To Skill or Not to Skill: Waivers and COVID-19

As a result of COVID-19, CMS announced under section 1812(f) of the Social Security Act to waive the 3-day hospitalization coverage requirement for a skilled nursing facility stay effective as of 3/1/2020. This waiver allows for temporary emergency coverage for SNF services without the previously required qualifying hospital stay, and it also is directed towards those residents who have experienced dislocations and/or are otherwise affected by COVID-19 emergency. This waiver targets those residents who were either evacuated from a nursing home in an emergency area, discharged from a hospital in order to provide care for more seriously ill patients, and/or needed SNF care as a result of the emergency.  With this new waiver, a skilled nursing facility can complete the following:

  • Skill residents directly from the community (no hospitalization required)
  • Skill current long term residents
  • No hospital transfer is required at all
  • No 60 day break required for residents who have exhausted and still need daily skilled nursing care

Learn more about the CMS Waiver guidelines by reading the full report.

Many providers have expressed some concerns and/or questions regarding the use of waivers especially when it comes to current long-term care residents and their ability to qualify as skill in place.  There are some important questions to consider when trying to decide whether or not a resident would qualify under this waiver which include the following:

  1. Does the resident meet the skilled criteria for care?
  2. Has the resident’s care been impacted as a result of COVID-19?
  3. Does the direct care staff have the competencies in place to care for this resident?

Before determining the COVID-19 impact, the first question has to be whether or not the resident requires skilled services. To assist with this question, It is important to go back and revisit what qualifies as skilled care which has NOT changed with the waiver.  For skilled services, one of the following must be met:

  • 7 days a week for nursing services and/or
  • 5-7 days per week for therapy

The coverage categories for skilled care include:

  • Skilled therapy
  • Skilled nursing
  • Observation and Assessment
  • Coordination or care plan
  • Teaching and training

If the resident does not meet the above criteria for skilled services, the resident cannot be skilled. It is important to remember that a resident may still be skilled for nursing without any therapy services. While this does not happen as frequently, it can still be completed.

Once the resident has been determined to require skilled services, the  second question has to do with the portion of the waiver that states that it only applies to those beneficiaries “who experience dislocations or are otherwise affected by the emergency”. This may appear confusing at first when trying to decide which residents would qualify as “skill in place”, but it is important to remember the primary reason for the waiver which is COVID-19.  As long as you keep this in mind, it will help provide some assistance when determining which residents may qualify for the waiver.

For example,  If a physician decides to treat a resident in house for a change in condition, like acute Pneumonia or COPD exacerbation, instead of sending that resident to the hospital where there is a high risk of exposure to COVID-19, then that resident may qualify as a “skill in place”.  The physician, as well as the care team, must provide the necessary documentation regarding the change in condition as well as the reason why the resident qualified as a “skill in place” instead of transferring to the hospital.

Finally, the last question has to do with the competencies of the care staff. In the above example, the resident would only qualify as skill in place if the direct care staff had the competencies in place to care for the resident whether it be IV’s, etc. If the resident’s condition were to deteriorate and an intervention was needed that the staff were not competent in, then the resident would require a transfer to a higher level of care. During this time, it is important to go back and revisit your Facility-Wide Assessment and determine what resident populations, diagnoses, and conditions are the direct staff competent in and able to care for.  Does the Facility-Wide Assessment need to be updated with additional education, training, and competencies to care for higher acuity residents?

If you have additional questions and/or concerns, Synergy Care Inc., in affiliation with Broussard Healthcare Consulting, is here to help provide the additional support if needed for your organization amidst the COVID-19 pandemic.

For more information about how Synergy Care Inc. and/or Broussard Healthcare Consulting can help, please contact or check out our dedicated COVID-19 resource page at or our Resource Hub at