As you are aware, the Centers for Disease Control and Prevention (CDC) is currently recommending social distancing to minimize risk of contracting the disease if COVID-19 is spreading in your community. This is especially important for people who are at higher risk from the disease, including persons age 60 and older and those with chronic health conditions.
This does not mean that persons supported should be restricted from all community activities. It does mean, however, that providers should help persons supported and their families or conservators, as applicable, understand the potential risk of exposure so they can make informed decisions about participation in community activities.
In the event that persons supported or their conservators decide to forego community-based activities in the short-term, DIDD and TennCare want to make sure that options are available to provide supports at home, where the risk of COVID-19 infection is reduced.
As you are aware, there is currently a special needs adjustment (i.e., an additional payment) that providers may be authorized to receive for persons supported who are receiving residential services when the person is not able to participate in community activities for certain reasons (Residential Special Needs Adjustment - Homebound). These reasons include “significantly health compromised,” which is defined as “a chronic health issue, supported by current medical records that restricts the person from leaving their home under certain pre-determined circumstances, including…exposure (geographically) to high incidences of communicable disease etc., that would further compromise the individual’s health and physical well-being.” While this provision would typically apply only to individuals with specifically diagnosed chronic diseases, based on the current COVID-19 pandemic and the State of Emergency declared by Governor Lee, we believe this provision can be reasonably applied to any individual supported in the waiver at this time. TennCare will follow up with CMS to pursue additional authority for this short-term use, if determined to be needed. Please note, this should not be confused with the Residential Special Needs Adjustment that has been in place for several years.
A comparable benefit, called Non-Residential Homebound Support Service, is available to persons in the same circumstances that do not receive residential services.
While both the Residential Special Needs Adjustment - Homebound and the Non-Residential Homebound Support Service typically cannot be billed until the homebound requirement is met—unable to participate in any employment or day service OR to leave the home except for medical treatment or medical appointments and for at no more than 2 hours a day for at least 5 days in the billing period, due to the chronic nature of the threat of exposure to COVID-19, effective Friday, March 13, 2020, the homebound definition shall be met on any day when a person does not participate in employment or community activities.
All other limitations pertaining to this benefit (and other employment and day services, as applicable) shall continue to apply.
In order to make these benefits available, DIDD will be adding the Residential Special Needs Adjustment—Homebound or Non-Residential Homebound Support Service, as applicable, to the cost plan of each person currently receiving any day service for a period of 30 days, effective Friday, March 13, 2020. For persons receiving residential services, Level 4 or Level 6 payment for the Residential Special Needs Adjustment – Homebound will be authorized only when this level of payment is also authorized for Community Participation. The level of reimbursement for Non-Residential Homebound Support Service shall be based on the level of payment currently authorized for Community Participation. The addition of the applicable Homebound service will be made by the Department and will not require submission of an amended ISP at this time.
Again, this is not a mandate by the department to discontinue all community participation; the expectation is, as always, providers should support persons to make informed decisions regarding their choice to participate in community activities.
DIDD and TennCare will reevaluate prior to the end of the 30-day period to determine whether an extension is warranted.
Further Guidance on Homebound:
To follow up on the recent Open Line and guidance from our Central office, please do not send amended ISPs into the regional offices to add the temporary, COVID-19-related Homebound service. As stated, this service will be added, by DIDD, to all current cost plans with an approved Day service. The applicable Homebound service will be effective 3/13/20 for a period of 30 days.
Please note that we will be matching the applicable Homebound service to the provider of residential services or, for those persons who do not have a residential provider, we will assign the applicable Homebound service to his/her current Day service provider. For any exceptional circumstances (ex – person will be getting Homebound from PA provider rather than Day provider,), please email the regional administrative services office directly and we will do our best to get the cost plans adjusted accordingly.
Please be aware that, in order to bill for the homebound services, 6 hours of service must be provided.
Update: Homebound Extension
DIDD will be extending the period in which the Residential Special Needs Adjustment—Homebound or Non-Residential Homebound Support Service, as applicable, is temporarily approved on the cost plan of each person currently receiving any day service. This temporary approval period was originally indicated to be a period of 30-days and began on March 13, 2020. The extension of this period will take effect on April 12, 2020, and will continue through June 10, 2020. Cost plan adjustments for the applicable Homebound service will be made by the Department and will not require submission of an amended ISP at this time. DIDD and TennCare will continue to reevaluate and make adjustments to extend or withdraw these approval dates as the situation with COVID-19 continues to unfold.
DIDD is providing the following guidance to Independent Support Coordinators (ISC) and Self-Determination Case Managers in regard to face-to-face visit requirements and Circle of Support Meetings.
Effective immediately and for the remainder of March and April, DIDD is permitting ISCs and SD Case Managers to conduct visits and Circle of Support Meetings remotely; using phone or video conferencing solutions. When either of these responsibilities are completed in place of a required face-to-face meeting, the ISC or SD Case Manager should document the occurrence in a corresponding service note.
For Individual Support Coordinator and SD Case Manager meetings that require signature sheets, ISCs and CMs should write down people’s names (the name of everyone who participates in the meeting) on the signature sheet. The ISC/CM should sign and date the form and identify somewhere on the signature sheet the phone call was held in lieu of a face-to-face meeting due to COVID 19 precautions.
DIDD has implemented a no visitors policy at the state-run community homes (ICF/IIDs) and is requiring an inobtrusive temperature check of employees before entering the home. Further guidance from TennCare and CMS related to Long Term Care Facilities is below.
Families should be encouraged to utilize electronic means of visitation. Meetings and other appointments that are typically done face-to-face should be done using an electronic means of communication.
Effective March 18th, 2020, DIDD is tracking all COVID-19 testing for persons supported. Reporting requirements shall include the reporting of COVID-19 testing for any person supported. The Reportable Event Form (REF) is required to be completed as soon as possible, but no later than by the following business day. The provider completing the REF shall select “Other Type of Event” and specify “COVID-19 Testing” in the space provided. Details of the person’s status and test results would be expressed in the narrative section. “COVID-19” needs to be included in the subject line of the REF email. All positive test results shall be reported to the Abuse Hotline (1-888-633-1313) as soon as possible but no later than 4 hours of discovery. When test results are received after the initial report of testing, an amended REF with the results is required to be submitted by the following business day.
DIDD is utilizing this hotline because of its availability to receive and respond to calls 24 hours a day. DIDD will not be classifying positive cases of COVID-19 as abuse or neglect, rather this is an effort for providers to have a channel to report any positive cases to the department immediately.
When positive COVID-19 tests are reported to the Department through the 24-hour on-call hotline, we are requesting that names and last four digits of social security numbers for staff that have been exposed to the infected person be provided. The Department will use this information to cross-reference the staff member in the Relias training system to see if there are any other provider agencies the person may work for. Once DIDD has gathered this information a call will be made to any provider agencies the person may work for other than the provider agency that reported the positive test. If you are contacted regarding a staff person who may have been exposed to COVID-19 at another provider agency, please follow the processes in place for your agency.
At this time, investigators will be permitted to conduct direct witness interviews via FaceTime. If an investigator or witness requests a FaceTime interview, the investigator shall provide them this opportunity. As always, it is better to get the details timely so if a witness states that they do not have that capability to conduct a FaceTime interview, note this on the statement form and continue a telephonic interview. As already required, a witness will be asked to review and verify the information provided.
We have also revised in-person response guidance to investigators of abuse, neglect and exploitation to limit exposure to people supported without compromising quality of investigations.
All urgent situations, including adhering to PFH timeframes, should still be communicated to DIDD through the proper channels. DIDD reserves the right to appear in-person for case management, Protection from Harm visit or any other operational procedure if necessary.
The following Operational Guidance and Changes are in effect until April 24, 2020 unless otherwise noted:
Provider Contacts and Meetings
As a response to our continued efforts to minimize community spread in accordance with CDC guidance, DIDD will allow providers to complete home visits by phone or FaceTime until further notice. Supervisory contacts should be made with their staff on the regular schedule (3 times/month for SL and 2 times/month for FMRS) to go over applicable items on the supervisory checklist. Documentation should reflect responses on the form.
In regards to required meetings as dictated by the provider manual (i.e. IMC or Human Rights meetings), these meetings may be conducted either telephonically or through electronic means.
Housing Inspections and Transitions
DIDD has decided to suspend all housing inspections at this time. In addition, transitions are suspended from one residential home to another for people receiving residential services. Exceptions will be reviewed by regional transitions units and granted on a case-by-case basis and only approved for exceptional circumstance. A physical move would impact many internal and external entities and would require that some would have to engage in face-to-face contact. Planned transitions that will be impacted by the inability to complete an initial housing inspection will be prioritized as quickly as possible once inspections resume.
Any outstanding reinspection issues that can be resolved via electronic submission (i.e. FaceTime, email, photos, etc.) should be handled by contacting the appropriate inspector for resolution. Any inspections delayed during this time will not result in any penalty to the provider. You may continue to email the DIDD Inspections mailbox (DIDD.INSPECTIONS@tn.gov) with initial inspection requests as well as any other housing inspections needs. Be sure to copy the appropriate housing inspector on your requests and questions during this time. Contact information is as follows:
Crissonya Phillips, Statewide Director of Residential Services Crissonya.Phillips@tn.gov
Ronnie Taylor, DIDD Housing Inspector, East TN Ronnie.R.Tarlor@tn.gov
Karla Hall, DIDD Housing Inspector, Middle TN Karla.F.Hall@tn.gov
Sandra Clamp, DIDD Housing Inspector, West TN Sandra.Clamp@tn.gov
All provider supports visits will be suspended.
Family Support Program
Family Support programmatic reviews have been suspended through the month of April.
CPR/1st Aid Certifications
DIDD has been getting questions regarding CPR and First Aid certifications expiring and limited classes due to COVID-19. As a result, DIDD has been in touch with the American Heart Association (AHA), American Red Cross (ARC), and American Health and Safety Institute (ASHI/HSI). DIDD will extend the expiration dates for all CPR and First Aid Certifications for 60 days, then reevaluate. If you need further assistance, please contact Karen Chambers (email@example.com).
DIDD has the following information regarding certifications and expiration dates that assisted us in making our decision to extend the expiration dates by 60 days.
• AHA – Certifications recommends that employers and regulatory bodies consider extending recognition of an AHA Provider Card beyond its renewal date, for up to 60 days. However, please know that it is ultimately up to the discretion of employers and regulatory bodies who require current AHA Provider Cards to consider allowing extensions during this time.
• ARC – As of 3/17/2020, is still holding classes, and said to check their web site or your local chapter for schedules.
• ASHI/HIS – Under normal conditions, individuals without current certification may not participate in a Renewal Class. However, during the COVID-19 crisis, HSI will allow individuals with an ASHI, MEDIC First Aid, or EMS Safety certification card expired 90 days or less to participate in a Renewal Class. HSI is not extending the expiration period of a legitimately issued certification card (may not exceed two years from month of class completion). Given the level of disruption COVID-19 is causing, HSI expects regulatory agencies and employers who require emergency care training and certification for licensing or employment to be reasonably lenient about expiration dates. Leniency is the decision of employers and regulators, not HSI.
• Agency Trainers – If you have a trainer at your agency you can still have classes; however, DIDD advises all trainers follow existing recommendations outlined on the World Health Organization (WHO) website and the Centers for Disease Control and Prevention (CDC) recommendations, as well as the guidance of national, state, and local public health authorities, which will have the most up-to-date facts and will provide information on basic protective measures against COVID-19. Each trainer should take into consideration the risks and recommendations associated with the COVID-19 outbreak when making the determination to hold class or not.
On-site Quality Assurance surveys, Fiscal Accountability Reviews (FARs) and Employment and Community First CHOICES (ECF) surveys have been suspended through April 24, 2020.
Regarding ICF/IID surveys, all suspension information has been provided to state-operated and private ICF/IID providers via the CMS memo system which can be accessed at the following links:
Seating and Positioning Clinics:
Seating and Positioning Clinics will suspend clinic appointments. The clinic may continue to provide emergency services to some persons supported on a case-by-case basis. If a person supported has emergency seating and positioning needs, please contact Deborah Poirier at (615) 428-6254 to evaluate whether an exception may be granted. The suspension of services will remain in effect until at least April 24, 2020 at which time it will be determined whether clinic appointments may resume. Once clinic appointments resume, appointments that have been canceled will be rescheduled and new appointments will be scheduled.
Quality Assurance surveys, Fiscal Accountability Reviews (FARs) and Employment and Community First CHOICES (ECF) surveys have been suspended through April 24, 2020.
Regarding surveys for the private ICF/IID facilities, information from CMS has been conveyed earlier to those providers.
Community Providers of Clinical Services
Community providers of clinical services should opt for an electronic means of communication to conduct services whenever possible. Until further notice, documented electronic visits will be billable under the 1915(c) waivers. An exception may occur if all persons in the home are free of COVID-19 symptoms and the concern involves imminent risk that cannot be managed without a face-to-face visit. To determine if persons in the home are free of symptoms or recent exposure, ask questions according to the script entitled Script for Pre-visit Health Questions. An imminent risk is one that outweighs the risk of a COVID-19 infection to the person supported or the staff. If a visit is made, ensure that you follow all CDC guidance for hygiene prior to and throughout the visit.
Medication Administration Classes
- All in-person Regional Office Medication Administration classes will be canceled until further notice.
- Independent and agency medication administration trainers should also cancel/postpone in-person classes. DIDD will allow for quick rescheduling of canceled classes when appropriate.
- Medication administration certifications that expire in March and April 2020 will be extended to May 31st and the need for further extensions will be evaluated every 30 days.
- Medication administration class to be taught via webinar. Current curriculum and 20-hour class time will be required for people needing first-time Medication Administration Certification.
Reminder staff can begin work prior to medication administration training as long as they do not administer medication. As always they can work alongside a certified staff who administers all medication for that home.
Most of the licenses expiring at the end of March and April have already received a licensure survey to complete the renewal process. These licenses will be issued electronically once the associated fees are paid. For licenses which have not received a licensure survey, the current license will be placed in “Extended Status” until such time as surveys can be completed. An extension letter will be emailed to each licensee when a license is placed in “Extended Status”.
Risk Management visits to provider agencies have also been suspended, though auditors are available to make visits for any urgent situations which may arise.
Providers and service coordinators will be in close communication with families to discuss upcoming visits and to make sure services are provided, given everyone involved is comfortable. Below are links provided by the U.S. Department of Education to guide decisions in the days and weeks ahead. You will find guidance on providing services whether at home or in a clinical setting.
- Direct link to guidance for serving children with disabilities (Section B of the document relates specifically to Part C): Questions and Answers on Providing Services to Children with Disabilities During the COVID-19 Outbreak (March 12, 2020)
- Previously issued guidance documents including questions and answers applicable to school closings and distance learning (includes Part C ) Non-Regulatory Guidance on Flexibility and Waivers for Grantees and Program Participants Impacted by Federally Declared Disasters
- The Department’s COVID-19 webpage, which includes information and a number of additional resources: https://www.ed.gov/coronavirus
There is nothing more important than the well-being of our TEIS employees, providers and families. We are monitoring this situation closely with help from the U.S. Centers for Disease Control (CDC), Tennessee Department of Health, as well as other agencies. As the situation evolves, we may revisit these policies.
Please reach out Joan Kennedy at firstname.lastname@example.org if you have any further questions or concerns.
DIDD has received revised guidance from TEMA about provider acquisition of PPE. In coordination with TEMA, DIDD will collect provider PPE requests and submit them for consideration.
It’s important you understand that these supplies are very limited and in extremely high demand. Therefore, DIDD will consolidate the requests from providers, but cannot guarantee any fulfillment of orders. Additionally, DIDD will not be coordinating delivery of requests. All fulfillment of these requests will be at the discretion of Emergency Management Supply Chain priorities. By submitting a request, you are being placed into a queue with all other competing priorities within the state at this time. This by no means guarantees that you will be a recipient or can we promise a projection of when you will receive those supplies.
Please be mindful and responsible in making these requests as supplies are extremely limited. The form to request these supplies can be found here: https://stateoftennessee.formstack.com/forms/supply_request
We do want to make people aware that those who have requested items through the department will receive a receipt confirmation from the TEMA Logistics Unit once DIDD has submitted the request to them. This confirmation is connected to your original DIDD request.
Please note: this receipt is not a guarantee that the request will be fulfilled, just that it has been submitted and placed in line with all other statewide PPE requests. The Emergency Supply Chain Management is still processing requests based on prioritization as determined by regulatory authorities.
The Tennessee Department of Health has issued the following guidance on exposure, healthcare facilities and group settings:
What to Expect of You Were Possibly Exposed to COVID-19
How do I know if I was exposed?
You generally need to be in close contact with a sick person to get infected. Close contact includes:
- Living in the same household as a sick person with COVID-19
- Caring for a sick person with COVID-19
- Being within 6 feet of a sick person with COVID-19 for about 10 minutes or longer
- Being in direct contact with secretions from a sick person with COVID-19 (e.g., being coughed on, kissing, sharing utensils, etc.)
What to Expect After Being Tested for COVID-19 (see attached CaseGuidance.pdf)
- While waiting for results, you should strictly isolate yourself at home.
- Stay in a specific room and away from other people in your home to the extent possible. Use a separate bathroom, if available. Household members can consider staying in a separate location, if available, to decrease their risk of exposure.
- Where possible, ask others such as friends or family, to get food or necessities for you.
- If you must leave home, such as to seek medical care, wear a surgical mask if available.
Guidance for Healthcare Providers Diagnosed with COVID-19
Communicate with your Employer
- Immediately notify all of your employers if you are having symptoms and/or if you are being tested for COVID-19.
- Identify any times that you were at work during the 2 days before you began feeling ill and any days you worked while ill.
- You should strictly isolate yourself at home for at least 7 days after you became ill or until you are feeling well and without a fever (without fever reducing medication) for three consecutive days (whichever is longer).
- If you are asymptomatic, you should self-isolate and not work until for at least 7 days after testing was conducted.
- Stay in a specific room and away from other people in your home to the extent possible. Where possible, ask others such as friends or family, to get food or necessities for you.
Guidance for Healthcare Facilities with a HCP Diagnosed with COVID-19
- Determine all the days the employee worked on or after symptom onset.
- If the employee did not report any symptoms, determine all the days they worked on/after date of COVID-19 testing.
- Identify any patients and other employees who had close contact with the employee. Close contact is defined as spending more than a few minutes within 6 feet of the employee with confirmed COVID-19.
- Patients who have been discharged should be notified and instructed to quarantine for 14 days after their exposure.
- Patients who remain hospitalized should be isolated and placed on Standard, Contact, and Droplet Precautions with Eye Protection for 14 days after their last exposure.
- Consider work exclusion of asymptomatic employees determined to be close contacts of a known COVID-19 case. If this is not possible, the employees who continue to work should wear surgical masks for their entire shift for 14 days after the exposure and should undergo daily symptom and temperature monitoring while continuing to work.
- Employees who become symptomatic during monitoring should be excluded from work.
Guidance for Group Care Settings (see attached GroupCareGuidelines.pdf)
- Prevent the introduction of respiratory germs INTO your facility
- Prevent the spread of respiratory germs WITHIN your facility
- Prevent the spread of respiratory germs AMONG facilities
As you are all aware, the rapid spread of COVID-19 throughout the nation and our communities is presenting new staffing and support challenges for HCBS service providers across Tennessee. Through opportunities presented in the recent waiver language changes, as outlined in Memo 212 and Guidance Pertaining to Relaxed Staffing Requirements in Response to COVID-19 that expanded flexibility regarding staffing standards for the time-limited period where there is a declared Federal or State emergency, the Department of Intellectual and Developmental Disabilities and TennCare are working in collaboration to immediately expand access to Enabling Technology through its Appendix K proposal.
Guidance and Utilization Steps
DIDD Vendor Resources
DIDD’s Clinical Services Team continues to provide resources to assist persons supported, DIDD providers and other stakeholders in better understanding COVID-19 and its impact on the population we support.
Articles Written by Deputy Commissioner Bruce Davis about COVID-19
- Don’t Go Viral
- We’re All a Part of this Community
- Telehealth Now
- COVID-19 Response Plan
- COVID-19 Response Plan Update
All Open Lines and Special Editions since March 13, 2020 (by date)
- March 13, 2020 - Open Line
- March 16, 2020 - Special Edition Open Line
- March 18, 2020 - Special Edition Open Line
- March 19, 2020 - Special Edition Open Line
- March 20, 2020 - Open Line
- March 27, 2020 - Open Line
- March 30, 2020 - Special Edition Open Line
- April 2, 2020 - Special Edition Open Line
- April 3, 2020 - Open Line
- April 6, 2020 - Special Edition Open Line
- April 7, 2020 - Special Edition Open Line
A summary of all guidance issued thus far from CMS can be found here:
DIDD COVID-19 INQUIRIES
DIDD has established an inbox for community and provider inquiries about COVID-19 at DIDD.Covid19@tn.gov. We will work to answer all questions in the inbox as quickly as possible.