APTA issued this guidance on November 5:

The U.S. Centers for Medicare & Medicaid Services and the Occupational Safety and Health Administration have released their expansive new rules on coronavirus vaccines. The CMS rule, which essentially mandates vaccination with limited exceptions, applies to an estimated 76,000 health care facilities and 17 million workers, while OSHA's rule requiring vaccination or weekly testing is focused on all entities with 100 or more employees. Both rules officially went into effect on Nov. 5, with full compliance expected by Jan. 4, 2022.

What does it all mean for PTs and PTAs? Our latest APTA Practice Advisory provides an in-depth look at the CMS rule to help members navigate the requirements. It's highly recommended reading, but for a quick overview, here are six things you should know about the new rules right now.

1. If you work for just about any health care facility, the CMS rule probably applies to you.
The CMS rule requires vaccination for staff associated with any facility regulated by Medicare conditions of participation or conditions for coverage. That's a large swath that includes everything from nursing homes to ambulatory surgical centers to clinics, rehabilitation agencies, and public health agencies as providers of outpatient physical therapy and speech-language pathology services (see the APTA Practice Advisory for a detailed list). And it applies to not just health care providers, but to all current and future staff including students, trainees, and volunteers, as well as anyone who provides services under contracts or other arrangements with the facility.

2. The CMS rule doesn't apply to private physical therapy practices.
The line between who does and doesn't have to follow the new rule is drawn around the Medicare Conditions of Participation. Since private practices aren't subject to those conditions, they are not addressed in the new rule.

3. First shots need to be received by Dec. 5, and the second before Jan. 4.
The CMS rule now in place has two compliance phases. At phase one, effective Dec. 5, all employees must have received their first vaccine dose or been granted a formal exemption (more on that below), and facilities must have policies and procedures in place for tracking compliance. Phase two begins on Jan. 4 — that's the deadline for all employees to be fully vaccinated. Employees who are fewer than 14 days from their second shot by then will need to take additional safety precautions until those days are up.

4. There are (limited) exemptions.
If you work 100% remotely, you aren't subject to the CMS requirements. The rule also carves out the potential for exceptions based on medical conditions and religious beliefs. Facilities are permitted to develop their own policies and procedures for making exception determinations, but they must follow applicable federal law, and in the case of medical exemptions they must document the specific contraindications and include a statement from a health care practitioner affirming the need for an exemption. The exempted employees must in turn receive accommodations in line with Equal Employment Opportunity Commission guidelines.

5. The rule has teeth.
Facilities need to take the new rule seriously. For nursing homes, home health agencies, and hospice the ramifications of noncompliance include monetary penalties, denial of payment, and even termination from the Medicare and Medicaid program as a final measure. The remedy for noncompliance among hospitals and certain other acute and continuing care providers is termination. At the same time, CMS says its goal is to bring health care facilities into compliance, and that termination would be a last resort. For more detail, check out the APTA Practice Advisory.

6. If the CMS rule doesn't apply to you, the OSHA rule might.
Although the vast majority of PTs and PTAs affected by the new rules are subject to the CMS version, it's also possible that some may be required to follow the new OSHA requirements. That rule, which applies to employers with 100 or more employees, takes a bit less stringent approach than CMS does, requiring either a full course of vaccine or weekly COVID-19 testing. The vaccine will be supplied to employees free of charge, but employers aren't required to pay for either testing or masks, and could pass along these costs to their nonvaccinated employees. Check out the entire OSHA rule.

Important note:  The OSHA Emergency Temporary Standard (ETS) referenced below MAY or MAY NOT apply to non-hospital healthcare settings.  Please review this flow chart to determine whether or not the ETS applies to your setting.

If the ETS does not apply all should keep current MDHHS recommendations in consideration.  

OSHA Emergency Temporary Rule:  June 22, 2021:  Masks and other precautions are still necessary in healthcare settings.  August update continues to recommend special consideration for certain health care settings.    

Under the latest version of the MIOSHA Emergency Rules, the state’s Workplace Safety Rules are in line with the OSHA Standards. Specifically, MIOSHA’s Emergency Rules are adopted from Subpart U in the OSHA Standards. Subpart U is the COVID-19 Emergency Temporary Standard and provides standards that healthcare settings must follow. Under the latest rules, only healthcare settings have certain protocols and standards to follow. All other sectors and workplaces are encouraged to follow CDC and OSHA guidelines. The updated rules are effective today and are set to expire on December 22, 2021.

To view the latest MIOSHA Emergency Rules, please click here. To view Subpart U from the OSHA Standards, please click here. To view a press release on the new MIOSHA rules, please click here.

View the OHSA requirements here: https://www.osha.gov/coronavirus/ets   APTA additional guidance:  https://www.apta.org/news/2021/06/14/osha-covid-rules

MDHHS updated guidance effective June 22 which states:  Healthcare Facilities, such as hospitals, ambulatory care settings and surgical centers - As of now CDC healthcare guidance remains unchanged. Facilities should continue to follow CDC  guidance. https://www.michigan.gov/documents/coronavirus/MDHHS_Face_Mask_Recommendations_5.20.21_725941_7.pdf

CDC Guidance from February 2021 remains in effect for health care settings: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html

CDC Guidance:

Implement Telehealth and Nurse-Directed Triage Protocols

• Continue to use telehealth strategies to reduce the risk of SARS-CoV-2 transmission in healthcare settings while maintaining high quality patient care.
• When scheduling appointments for routine medical care (e.g., annual physical, elective surgery):
  • Advise patients that they should put on their own well-fitting form of source control (see Implement Universal Source Control Measures for more details) before entering the facility.
  • Instruct patients to call ahead and discuss the need to reschedule their appointment if they have symptoms of COVID-19 within the 10 days prior to their appointment, if they have been diagnosed with SARS-CoV-2 infection within the 10 days prior to their appointment, or if they have had close contact with someone with suspected or confirmed SARS-CoV-2 infection within 14 days prior to their scheduled appointment.

• When scheduling appointments for patients requesting evaluation for possible SARS-CoV-2 infection, use nurse-directed triage protocols to determine if an appointment is necessary or if the patient can be managed from home.
  • If the patient must come in for an appointment, instruct them (or their responsible party if they are unable to communicate) to take appropriate preventive actions (e.g., follow triage procedures, put on their own well-fitting form of source control before entry and throughout their visit or, if a well-fitting form of source control cannot be tolerated, hold a tissue against their mouth and nose to contain respiratory secretions) and immediately inform triage personnel upon arrival (e.g., call from car) so they can be placed in an examination room.

Screen and Triage Everyone Entering a Healthcare Facility for Signs and Symptoms of COVID-19

Although screening for symptoms will not identify asymptomatic or pre-symptomatic individuals with SARS-CoV-2 infection, symptom screening remains an important strategy to identify those who could have COVID-19 so appropriate precautions can be implemented.

• Take steps to ensure that everyone adheres to source control measures and hand hygiene practices while in a healthcare facility
  • Post visual alerts (e.g., signs, posters pdf icon[572 KB, 1 page]) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) to provide instructions (in appropriate languages) about wearing a well-fitting form of source control and how and when to perform hand hygiene.
  • Provide supplies for respiratory hygiene and cough etiquette, including alcohol-based hand sanitizer (ABHS) with 60-95% alcohol, tissues, and no-touch receptacles for disposal, at healthcare facility entrances, waiting rooms, and patient check-ins.
• Limit and monitor points of entry to the facility.
• Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19,  or exposure to others with suspected or confirmed SARS-CoV-2 infection and that they are practicing source control.
  • Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which, prior to arrival at the facility, people report absence of fever and symptoms of COVID-19, absence of a diagnosis of SARS-CoV-2 infection in the prior 10 days, and confirm they have not been exposed to others with SARS-CoV-2 infection during the prior 14 days.
    • Fever can be either measured temperature ≥100.0°F or subjective fever. People might not notice symptoms of fever at the lower temperature threshold that is used for those entering a healthcare setting, so they should be encouraged to actively take their temperature at home or have their temperature taken upon arrival.
    • Obtaining reliable temperature readings is affected by multiple factors, including:
      • The ambient environment in which the temperature is measured: If the environment is extremely hot or cold, body temperature readings may be affected, regardless of the temperature-taking device that is used.
      • Proper calibration of the thermometers per manufacturer standards: Improper calibration can lead to incorrect temperature readings.
      • Proper usage and reading of the thermometers: Non-contact infrared thermometers frequently used for health screening must be held at an established distance from the temporal artery in the forehead to take the temperature correctly. Holding the device too far from or too close to the temporal artery affects the reading.
• Properly manage anyone with suspected or confirmed SARS-CoV-2 infection or who has had contact with someone with suspected or confirmed SARS-CoV-2 infection:
  • Healthcare personnel (HCP) should be excluded from work and should notify occupational health services to arrange for further evaluation.
  • Visitors should be restricted from entering the facility and be referred for proper evaluation.
• Patients should be isolated in an examination room with the door closed.
• If an examination room is not immediately available, such patients should not wait among other patients seeking care.
  • Identify a separate, well-ventilated space that allows waiting patients to be separated by 6 or more feet, with easy access to respiratory hygiene supplies.
  • In some settings, patients might opt to wait in a personal vehicle or outside the healthcare facility where they can be contacted by mobile phone when it is their turn to be evaluated.
  • Depending on the level of transmission in the community, facilities might also consider designating a separate area at the facility (e.g., an ancillary building or temporary structure) or nearby location as an evaluation area where patients with symptoms of COVID-19 can seek evaluation and care.

Re-evaluate admitted patients for signs and symptoms of COVID-19

Screening for fever and symptoms should also be incorporated into daily assessments of all admitted patients. All fevers and symptoms consistent with COVID-19 among admitted patients should be properly managed and evaluated (e.g., place any patient with unexplained fever or symptoms of COVID-19 on appropriate Transmission-Based Precautions and evaluate).

Implement Universal Source Control Measures

Source control refers to use of well-fitting cloth masks, facemasks, or respirators to cover a person’s mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. In addition to providing source control, these devices also offer varying levels of protection for the wearer against exposure to infectious droplets and particles produced by infected people. Ensuring a proper fit is important to optimize both the source control and protection offered. Because of the potential for asymptomatic and pre-symptomatic transmission, source control measures are recommended for everyone in a healthcare facility, even if they do not have symptoms of COVID-19.

• Patients and visitors should wear their own well-fitting form of source control upon arrival to and throughout their stay in the facility. If they do not bring their own, they should be offered an option that is equivalent to what is recommended for people in the community
  • Patients may remove their source control when in their rooms but should put it back on when around others (e.g., when visitors enter their room) or leaving their room.
  • Cloth masks, facemasks and respirators should not be placed on young children under age 2, anyone who cannot wear one safely, such as someone who has a disability or an underlying medical condition that precludes wearing a mask safely, or anyone who is unconscious, incapacitated or otherwise unable to remove their cloth mask, facemask or respirator without assistance.
  • Visitors who are not able to wear source control should be encouraged to use alternatives to on-site visits with patients (e.g., telephone or internet communication), particularly if the patient is at increased risk for severe illness from SARS-CoV-2 infection.
• For guidance on recommended source control for HCP, refer to Implement Universal Use of Personal Protective Equipment below.
  • HCP should wear well-fitting source control at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers.
  • To reduce the number of times HCP must touch their face and potential risk for self-contamination, when used for source control, HCP should consider continuing to wear the same respirator or well-fitting facemask (extended use) throughout their entire work shift.
  • HCP should remove their respirator or facemask, perform hand hygiene, and put on their community source control when leaving the facility at the end of their shift.
• Educate patients, visitors, and HCP about the importance of performing hand hygiene, including immediately before and after any contact with their cloth mask, facemask, or respirator.

Encourage Physical Distancing

Healthcare delivery requires close physical contact between patients and HCP. However, when possible, physical distancing (maintaining at least 6 feet between people) is an important strategy to prevent SARS-CoV-2 transmission.

Examples of how physical distancing can be implemented for patients include:

• Limiting visitors to the facility to those essential for the patient’s physical or emotional well-being and care (e.g., care partner, parent).
  • Encourage use of alternative mechanisms for patient and visitor interactions such as video-call applications on cell phones or tablets.
• Scheduling appointments to limit the number of patients in waiting rooms, or creating a process so that patients can wait outside or in their vehicle while waiting for their appointment.
• Arranging seating in waiting rooms so patients can sit at least 6 feet apart.
• Modifying in-person group healthcare activities (e.g., group therapy, recreational activities) by implementing virtual methods (e.g., video format for group therapy) or scheduling smaller in-person group sessions while having patients sit at least 6 feet apart.
  • In some circumstances, such as higher levels of community transmission or numbers of patients with COVID-19 being cared for at the facility, and when healthcare-associated transmission is occurring, facilities might cancel in-person group activities in favor of an exclusively virtual format.

For HCP, the potential for exposure to SARS-CoV-2 is not limited to direct patient care interactions. Transmission can also occur through unprotected exposures to asymptomatic or pre-symptomatic co-workers in breakrooms or co-workers or visitors in other common areas. Examples of how physical distancing can be implemented for HCP include:

• Reminding HCP that the potential for exposure to SARS-CoV-2 is not limited to direct patient care interactions.
• Emphasizing the importance of source control and physical distancing in non-patient care areas.
• Providing family meeting areas where all individuals (e.g., visitors, HCP) can remain at least 6 feet apart from each other.
• Designating areas and staggered schedules for HCP to take breaks, eat, and drink that allow them to remain at least 6 feet apart from each other, especially when they must be unmasked.

Implement Universal Use of Personal Protective Equipment

Transmission from asymptomatic or pre-symptomatic patients with SARS-CoV-2 infection can occur in healthcare settings, particularly in areas with moderate to substantial community transmission.

The fit of the medical device used to cover the wearer’s mouth and nose is a critical factor in the level of source control (preventing exposure of others) and level of the wearer’s exposure to infectious particles. Respirators offer the highest level of both source control and protection against inhalation of infectious particles in the air.  Facemasks that conform to the wearer’s face so that more air moves through the material of the facemask rather than through gaps at the edges are more effective for source control than facemasks with gaps and can also reduce the wearer’s exposure to particles in the air. Improving how a facemask fits can increase the facemask’s effectiveness for decreasing particles emitted from the wearer and to which the wearer is exposed.

PPE recommended for the care of patients with suspected or confirmed SARS-CoV-2 infection is described in Section 2.

HCP working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with SARS-CoV-2 infection. If SARS-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history):

• HCP should follow Standard Precautions (and Transmission-Based Precautions if required based on the suspected diagnosis; for example, use an N95 respirator or equivalent or higher level respirator if the patient is suspected to have tuberculosis).
• Additionally, HCP should use PPE as described below:
  • N95 respirators or equivalent or higher-level respirators should be used for
    • All aerosol-generating procedures (refer to Which procedures are considered aerosol generating procedures in healthcare settings? ) AND
    • All surgical procedures that might pose higher risk for transmission if the patient has COVID-19 (e.g., that generate potentially infectious aerosols or involving anatomic regions where viral loads might be higher, such as the nose and throat, oropharynx, respiratory tract) (refer to Surgical FAQ During the COVID-19 pandemic, are there special considerations for surgical or other procedural settings, including performance of AGPs?).
  • One of the following should be worn by HCP for source control while in the facility and for protection during patient care encounters:
    • An N95 respirator OR
    • A respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering facepiece respirators OR
    • A well-fitting facemask (e.g., selection of a facemask with a nose wire to help the facemask conform to the face; selection of a facemask with ties rather than ear loops; use of a mask fitter; tying the facemask’s ear loops and tucking in the side pleats; fastening the facemask’s ear loops behind the wearer’s headexternal icon; use of a cloth mask over the facemask to help it conform to the wearer’s face)
      • Additional information about strategies to improve fit and filtration, are available in Improve the Fit and Increase the Filtration of Your Mask to Help Stop the Spread of COVID-19. CDC has also created an FAQ addressing use of 2 masks at the same time in a healthcare setting.
      • If implementing new strategies or equipment to improve fit, HCP should receive training on how to safely don and doff their facemask and on the facility protocol for cleaning and disinfecting any reusable equipment (e.g., fitter). HCP should also ensure that any new strategies or equipment do not impede their vision or ability to breathe.
  • Eye protection should be worn during patient care encounters to ensure the eyes are also protected from exposure to respiratory secretions.

HCP working in areas with minimal to no community transmission, should continue to adhere to Standard and Transmission-Based Precautions based on anticipated exposures and suspected or confirmed diagnoses. This might include use of eye protection, an N95 or equivalent or higher-level respirator, as well as other personal protective equipment (PPE). In addition, universal use of a well-fitting facemask for source control is recommended for HCP if not otherwise wearing a respirator.

Consider Performing Targeted SARS-CoV-2 Testing of Patients Without Signs or Symptoms of COVID-19

In addition to the use of universal PPE and source control in healthcare settings, targeted SARS-CoV-2 testing of patients without signs or symptoms of COVID-19 might be used to identify those with asymptomatic or pre-symptomatic SARS-CoV-2 infection and further reduce risk for exposures in some healthcare settings. Depending on guidance from local and state health departments, testing availability, and how rapidly results are available, facilities can consider implementing pre-admission or pre-procedure screening testing with authorized nucleic acid or antigen detection assays for SARS-CoV-2.
Testing results might inform decisions about rescheduling elective procedures or about the need for additional Transmission-Based Precautions when caring for the patient. Limitations of using this testing strategy include obtaining negative results in patients during their incubation period who later become infectious and false negative test results, depending on the test method used.