laboratories authorized by the Commonwealth to conduct SARS-CoV-2 testing. RRHCPs will also be able to assist beginning in July.
How can facilities get assistance in obtaining supplies to conduct the swabbing?
Facilities should first reach out to their laboratory or medical supply vendors to procure sufficient supplies to conduct specimen collection. If normal supply chain procurements are unable to provide sufficient supplies, facilities lacking testing supplies can send an email to ra-dhCOVIDtesting@pa.gov. The facility will receive an autoreply with a link to a form to request support, including supplies, from DOH. The form must be completed in its entirety. Shipments will be based on the quantities available at the time the request is reviewed.
Is there a specific type of swab or test that facilities should be using? Does one type of swab have a higher or lower error rate then the other?
Viral testing (i.e., RT-PCR) should be used to inform additional actions necessary to keep SARS-CoV-2 out of facilities, detect COVID-19 cases quickly, and stop transmission. Facilities should consult with the laboratory that will be performing the testing as to the appropriate and approved specimen collection methods, which are often either Nasal Pharyngeal (NP) or Anterior Nares (nostril) swab. Both swab types can typically be used; current CDC guidance does not recommend one collection type over another. Testing practices should aim for rapid turn-around times (e.g., less than 48 hours) in order to facilitate effective action. At the current time, antibody test results should not be used to diagnose someone with an active SARS-CoV-2 infection and should not be used to inform infection prevention and control actions.
How can a facility without a clinical staff order testing for staff and residents?
RRHCPs will be established by DHS and available to support facilities without clinical staff beginning in July. RRHCPs will provide the support of clinical staff, who will be able to order, perform, and report the results of the testing. However, if a facility needs to perform universal testing before RRHCPs are operational, they should still complete the survey at ra-dhCOVIDtesting@pa.gov to request assistance from DOH and DHS.
Who gets billed for the COVID-19 test?
The individual's primary health care coverage should be billed for the COVID-19 test. The RRHCP grants specify that the health systems are going to be providing testing support, beginning at the start of July, which could also bill the primary health care coverage or Medicare or Medical assistance. Facilities can also use CARES Act funding distributed by DHS to cover the costs of testing for some of their staff or residents. Each facility's staff should consult with their employer to determine how the test should be paid for and whether there are any particular testing arrangements in place for that facility's staff.
The Health Resources and Services Administration (HRSA) will pay claims for testing for uninsured individuals. Information is available at https://www.hrsa.gov/coviduninsuredclaim/frequently-asked-questions.
The Commonwealth is currently paying for no-cost testing at Walmart (in cooperation with Quest Laboratories, until September 25) and Rite Aid (until at least August 31) to perform free, on-site testing, which may be an option for staff. Any staff who work at a PCH, ALR, of ICF can specify that they work in the health care field (during the pre-screening process) and should have their test covered at no cost. The website for Rite Aid and the website for Walmart (in cooperation with Quest laboratories) is available. There are a total of 19 sites available throughout the state.
How can a DHS-licensed facility that is not mandated by this Order undertake universal testing?
All long-term care facilities licensed by DHS are free to submit their request for testing assistance to ra-dhCOVIDtesting@pa.gov to notify DHS and DOH. However, certain elements of this testing survey may be difficult to complete (such as requirements for an ordering physician). All facilities may contact their licensing program offices for additional help and support, and the RRHCPs will be available to assist all DHS-licensed facilities undertake testing after the RRHC program is operational near the beginning of July.
Who do I contact if I have additional questions?
If you are a facility licensed by OLTL, contact RAemail@example.com. If you are a facility licensed by the ODP, contact RA-PWODPEMRGNCYRSPRQ@pa.gov. If you are a type of facility not mandated to conduct universal testing by the Secretary's Order, please contact your licensing program office or RRHCP after July 1, 2020.