availability) also affects the number of residents for which each NF can provide care. COVID-19 positive residents will increase the staff and resources required to provide care, further limiting the number of residents that a NF can serve. Resident Demographics All NF residents must meet medical necessity to reside in a NF. While all have medical needs, each resident is unique and might require rehabilitation services, minimal supportive care, or significant medical care. Resident conditions will vary physically and mentally, affectingmobility and intellectual capacity. Impact of resident demographics on COVID -19 response: All NF residents require care from medical professionals. NFs may experience staffing shortages as the pandemic continues. Also, the subpopulation of residents with dementia and Alzheimer’s disease are often unable to express when they experience symptoms and could unknowingly (and without staff knowing) spread the virus if infected. This population is also less likely to understand why physical distancing and quarantine are necessary and can present challengingbehaviors when staff attempt to enforce such restrictions. Other subpopulations require specialized medical care, including specialized diets, ventilator care, gastronomy (feeding) tubes, and wound care for pressure sores. These specialized needs require a combination of skilled and non-skilled caregivers. Having COVID-19 infections in a NF will increase the demands on and for staff. NF Staffing Considerations The NF workforce is made up of medical professionals and direct care staff including: registered nurses (RNs), licensed vocational nurses (LVNs), certified nurse aides (CNAs), medication aides, respiratory therapists, NF support staff, and other skilled and non-skilled workers. Rules require NFs to provide nursing services at a ratio of not less than one licensed nurse for every 20 residents, or a minimum of 0.4 licensed-care hours per resident perday. Impact of NF staffing considerations on COVID-19 response: Many NF residents’ daily activities, such as dining, bathing, grooming and ambulating, require partial or total assistance from NF staff. Caring for someone with COVID-19 requires additional time and resources, including PPE, to maintain infection control and protect other residents and staff. As staff are exposed, become symptomatic or test positive for COVID-19, the available workforce will decline making it even more challenging for NFs to provide care. Additionally, NFs don’t normally have a physician on-site. Typically, there is an RN and several LVNs and CNAs on staff. Staffing shortages resulting from possible Page | 15 exposure could lead to NFs refusing to admit residents because they cannot provide care. It is also common for NF staff to work in more than one NF, so if an employee is exposed, it is likely he or she will expose residents and staff in more than one NF, making it difficult to contain spread. A NF should follow CDC guidance on how to mitigate Staff Shortages. Visitors During routine NF operations, visitors including family members, volunteers, consultants, external providers, and contractors regularly enter facilities. Many perform services essential for NF function, or in the case of service providers such as hospice and dialysis staff, they provide services critical to resident care. HHSC and CMS have updated visitation requirements and guidance throughout the pandemic. Please read the most recent version of the QSO 20-39-Revised for more information. Impact of visitors on COVID-19 response: Despite efforts to screen visitors prior to allowing them to enter the NF, every person allowed inside the building increases the risk of infection. Some people will present as asymptomatic during screening but will have COVID-19 and unknowingly spread the virus. Some will choose not to get vaccinated. Some visitors will not follow standard precautions such as proper hand-washing, use of hand sanitizer, use recommended or required PPE, isolation protocols, and limiting the number of areas in the building that they access – all of which increases the risk of infection for residents andstaff. Visitors, residents, and resident representatives should be made aware of the potential risk of visiting and necessary precautions related to COVID-19 in order to visit the resident. Page | 16 6.To Do’s for Nursing Facilities: • Review resources listed under List of Referenced Resources • Read the CDC’s LTC Webinar Series • Read CMS blanket (1135) waivers o Note: Update from QSO 20-34-NH released 06/25/2020 - The blanket waiver for reporting staffing data has been lifted. Also, all facilities are required to resume submitting staffing data through the Payroll-Based Journal system. o [Update from QSO-22-15-NH released 04/07/20222020 – Read QSO 22-15 for more information on which Emergency Declaration Blanket Waivers have been lifted.] o Note: [Temporary walls or barriers are not required and the waiver permitting temporary walls or barriers ended on 06/06/2022.] • Read QSO 20-39 Revised detailing nursing home visitation, revised [03/10/2022]. • Read QSO 20-38 Revised for testing requirements, revised [03/10/2022]. • Read Emergency Rules for COVID-19 Mitigation updated [3/28/2022]. • Comply with all CMS and CDC guidance related to infection control. (NFs need to frequently monitor CDC and CMS guidance, as