Important Risk Management Information

  COVID-19

Below are categorized answers to risk management questions received from Coverys clients regarding COVID-19. Recommendations will be updated as the situation evolves. For the most up-to-date information, we encourage you to visit the Centers for Disease Control and Prevention (CDC) website and your state public health department for resources specific to your state.
 
  • Behavioral Health
    What guidelines or resources are available for prescribing methadone and buprenorphine during the COVID-19 pandemic? Are there resources for treating substance use disorders?
       
    Is there guidance for providing inpatient psychiatric care during the COVID-19 crisis?

    SAMHSA addresses inpatient, outpatient, and residential treatment options for COVID-19 in Considerations for the Care and Treatment of Mental and Substance Use Disorders in the COVID-19 Epidemic.
     
    What resources are available to deal with patients in an immediate crisis?

    The American Psychiatric Association’s COVID-19 Information Hub includes resources for patients who need immediate assistance. This site also provides resources for psychiatrists, families, hospitalists, primary care practitioners, and healthcare leaders.
     
    Where can I find information on coping with stress?

    The Centers for Disease Control and Prevention provides information on stress and coping during COVID-19. The From Trauma to Mindfulness blog article “Anxiety, Depression and COVID-19: Now’s the Time to Feel Our Feelings – Here’s 8 Ways How to” offers helpful tips on anxiety and depression related to COVID-19.
     
    Are there resources available for developing a virtual grief and loss support group?

    The Hospice Foundation of America’s on-demand webinar How to Develop and Manage Virtual Grief Support Groups was recorded on March 26, 2020, in response to COVID-19.
     
    Is there guidance available for palliative care programs during COVID-19?

    The article “What Should Palliative Care’s Response Be to the COVID-19 Pandemic?” in the Journal of Pain and Symptom Management provides guidance for palliative care programs during COVID-19.
     
    The Hospice & Palliative Nurses Association provides palliative care guidance specific to nursing.
  • Credentialing & Privileging
    Can I use volunteers?

    If there is a need to utilize volunteers, refer to state emergency credentialing guidelines through your licensing board. If you are part of a hospital system, review medical staff bylaws for emergency credentialing procedures.

    Do I need to credential and privilege providers who volunteer to work for temporary or relief purposes?

    Follow your medical staff bylaws for granting disaster privileges to licensed independent practitioners who volunteer to work. Ensure that they have medical malpractice liability coverage.
    • If they have their own coverage, obtain a certificate of insurance and keep it on file.
    • If they do not have their own coverage, contact your agent so that they can be added to your policy.

    Is it OK for providers to practice outside of their specialty?

    Being in a state of emergency does not relieve providers of providing appropriate care. Exercise due diligence to ensure that the providers who are caring for patients are competent. Consider the following:
    • Implement an emergency privileging procedure and skills checklist.
    • Verify competence and document the verification.
    • Get input from the providers regarding what care they are comfortable providing. Do NOT require providers to practice outside their comfort zone or scope of practice.
    • Use providers who are practicing outside their specialty as backup only. Do NOT place them in the position of running a unit or department alone. Have them work as a resource so that they can get a consult or help if needed.
    • Consider items identified on this Scope of Practice Checklist.

    Where can I find additional emergency credentialing information?

    Several organizations have emergency credentialing and privileging resources:

    You may also find the CMS Section 1135 Waivers helpful.
  • Disclaimers/Informed Consent
    Should I have my patients sign a disclaimer making them aware that there is a risk of COVID-19 transmission when they come to the office? Will a disclaimer protect me from liability associated with alleged exposure to COVID-19?

    That there is a risk of COVID-19 exposure in any public setting is common knowledge at this point, and a disclaimer may be superfluous. Practices should be aware of and following current Centers for Disease Control and Prevention (CDC) guidelines to mitigate virus transmission. Practices may wish to communicate this to patients. We urge you to consult with your state medical society, professional organizations, and attorney for their advice. Note, however, that a disclaimer alone may not, in and of itself, protect a practice against all liability in the event of a claim alleging exposure to COVID-19.
     
    Should I have patients sign an informed consent acknowledging that there is a risk of COVID-19 transmission when they come to a healthcare organization? Will an informed consent protect me from liability associated with alleged exposure to COVID-19?

    There is a risk of COVID-19 transmission in any public setting. Below we are providing some sample language that you could consider adding to an informed consent form. We urge you to consult with your state medical society, professional organizations, and attorney for their advice. All entities should be aware of and try to adhere to current CDC guidelines to mitigate transmission of the virus. Using a specific informed consent may not, in and of itself, protect a practice against any liability in event of a claim alleging exposure to COVID-19.
     
    Does Coverys have sample language that addresses the risk of contracting COVID-19?

    Below is sample language:
     
    I have been informed that I may contract the COVID-19 virus associated with the current pandemic and that a physician may order COVID-19 screening. All results will be confidentially reported to my physician and to any entities as required by law. I have the right to refuse testing and know that such refusal may result in postponing or cancelling procedures recommended by my health providers. If my test results confirm I have COVID-19, I will be informed and given education.
     
    Prior to using any standard language in an informed consent form, consult your attorney.
     
    How should I document patient consent to treatment during the COVID-19 pandemic?

    Many practitioners believe obtaining a signed informed consent is the best way to protect against liability resulting from risks associated with medical care and treatment, including invasive procedures and surgery. A signed informed consent is a way to demonstrate patient understanding of the benefits, risks, and alternatives to more invasive procedures. In cases involving a lack of informed consent, some patients allege they did not understand the risks of a procedure when they signed an informed consent form.  
     
    Educating patients about risks, benefits, and alternatives helps them to understand what to expect before they consent to treatment of any kind. Documenting this education in the medical record not only provides a record of the patient’s care, it also helps protect you in the event of a medical professional liability claim. The following documentation practices may protect you:
    • Document the informed consent discussion with the patient in the medical record.
    • Document the patient’s choice to cancel or reschedule because of COVID-19 exposure risk as an informed refusal in the medical record.
    • Document all information and education provided to the patient about steps you will take to minimize spread of infection from COVID-19, including cleaning protocols, personal protective equipment (PPE) use, physical distancing requirements, and efforts to minimize unnecessary exposures to unessential staff, other patients, or visitors.
    • Document the use of any educational resources from federal, state, and local agencies providing guidance on COVID-19 risks and requirements.
    • Document your efforts to educate the patient on the responsibilities of both the practice and the patient and the patient’s willingness to adhere to them.
     
    I am starting to reschedule postponed procedures. Do I need to have new informed consent discussions with patients?

    Logistically, an informed consent discussion occurs between the practitioner and patient when making a decision on whether or not to schedule a procedure. These discussions may have occurred prior to the current pandemic, and you may not have originally discussed the risks related to COVID-19 exposure.

    Further, the patient’s health status may have changed during the delay. A recent history and physical (H&P) completed within 30 days of a procedure is a Centers for Medicare and Medicaid Services (CMS) requirement for performing a procedure.

    To determine whether or not a new informed consent discussion is warranted:
    • Determine if risks related to COVID-19 exposure were included in the original informed consent discussion.
    • Review the patient’s current (within 30 days) H&P to determine if there has been a change in health status that could impact the risks, benefits, and alternatives of the procedure.

    Document your review and decision in the patient’s medical record.
  • Documentation
    What documentation tips can you offer during these unprecedented times?

    Adherence to good documentation practices is essential to patient safety and allows healthcare providers to communicate effectively. Reinforce the following practices with providers and staff:
    • Document all communications with patients, regardless of modality, in the medical record. Include the communication of both abnormal and normal test results. When test results require a follow-up action, document the communication of this action and any additional recommendations.
    • Clearly document your clinical decision-making.
    • Document any limitations to your ability to fully assess the patient and what you did based on that. For example:
      • “The exam was limited due to the patient’s need to self-quarantine for COVID-19 symptoms. The patient was examined virtually in a private area. The patient had partial ROM and increased pain. She was instructed to elevate the area, continue with OTC pain medications, and check in with me tomorrow.”
    • If an encounter is conducted virtually, be sure to document not only the encounter but any sites that were linked, the mode of service delivery or technology used, any technical difficulties, and all patient-related electronic communications such as lab/test results. The American Telemedicine Association offers standardized forms that can help providers achieve compliance with documentation.

    Do you have any recommendations for timeline documentation to mitigate liability from COVID-19 claims?

    How individual organizations respond to the COVID-19 pandemic varies considerably. Multiple factors influence the response. Some of these factors include where you are located, whether or not you experienced a surge, the resources available to you, and when testing became available to you. Given the rapid pace of change and fluctuating mandates/guidance from federal, state, and local agencies, it may be difficult in the future to recollect exactly what you implemented to prevent exposure to COVID-19 and when you implemented it.
    • Consider creating a master timeline of all critical dates and any corresponding documentation. Include:
      • First COVID-19 case diagnosed at facility.
      • Critical communications to staff members and patients.
      • Critical communications or guidance released from federal, state, and local agencies.
      • Federal, state, and local closures and reopenings.
      • All COVID-19 testing.
      • All equipment, capacity, and patient care issues encountered.
      • All staffing changes.
      • The COVID-19 screening questions asked.
      • The COVID-19 precautions implemented.
    • Be sure to maintain any corresponding documentation referenced in the timeline.
     
    Coverys developed a sample COVID-19 Timeline that you may find helpful.
  • Emergent, Urgent & Nonemergent Care Decisions
    Should I cancel non-urgent outpatient visits?

    Consider rescheduling all routine non-urgent visits, such as annual physicals or routine dental cleanings. Reach out to your local health department or the CDC for further guidance on duration. Ensure routine visits have been rescheduled or a system is in place to follow up on these patients.

    Is there any guidance on what constitutes emergent or urgent dental care?

    The American Dental Association released guidance on dental emergencies and nonemergency care. The ADA cautions dentists to use their own professional judgment to determine a patient’s need for emergent or urgent care.

    How should I handle patient requests for a sick visit?

    Clinicians should use clinical judgement to determine whether a patient has symptoms consistent with COVID-19 and whether the patient should be tested based on current CDC guidelines. Relevant questions to ask include whether the patient has had a known exposure to someone diagnosed with COVID-19, and/or if they have a fever, cough, or difficulty breathing. More info: evaluation and laboratory testing for patients with COVID-19.

    Is there any triage guidance for nonemergent surgical procedures? When should a decision be made? Who should be involved in deciding to proceed or postpone surgery?

    The American College of Surgeons (ACS) released guidance on triage for nonemergent surgical procedures. The ACS and the American Society of Anesthesiologists recommend that decisions be made on a daily basis, no later than the day before surgery, by a leadership team representing surgery, anesthesiology, and nursing.

    My state has executed an executive order to NOT perform non-urgent testing. My specialty depends on some testing that the state considers non-urgent for medication management. Any suggestions for reducing risks in these difficult times? 

    Check your specialty society to see if they have any guidance on deferring non-urgent testing. From a risk management perspective, it’s important for practitioners to continue to monitor their patients who must defer non-urgent testing, especially if the testing impacts medication management. Given that it is unknown when you will be able to schedule deferred non-urgent tests, set a frequency to check in with patients. Determine their current clinical status. Has anything changed that would require urgent testing? Document this assessment and whether or not the test is still considered non-urgent and therefore must continue to be deferred due to the current state executive order. 
  • EMTALA/Alternative Sites/Surge Facilities
    Can patients be screened at an alternative testing site that is on an off-campus hospital location to prevent the spread of COVID-19?

    CMS has addressed EMTALA within the COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers.

    CMS is waiving the enforcement section 1867 of EMTALA to allow hospitals, psychiatric hospitals, and critical access hospitals to screen patients at a location off-site from the facility’s campus to prevent the spread of COVID-19 as long as it is consistent with the respective state’s emergency or pandemic plan. Before implementing an alternative testing site, check your state’s emergency or pandemic plan.

    Our policyholders may contact Coverys Underwriting regarding alternative testing site coverage questions at coviduw@coverys.com.

    Can suspected COVID-19 patients be redirected from the ED for an off-campus medical screening examination (MSE)?

    The CMS waiver gives hospitals flexibility regarding the management of emergency department COVID-19 screening and treatment resources. With this waiver, a hospital is permitted to redirect patients seeking COVID-19 screening to an alternative site, even off campus, to conduct an MSE there. This waiver only allows for redirection or transfer to deal with the COVID-19 pandemic. Hospitals should not otherwise take actions inconsistent with EMTALA. In addition, the waiver expressly states that it does not apply to any action taken that discriminates among individuals on the basis of their source of payment or their ability to pay.

    The facility is at or overcapacity or anticipates being there shortly. Can “surge facilities” be used and what should be considered?

    CMS is waiving the physical environment requirements (42 CFR 482.41) to allow hospitals to use nonhospital buildings such as hotels, dorms, and ambulatory surgery centers for patient care and quarantine sites. The utilization of these facilities DOES require state approval. CMS is also waiving the provider-based rules (42 CFR 413.65) to allow hospitals to operate any location meeting the conditions of participation as hospital locations.

    If considering using surge facilities, numerous waivers apply to reduce burdens at the expanded alternative site locations, which are described in the waivers as “surge capacity sites” and surge facilities. Check the CMS waivers and your state’s requirements. For example, your state may require inspection by the fire marshal prior to occupying a surge facility. In addition, the CDC offers alternate care sites and isolation sites guidance.

    Our policyholders may contact Coverys Underwriting regarding surge facility coverage questions at coviduw@coverys.com.
  • Ethics and the Allocation of Vital Resources (Human, Space, and Equipment)
    Do you have any guidance on the ethical issues related to allocation of resources?

    The allocation of vital resources in healthcare is a worst-case scenario for all involved and should be approached with thoughtfulness, consistency, and equity. Four key considerations when developing a policy or approach to allocation or rationing of testing and care include: (1) equal opportunity and access to care, (2) consistent methodology to utilizing resources, (3) a communication strategy, and (4) how and when to stop treatment.
  • Finances
    What resources are available to our organizations/facilities to help us with financial struggles during this pandemic?

    On March 27, 2020, President Trump signed the Coronavirus Aid, Relief, and Economic Security (CARES) Act into law. The CARES Act has been enacted as a direct response to the COVID-19 pandemic and is intended to provide immediate and ongoing economic relief to individuals and businesses affected by the crisis. The CARES Act specifically provides critical resources to assist hospitals and healthcare systems. The following are links to trade group sources and CMS information regarding financial assistance that may be available under the CARES Act:
  • Healthcare Worker Safety & Emotional Wellbeing
    Is there guidance for healthcare worker exposure to COVID-19?

    The CDC offers guidance for healthcare workers who have been exposed to COVID-19. Check with your local health department to determine if they have additional guidance for you to follow.

    CDC guidance for exposure IN a healthcare setting:

    CDC guidance for healthcare worker exposure OUTSIDE of the healthcare setting:
    The CDC also offers:
    When can a healthcare worker return to work after confirmed or suspected COVID-19 infection?

    The CDC has developed Criteria for Return to Work for Healthcare Personnel with Confirmed or Suspected COVID-19 (Interim Guidance). Check with your local health department to determine if they have additional guidance for you to follow.

    In addition, the CDC advises that symptomatic healthcare facility workers are a testing priority.

    How do I have a conversation with a staff member to help assess and support their well-being?

    It is important for managers and supervisors to identify signs of burnout and moral distress in their employees and to address these concerns at the individual level. The institution should also consider establishing proactive wellness programs to mitigate these risks. Coverys’ Burnout and Moral Distress Checklist and Worksheet for Managers can assist the healthcare provider in assessment and discussion and help to develop a plan when these issues are noted. It also provides wellness program recommendations for institutions. 

     
  • Home Visits
    Some patients do NOT have access to telehealth, but have an urgent need for healthcare services. During the COVID-19 pandemic, can practitioners conduct home visits for patients who do NOT have access to telehealth resources? What are the risk management considerations? Are there any home visit resources?
     
    Check with your insurer to see if home visits are covered under your policy. Practitioners with insurance issued by a Coverys company can submit coverage questions related to COVID-19 to coviduw@coverys.com.
     
    Physician house calls were being done in various parts of the country prior to COVID-19. Exclusive of COVID-19, risk management considerations include:
    • Ensure you are following both state and federal regulations regarding home medical visits.
    • Consider the supplies and equipment you will need to assess, treat, and/or monitor the patient.
    • Ensure that equipment is appropriately cleaned after each patient visit.
    • Define who will communicate with the patient to schedule the visit and who will perform follow-up as needed.
    • Discuss expectations with patients and ensure they understand the goals and limitations of the home medical visit.
    • Ensure that the visit is documented.
     
    Since COVID-19, there are additional risk management considerations:
    • Preserve PPE by limiting physician home visits to patients who have an urgent need to see a physician and who do NOT have access to telehealth resources.
    • Weigh the risks versus benefits of a physician home visit. While there are risks associated with physician home visits, they may prevent at-risk patients from seeking care at emergency departments and/or physician offices where they may be exposed to COVID-19. 
     
    The American Academy of Home Care Medicine offers resources that may be helpful.
  • Infection Prevention/Personal Protective Equipment
    What do I do if I experience a shortage of hand sanitizer?

    Due to the shortage of alcohol-based hand sanitizers, the FDA has published Policy for Temporary Compounding of Certain Alcohol-Based Hand Sanitizer Products During the Public Health Emergency: Immediately in Effect Guidance for Industry. This policy provides not only specific compounding guidance but labelling instructions.

    What strategies should our facility use to optimize the use of N95 respirators?

    Some essential supplies, such as N95 face masks, are available in limited quantities. In order to optimize the use of these critical supplies, it is important to strategically prioritize use and minimize waste. Follow the suggestions as outlined in Checklist for Healthcare Facilities: Strategies for Optimizing the Supply of N95 Respirators during the COVID-19 Response.

    Are there ways to limit exposure in the office setting?

    Managing patient flow and good infection control practices in the office setting are essential in order to minimize exposure. Consider implementing the following:
    • Post signs at designated entry points asking patients to call the office before entering if they do not have a prescheduled appointment.
    • Explore the option of using telehealth to communicate with patients. According to The Office for Civil Rights (OCR) at the Department of Health and Human Services (HHS), a covered healthcare provider can use any available nonpublic facing remote audio or video communication products to communicate with patients during the COVID-19 nationwide public health emergency. See the OCR and HHS notice. Consult your state health department for further guidance as well.
      • Federal and state telemedicine-related licensure requirements are evolving rapidly during this crisis, and it is important for providers to be aware of their own licensure circumstances and requirements for practicing in other states.
      • View a Telemedicine Self-Assessment Questionnaire – Sample 
    • Have masks available at the entry for patients with respiratory illnesses. Include signage showing appropriate “donning and doffing” methods so patients wear their masks appropriately. Include pictures with the instructions so all can understand the procedure.
    • Ensure an adequate amount of hand sanitizers is available. Due to the shortage of alcohol-based hand sanitizers, the FDA has published Policy for Temporary Compounding of Certain Alcohol-Based Hand Sanitizer Products During the Public Health Emergency: Immediately in Effect Guidance for Industry.
    • Ensure that frequently touched areas are disinfected often. See the list of disinfectants that meet criteria for use against SARS-CoV-2. Provide “no touch” receptacles for tissues.
    • Develop a plan to minimize exposure when assessing and testing symptomatic patients. Follow the CDC guidelines.
      • If alternative testing locations outside of the office environment are being used (e.g., parking lot, parking garage), develop and implement a process for patient and specimen identification and to track and follow up on test results.
    • Follow proper labeling procedures when obtaining specimens.

    How do I know if my N95 respirator masks are certified by the National Institute for Occupational Safety and Health (NIOSH)?

    N95 respirator masks must be clearly labeled that they are certified by NIOSH to be compliant for use in healthcare. When you receive masks, inspect them to make sure they are NIOSH certified. NIOSH has discovered that some manufacturers have fraudulently distributed counterfeit masks. Indications that a mask may be counterfeit include:
    • It does not have markings.
    • It does not have an approval number on mask or headband.
    • It does not say NIOSH.
    • It has an incorrect spelling of NIOSH.
    • It has decorative coverings.
    • It claims that it is approved for children ─ NIOSH does not certify masks for children.
    • It has ear loops instead of headbands.

    The CDC provides images of counterfeit masks on its website.
     
    The Food and Drug Administration (FDA) has issued emergency use authorizations (EUAs) for PPE and related medical devices, including non-NIOSH-approved disposable filtering facepiece respirators. EUAs allow the use of unapproved medical products to diagnose, treat, or prevent serious life-threatening diseases when government-approved products are not available during an emergency such as a pandemic. You can find FAQs on the EUAs for non-NIOSH-approved respirators during the COVID-19 pandemic on the FDA’s website.
     
    How can I access respirators and PPE if my vendor is out of stock?

    N95 masks or filtering facepiece respirators (FFRs) are in high demand in the healthcare sector because of the COVID-19 pandemic. Many suppliers do not have masks available, and other PPE and supplies are in short supply as well.
     
    Here are some tips for coping with shortages:
    • Refer to the CDC webpage dedicated to NIOSH-Approved N95 Particulate Filtering Facepiece Respirators, where you can find extensive information about surgical N95 masks, a comprehensive table listing NIOSH-approved N95 masks, and an alphabetical list of manufacturers, including contact information.
    • Review this CDC checklist to optimize N95 respirator mask supplies.
    • Research vendors that you might not normally do business with to determine if they have PPE appropriate for your needs.
    • Reach out to government agencies for assistance. As part of the Whole-of-America response, FEMA and HHS are coordinating with other federal departments and agencies to identify medical supply shortages created by COVID-19. FEMA is working with the public and private sector to fill gaps in the supply chain and both the EPA and regional FEMA agencies are involved in distributing PPE to healthcare providers in high-demand areas throughout the country.
    • Consider contacting state and county departments of health, medical societies, elected officials, or national professional organizations for additional support if you continue to experience regional shortages and cannot procure supplies through FEMA or the EPA.
     
    What steps can I take to preserve and decontaminate available respirator masks?

    According to the CDC, “While disposable filtering facepiece respirators (FFRs), like N95s, are not approved for routine decontamination as conventional standards of care, FFR decontamination and reuse may be needed during times of shortage to ensure continued availability.” Because of the ongoing shortages imposed by COVID-19, many practitioners are forced to reuse disposable masks. CDC Strategies to Optimize the Supply of PPE and Equipment offer steps to extend the life of PPE and other equipment. CDC guidelines are also available to help conserve PPE.
     
    Reuse of contaminated disposable FFRs like N95 respirator masks can pose risks for infection spread. Decontamination methods are being used to minimize those risks. The CDC webpage on Decontamination and Reuse of Filtering Facepiece Respirators provides additional guidance for decontamination strategies.
     
    How can I determine the level of risk exposure for my staff and how to protect them?

    The Occupational Safety and Health Administration (OSHA) classifies risk for exposure to SARS-CoV-2 as low, medium, high, and very high. Healthcare workers, unless working remotely or via telemedicine, fall into the high and the very high exposure risk categories.

    According to OSHA 1910.132 - General requirements, employers must do a hazard assessment of their work environment to determine potential exposure risks for staff, document the assessment, and provide the appropriate protection for their staff.
     
    Per CDC guidance:
    • Clerical personnel in the healthcare setting may wear cloth face coverings while at work.
    • Clinical workers may wear cloth face coverings when not engaged in patient care.
    • Clinical workers may switch to respirators or facemasks when PPE is required.
    • Always do hand hygiene after touching your mask.
    • Workers should remove their PPE and put on cloth masks at the end of the shift.
    • Educate staff on how to remove PPE without self-contamination.

    Coverys policyholders can access additional guidance from the Risk Management library on the Coverys Customer Portal.

    Where can I find guidance on infection prevention measures for inpatient psychiatric units?

    The Association for Professionals in Infection Control and Epidemiology (APIC) provides recommendations for infection prevention in inpatient psychiatric units.

     
  • Patient Education & Communication
    Should I have patients sign an acknowledgment that I provided education on COVID-19 transmission before and during an in-person patient visit?

    While it is common knowledge that there is a risk of COVID-19 transmission in any public setting, planning for and preparing patient education is an important part of mitigating the risk of COVID-19 transmission in a healthcare setting. Coverys offers Tips for Educating Patients about COVID-19 and Documenting Patient Education to help you develop your patient education plan.

    To confirm that the patient received COVID-19 education before and during an in-person patient visit, you may consider listing patient education on an acknowledgment form and asking the patient to sign it. Coverys has a sample Patient Education Acknowledgment Form that you may find helpful. 


    What resources are there for understanding COVID-19 testing options?

    There are two types of testing: a viral test to detect a current infection and an antibody test to determine previous infection. The CDC offers guidance on Testing for COVID-19, and the FDA’s Coronavirus Testing Basics describes test differences and limitations.

     
    How can I best address the risks of coronavirus infection with patients?

    Educating patients on the risks associated with COVID-19 requires practitioners to address the following:
    • Known signs and symptoms of the virus and how the virus will affect the patient.
    • All steps the practice is taking to reduce the risk for spread of infection and promote patient safety, including:
      • Assessment of staff for infection.
      • Requirements for masks and handwashing while in the office.
      • Steps to clean the environment and equipment.
    • Specific risk mitigation strategies or steps that will be taken to reduce potential modes of infection transmission associated with each procedure:
      • Bloodborne.
      • Aerosol.
      • Contact spread.
    • Unique risk factors such as immunocompromise or other comorbid diseases that may require additional protective actions.
     
    Patients and staff pass through different environments before arriving in the healthcare setting. It is difficult to determine where they may be exposed to the virus. Even with education and the best preventive protocols in place, there is no way to effectively guarantee the prevention of COVID-19 transmission.
     
    What responsibilities can be expected from patients?

    Both patients and staff will have concerns about becoming infected, but, they also have a responsibility to prevent the spread of infection. When scheduling appointments, let patients know in advance that the office is taking steps to reduce virus transmission, but also outline patient responsibilities and notify them of expectations before they arrive. Expectations may vary by facility, but at a minimum should include:
    1. Screening for infection.
    2. Asking patients and staff to report specific symptoms (e.g., fever, congestion, coughing/sneezing, difficulty breathing, etc.).
    3. Requiring mask use and physical distancing while in the office.
    4. Requiring patient handwashing before assessment and care.

    Addressing expectations with patients beforehand can help save time and reduce the risk for conflicts when they arrive. Coverys offers Tips for Educating Patients about COVID-19 and Documenting Patient Education to help you prepare patients when scheduling appointments.
     
    What resources can I provide to help educate my patients on COVID-19 risks and risk mitigation strategies?

    The CDC has numerous printable resources you can use to provide patient education about COVID-19. Most of these resources are specific to different healthcare settings and patient needs. A few samples of the CDC resources for general patient education on COVID-19 include How to Protect Yourself and Please Read Before Entering.
     
    If our practice prior to the pandemic was to communicate only positive test results directly to the patient by phone or in person, can we continue this same practice with COVID-19 test results?

    The result of any COVID-19 test, whether positive or negative, requires patient-specific education, follow up, and a direct discussion with the patient or caregiver. Consider the following recommendations:
    • Use patient contact as an opportunity to provide the necessary education and address their concerns and anxieties.
    • Evaluate patient symptoms, possible exposures, and living/working situations to recommend next steps.
    • Inform patients that negative results do not guarantee they don’t have the COVID-19 virus or won’t get it in the future and may require additional testing.
    • Document all test results and patient conversations in the medical record as well as other pertinent clinical findings and follow-up recommendations.
    • Follow state and local public health reporting requirements for COVID-19.
    • Provide patient educational resources as needed. Consider using the CDC’s Fact Sheet for Patients.
    • Consider reviewing the American Medical Association’s guidance on Reporting Clinical Test Results. Additional risk management guidance is available for Coverys policyholders in Diagnostic Accuracy: Testing, Tracking and Follow-up in our Customer Portal. 
  • Reopening
    Does Coverys have a resource for reopening an ambulatory practice?
     
    To assist in recovery and reentry, Coverys has developed a COVID-19 Checklist for Reopening Ambulatory Practices.
     
    Our organization has implemented a policy that all outpatients who present to physician offices and outpatient clinics for treatment must wear a mask. We provide a mask if the patient does not have one. What guidance do you have for handling situations where a patient refuses to wear a mask? Can we refuse to see or treat the patient?
     
    The Centers for Disease Control and Prevention recommends wearing cloth face coverings in public settings where other social distancing measures are difficult to maintain. Outpatient offices and clinics fall into this category of public settings. Additionally, The Centers for Medicare and Medicaid Services (CMS) recommends that patients who present for care should wear a store-bought or homemade cloth face covering if they do not already possess surgical masks.
     
    In response to these recommendations, many ambulatory practices have developed policies requiring all patients to wear a mask if there are no medical contraindications preventing it. To mitigate possible confrontational situations:
    • Recognize that patients are often more willing to comply with requirements when they are well-informed.
    • Educate patients prior to their appointments regarding the mask requirement and the reason behind it.
    • Remind patients that providing a safe environment for all is everyone’s responsibility.
    • If a patient refuses to wear a mask and does not have a contraindication, consider postponing the treatment or visit depending on the patient’s clinical presentation or offering a virtual visit as appropriate.
     
    As elective procedure restrictions are being lifted, we are concerned about associated risks with backlogs and delays. What guidance can you provide for resuming elective surgeries?
     

    Does Coverys have a resource for resuming procedures?

    To assist in reentry into the surgical and procedures areas, Coverys has developed a COVID-19 Checklist for Resuming Surgeries and Procedures.
  • Staffing
    I am worried about the stress to my office staff. Do you have any tips?

    Minimizing stress is not only important for the well-being of the provider, but for patient safety as well. When providers are stressed or burned out, they are more likely to disregard policies and procedures that enhance patient safety. Be vigilant to prevent shortcuts and workarounds and ensure staff is supported by:
    • Increasing management walk rounds.
    • Providing morale boosters for providers and staff.
    • Encouraging situational awareness to identify early signs of fatigue.
    • Participating in an employee assistance program, if you have one, as this may benefit them by discussing their anxiety/stress issues and give them coping suggestions.
    • Implementing virtual check-in huddles (daily, biweekly, as needed) with staff working from home to monitor well-being.

    What plans should be in place for staff who work from home?

    In the event social distancing strategies are recommended by state and local health authorities or if employees are exhibiting symptoms, telework should be encouraged. Ensure that you have the IT infrastructure to support multiple teleworkers, and that you have policies and procedures in place that address privacy issues. Consider the following:
    • Identify appropriate staff members and the duties they may complete from home.
    • Ensure that teleworkers use secure computer access for organization and patient information.
    • Reinforce the use of confidentiality and privacy policies and statements.

    For employers: The CDC offers interim guidance for businesses and employers.

    We are experiencing an influx of patients due to COVID-19 and may not have enough nurses to cover the rising need. What are some options for staffing during this emergency?
     
    Due to the COVID-19 pandemic, state boards of nursing are modifying their licensure requirements and scope of practice in order to meet the patient surge. Check with the board of nursing in your state for modifications due to COVID-19.
     
    Here are some useful links to assist your organization in evaluating your options:

    In response to financial challenges encountered from COVID-19, our practice is considering laying off or furloughing practitioners. What guidance can you provide for this situation?
     
    Laying off or furloughing practitioners is a difficult decision being made by a number of practices during the COVID-19 pandemic. A recent Medical Group Management Association survey found that 97% of practices have experienced a negative financial impact directly or indirectly related to COVID-19. Almost half of all practices had furloughed employees. From a risk management perspective, continuity of care for patients is paramount. If you plan to lay off or furlough a practitioner assigned to oversee care for specific patients, consider the following risk management recommendations:
    • Determine who will take care of the practitioner’s patients.
    • Identify any of the practitioner’s patients who have ongoing care or follow-up needs.
    • Implement a care transition process. Ideally, have the furloughed or laid-off practitioner speak to the practitioner who is assuming patient care to provide an update on ongoing care and follow-up needs.
    • Notify patients. If patients are temporarily assigned to another practitioner during the pandemic, let them know whom they can contact with questions about their care. Recognizing that this is a temporary situation, consider using electronic methods to communicate this message. For example, post a message on your website, send a message through the patient portal, and/or leave an outgoing message on your phone.
    • If you know that a laid-off practitioner will NOT rejoin the practice when this crisis resolves, follow your state regulations for patient notification.
  • Telemedicine
    Does Coverys have a sample telemedicine consent form?

    Coverys has two sample telemedicine consent forms:

    The forms were developed using plain language principles. They are intended to be easy to read, understand, and use.

    What other telemedicine resources does Coverys have?

    Coverys also offers the following telemedicine resources:

    Where can I find telepsychiatry resources?
     
    The American Psychiatric Association published:
     
    COVID-19: A guide to making telepsychiatry work presented by Clinical Psychiatry News may be helpful.


    I have an elderly patient who is now quarantined in her daughter’s home in a neighboring state. Can I provide services to her via telepsychiatry?

    CMS issued emergency guidance that allows Medicare patients to receive behavioral health services via telemedicine regardless of their geographic location. State laws vary with respect to licensure requirements for providing telemedicine. Practitioners are responsible for ensuring practice across state lines is allowable under their current licensure.
     
    Are there resources for Medicare coverage and payment of telemedicine services?

    CMS’ Medicare Telemedicine Health Care Provider Fact Sheet contains information on Medicare coverage and payment of virtual services.


Coverys policyholders can log in to Coverys Customer Portal for more risk management guidance, sample tools, and checklists.



 
 Contacts for Coverys Policyholders
   

This information is intended to provide general guidelines for risk management. It is not intended and should not be construed as legal or medical advice. Your organization should add to and modify this tool to address the compliance standards and regulations applicable in your state or organization.

The links included are being provided as a convenience and for informational purposes only; they are not intended and should not be construed as legal or medical advice. Coverys bears no responsibility for the accuracy, legality or content of the external site or for that of subsequent links. Contact the external site for answers to questions regarding its content.