Resources for Unprecedented Times

  COVID-19

Below are answers to COVID-19 risk management questions from Coverys clients. 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.
 
  • Claims Mitigation & 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.
  • Credentialing & Privileging
    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.
     
  • 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.
  • Healthcare Worker Safety & Emotional Well-being
    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. 

    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.
  • Infection Prevention/Personal Protective Equipment
    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.
  • Maintaining Readiness
    With the ever-changing local, state, and national pandemic landscape and the surge in cases, what resources are there for maintaining readiness?
     
    Each facility and practice is unique and in a different phase of the pandemic continuum. Consider utilizing the following resources to maintain readiness:


     
    Overall Preparedness:

    Hospital and Critical Access Facilities:
    Long-Term Care Facilities:
    Dental Practices:
  • 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. 

    As the COVID-19 pandemic shows no signs of letting up, healthcare workers and patients will be wearing masks for an unforeseen amount of time. Do you have any tips on how to communicate effectively while wearing a mask? How can we engage our patients and ensure we are showing empathy and concern while wearing a mask?

    Mask-wearing presents communication challenges for everyone. Masks muffle sound, making it more difficult to understand speech and some higher-pitched voices. Masks also remove our ability to read lips and see facial expressions, making it more difficult to understand what we’re hearing.

    A recent Harvard Business Review article, How to Build Rapport…While Wearing a Mask, provides the following useful tips:
    • Avoid clear masks unless necessary. Some people find them unsettling, and they tend to fog up.
    • Practice your “mask voice.” Include the following key elements:
      • Pause: Give people opportunities to jump in or respond.
      • Accentuate: Accentuate key phrases and information.
      • Volume: Speak up, but don’t shout.
      • Emotion: Try to make your voice more expressive by conveying positive emotions, such as excitement, awe, gratitude, and sympathy.
    • Practice active listening. Show interest by periodically nodding and making sounds of understanding.
    • Use gestures and body language.
    • Mirror your counterpart. Imitate the body language of the person with whom you are interacting.
    • Smile with your eyes. When you smile, a wrinkling occurs at the outer edges of your eyes.1

    The National Institute on Deafness and Other Communication Disorders has also published 8 Tips for Improving Communication When Wearing a Face Covering:
    • Be aware.
    • Be patient.
    • Be mindful.
    • Be loud and clear.
    • Turn down background volume.
    • Communicate another way.
    • Confirm that your statement is clear.
    • Bring a friend or be a friend.2

    References:

    1. York D. How to build rapport...while wearing a mask. Harvard Business Review website. https://hbr.org/2020/09/how-to-build-rapport-while-wearing-a-mask. Published September 28, 2020. Accessed November 2, 2020.

    2. 8 tips for improving communication while wearing a face covering. National Institute on Deafness and Other Communication Disorders website. https://www.nidcd.nih.gov/sites/default/files/Documents/multimedia/NIDCD_Mask_Infographic_Revised_-_508-073120.pdf.  Accessed November 2, 2020.
  • 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.

    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:
  • 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.
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.