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Safer At Home Extended to the end of June!

Monday, June 29, 2020  
Posted by: Rachel Wendt
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Editors Note: This article is being constantly updated as new information is made available. Please continue checking this article for updates.

 

In the last month, our nation and the entire world are coming to terms with the unprecedented health and business impact of Coronavirus. At the CCA, we have never been more acutely aware that many chiropractors operate as solo practitioners or small businesses who may feel more isolated than large group practitioners. 

In addition to providing information updates, the CCA believes it is just as important that we serve as a bridge to remind members that our chiropractic community is strong and that we are here to help in any way we can. The CCA continues to work to stay abreast of developments and to share them with our members.

We have started a new page as we move into the phase "Safer-at-Home" here in Colorado. You can find the old articles by clicking here.

 

On this page:

TABLE OF CONTENTS

The following section is a listing of the many topics covered in this article. Each listing is a link that will take you to that section when clicked. Find the section that pertains to the information you need and click the link to jump to your information directly.

Governor Polis Orders

[4/27/2020] - Safer at home orders
[6/29/2020] - Safer at home and in the Vast, Great Outdoors & Public Health Order 20-28
[5/08/2020] - County Stay at home orders
[6/5/2020] - Interactive Safer At Home Map

Public Health Guidelines

[4/7/2020] - CDC Guidance for Health Care Providers who have been exposed to COVID19
[4/27/2020] - CDC Symptom Updates
[5/6/2020] - Amended Public Health Order 20-28
[4/27/2020] - Appendix E in PHO 20-28
[4/28/2020] - DORA's FAQs regarding the Safer-At-Home Order

Personal Protective Equipment

 [4/28/2020] - Where to find surgical masks and gloves and other PPE

Financial and Business Aid

 [5/6/2020] - Significant Help in CARES act via SBA Forgivable Loans
[UPDATED 5/11/2020] - Provider Relief fund, CARES Act and HHS

Business and Practice Considerations

[5/13/2020] - Considerations fro Expiring Certificates and/or Diplomates
[4/14/2020] - Telehealth
[3/17/2020] - HIPAA reminder regarding COVID-19
[3/17/2020] - X-Ray Regulator Requirements During COVID-19

Scam Warnings

[4/15/2020] - Coronavirus Scams 

Resources and Webinars

[UPDATED 5/13/2020] - All Resources
-Governor Polis Press Releases
-Governor Polis Executive Orders
-CDPHE Public Health Orders
-CDPHE Employee Health Screening Form 
-NCMIC Sample Informed Consent

 

UPDATE SAFER AT HOME [06/04/2020]

[Update 06.29.2020] -

On June 1, 2020, Governor Polis signed Executive Order D2020 091, Safer at Home and in the Vast, Great Outdoors – essentially extending the previous Executive Orders 044 & 079, “Safer at Home”. Public Health Order 20-28 (PHO 20-28) has also been extended through the end of June and the following still applies.

 

On June 19, 2020 the Colorado Department of Public Health & Environment released their 7th amended version of Public Health Order 20-28. This order includes guidance for indoor and outdoor events. THIS ORDER DOES NOT CHANGE ANYTHING FOR THE CHIROPRACTIC OFFICE FOR THE MOMENT.

[Update 6.29.2020] - Executive Order D2020 110 - extends the requirement for critical businesses wearing masks. Remember, chiropractors are considered critical businesses as we are healthcare providers. This Executive Order expires 30 days from June 20, 2020.

Public Health Order 20-28 (PHO 20-28) is also still in effect and requires chiropractors to wear masks. See above where it discusses Appendix E relating specifically to chiropractors and "limited healthcare settings". Find the latest amended version of PHO 20-28 here.

 

Read the full 7th amended PHO 20-28 here.

 

What does that mean for your office? Continue to practice as you have been practicing the last few weeks and the month of May following PHO 20-28 and Appendix E listed in the PHO 20-28.  

We encourage each chiropractor to become familiar with each of these documents listed above as they will impact your individual practices. To assist you in your review, below are a few key highlights of what is still required of chiropractors under Colorado’s “Safer at Home and in the Vast, Great Outdoors” order and Public Health Order 20-28:

  • Overall, all individuals are still encouraged to stay home whenever possible
  • Critical business, including chiropractors, may continue to operate, but are required to comply with the requirements set forth in PHO20-28.  PHO20-28 outlines critical businesses as defined in Appendix F, which states:

1.     Healthcare Operations, which includes: Hospitals, clinics, and walk-in health facilities […]

  • Further, chiropractic care has been identified in section III.K of PHO20-28 which defines limited healthcare settings.
  1.  K. Limited Healthcare Settings means those locations where certain healthcare services are provided, including acupuncture (not related to personal services), athletic training (not related to personal services), audiology services, services by hearing aid providers, chiropractic care, massage therapy (not related to personal services), naturopathic care, occupational therapy services, optometry services, podiatry services, physical therapy, and speech language pathology services. These individual services may only be performed with 10 or fewer people in a single location at a maximum of 50% occupancy for the location, whichever is less, including both employees and patients, e.g. 5 chiropractors providing services to 5 customers, with Social Distancing Requirements in place of 6 feet distancing between customers receiving servicesEmployees must wear medical grade masks at all times, and patients must wear at least a cloth face covering at all times. (emphasis added)
  • Appendix E applies to Limited Healthcare Settings, which includes chiropractic care. Directly below is a summary of Appendix E, however, this list is not inclusive. The full Appendix E is at the bottom of this email for your review.  Chiropractic offices must:
  • Provide services by appointment only, do not allow walk-ins or waiting for an appointment;
  • Continue to maintain 6 feet separation between clients and patients, when not directly performing service;
  • Those in the office, doctors and staff, who perform services with close, direct personal contact must wear medical grade masks and gloves; staff should wear gloves during any customer interaction;
  • Change gloves AND wash hands between every patient;
  • Clean and disinfect all shared equipment and tools between every patient;
  • Maintain detailed log of patient interactions to enable contact tracing if it becomes necessary. The log includes name, date, details of service performed and location of contact as well as the contact’s phone number;
  • Patients must wear at least a cloth face covering at all times and if a patient does not have a face covering, then a “disposable medical mask” can be provided;
  • Post signage for employees and patients on good hygiene and safety measures being taken;
  • Use remote alternatives whenever possible, such as drive-by supplement pick-up or telehealth;
  • Conduct symptom check for all patients, decline to provide services to anyone who has symptoms and refer them to their primary care physician;
  • Provide contactless payment options whenever possible;
  • Appropriately schedule patients so that providers have sufficient time to change PPE and ensure rooms and equipment can be cleaned and disinfected between each patient;
  • Use virtual waiting rooms when possible, i.e. parking lot waiting room
  • Maintain a plan to reduce or stop voluntary and elective procedures should a surge of COVID-19 cases occur in their region as determined by CHDPE;
  • Other important sections to note in PHO 20 28.
  1. Section II.I – Sets forth specific measures to implement for office protocol in general, measures related to your employees and measures regarding patients (pages 8-10)
  2. Section III.N – Social Distancing Requirements (page 15)
  3. Section III. Q – “Vulnerable Individual” (page 16)


Again, we encourage each of our member chiropractors to become familiar with the documents referenced in paragraph 1 above so that you can appropriately plan and implement your office and practice procedures to provided chiropractic care in compliance with Colorado’s “Safer at Home and in the Vast, Great Outdoors” orders.

  

View CDPHE's site regarding Limited Healthcare settings here

 

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List of vendors on where to get PPE

 

Disclaimer: The Colorado Chiropractic Association has ZERO affiliation with these suppliers below and have ZERO control over pricing and availability. We are simply trying to find suppliers so you can order the supplies you need for your office. Some suppliers have limited in-house stock which is based on first-come, first-served basis. Some companies purchase as needed (i.e. no in-house stock) and need about 2-weeks for shipping. We will continue to add more companies as we become aware.

 

Workwear on Wheelz (Denver based)

PDF of products

888-WOWSINC

888-949-7462

office@wowscrubs.biz

https://www.workwearonwheels.biz/protective-gear

·Have surgical masks, KN95, hand sanitizer.

·Order online and they will ship or call them as you may be able to pick up an order in person.

 

New products, with at-once availability, from Workwear On Wheels, Inc - a CCA resource!
Reusable face shield - 2 pc. pack = $17.68  
Powder Free disposable Vinyl gloves - 100 pc box = $15.73 (Med/large/XL)
Reminder:  ALL product is shipped from Aurora, CO and is IN-STOCK! 

 

Falcon Distributors (Colorado Springs based)

Falcondistributors.com

Contact Steve Reynolds to order

719-520-1551

office@falcondistributors.com

To order - call the number above.

·Have surgical masks, KN95, hand sanitizer, CSI disinfectant, gloves (approved by CDC for killing COVID-19).

- The CSI Disinfectant comes in 12 quarts per case at a price of $156.13. It states right on the label that it kills Human CoronaVirus and Associated SARS CoronaVirus.

-  The Surgical Masks come 50 in a box at a price of $100.00. They are a 3-ply Face Mask with a BFE greater than 99%, are hypoallergenic, have an adaptable nose bar, very low resistance to breathing and a high filtration capacity.

- The KN95 Face Masks come 10 per bag and have an FDA Certification # 10066035. The price is $60.00 per bag.

- The Nitrile Gloves come either 100 gloves per box at $14.95 per box or a case of 1,000 gloves at $149.95.

- We have 16oz, 23oz and 32oz refill Hand Sanitizer that is made from 75% IPA and is FDA Certified. The prices are $15.00, $19.50 and $27.10 respectively. The 16oz and 23oz come with spray triggers and the 32oz is a refill bottle.

- We also have some IPA in 4oz and 8oz bottles remaining at $4.00 and $8.00 respectively.

 

 

Brand Nu’uveli Solutions

https://bandnsolutions.com/

View their PDF of products and minimums here

Isaac Belden – phone: 208-861-8110 isaac@bandnsolutions.com

Matthew Nu’uvali – phone: 208-392-0095 matthew@bandnsolutions.com

·       Have hand sanitizer, KN95 masks, 3 Ply masks, IR thermometers and more.

·       Minimum orders apply. Do not carry stock, all orders are made to ship.

·       One solution might be to work with other docs in your area to meet minimum orders

·       Check website for how to order or contact Isaac or Matthew above.

 

Anne McGilvray & Company

Contact to order:

Ellen Burnell

Tel (720) 351-1211

eburnell@annemcgilvray.com

 

Message from Ellen:

Click here for the PDF with product list on the different kinds medical masks and more.

Please see minimum in PDF of each product. For example: if they come in 20’s you have to buy in multiple of 20’s.

Thermometer comes in 1 so you only need to buy 1 or more.

There is no tax , but there is a shipping charge. It should be minimal because products are light.

The minimum for each order is $150.00 and a credit card is needed. They may send backorders if you order more than one product - like any company.

Chiropractors can combine their orders with other doctors. They will need to be shipped to one location.

 

Integrated Medical, Inc. (Centennial)

7012 S. Revere Pkwy, Suite 140

Centennial, CO 80112

303-792-0069

sales@integratedmedicalonline.com

 

Ordering –

www.integratedmedicalonline.com/Covid19

*Please set up an account on our website to access medical professional pricing.

*Order online, by phone, or by email.

*In-stock orders ship within 24 hours OR pick up at our office (call prior to check availability).

 

Inventory –

Note: All products are being allocated to our professional customers to ensure continued availability.

Gloves (nitrile, vinyl, and latex in Sm, Med, Lg) – in stock, prices vary, boxes of 100-200, OR cases of 10 boxes available

KN95 Masks – in stock, $60.00/box 10

Ear Loop Face Masks – limited supply (stock varies weekly), starting at $15.95/box of 50

Disinfectants

  • Cavicide & Caviwipes – in stock, starting at $11.95
  • Citrus II (gallon & 22oz spray) – in stock, prices vary
  • Isopropyl Alcohol (gallon & 16oz) – in stock, prices vary
  • Hand Sanitizer (12oz pumps) – limited supply

Infrared Thermometers – in stock, $77.95

Table Paper (and other paper products/linens) – in stock, prices vary

 

HealthID

https://www.healthyid.com

Receive an additional 3% discount (Use code: COC001) as well as FREE SHIPPING on orders over $79. If they need hand sanitizer in larger quantities or they would like to private label hand sanitizer have them call me directly at 719-433-1494 (Vaso Bjegovich).

-If the products are on our site that means there is stock. If items are out of stock we will remove the items from the site as soon as that happens.

 

 

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APPENDIX E: LIMITED HEALTHCARE SETTINGS PER PHO20-28

I. Effective April 27, 2020, Limited Healthcare Settings may resume if the healthcare

entity can demonstrate compliance with the requirements of this Order, including Section II.I and

may restart voluntary and elective surgeries and procedures in limited healthcare facilities and

offices with required personal protective equipment (PPE) in accord with the priorities,

requirements, and specific criteria below.

 

A. Employers and sole proprietors of Limited Healthcare Settings must implement the following measures within the overall workplace, including administrative and front office operations, to minimize disease transmission:

1. The practice must have access to adequate PPE in order to sustain recommended PPE use for its workforce for two weeks without the need for emergency PPE-conserving measures. If a practice proposes to extend the use of or reuse PPE, it must follow CDC guidance.1

2. The practice must implement strict infection control policies as recommended by the CDC.2

3. The practice must ensure a minimum of 6 feet of separation between clients and

patients, when not directly performing service, with no more than ten (10) people in the facility;

4. The practice must post signage for employees and patients on good hygiene and safety measures being taken; and

5. The practice must minimize in-home and in-facility services with remote alternatives whenever possible, such as drive-by services or virtual meetings.

6. Practices must maintain a plan to reduce or stop voluntary and elective surgeries and procedures should a surge/resurgence of COVID-19 cases occur in their region.

 

B. Employers of Limited Healthcare Settings must implement the following measures regarding employees to minimize disease transmission:

1. Services with close, direct personal contact must implement the following:

a. wear medical grade mask and gloves at all times;

b. change gloves and wash hands between every patient;

c. clean and disinfect all shared equipment and tools between every patient; and

d. maintain a detailed log of patient interactions to enable contact tracing if it becomes necessary. The log should include name, date, details of services performed, and location of contact, as well as the contact’s phone number

e. As of June 18, 2020, for services where the client cannot wear a mask, the
employee or practitioner must wear a face shield in addition to their mask.

2. Services with low personal contact must implement the following:

 a. maintain a minimum of six 6 feet of separation between customers and limit to no more than ten (10) people in the facility.

b. require face coverings and, if feasible, gloves for any customer interactions; and

c. provide guidance on strict hygiene precautions to employees.

3. The practice must require all administrative personnel to wear a facemask, that can be cloth if necessary. Masks may be removed when social distancing of at least 6 feet if possible (e.g., after entering a private office). In order to ensure staff can take off their masks for meals and breaks, scheduling and location for meals and breaks should ensure that at least a 6-foot distance can be maintained between staff when staff needs to remove their mask. It is important for healthcare settings to emphasize that hand hygiene is essential to maintaining employee safety, even if staff are wearing masks. If the facemask is touched, adjusted or removed, hand hygiene should be performed.

 

C. Limited Healthcare Settings must implement the following measures regarding customers to minimize disease transmission:

1. The practice must provide services by appointment only, do not allow walk-ins or waiting for an appointment;

2. The practice must require patients to wear face coverings; if a patient does not have a mask, a "disposable medical mask" could be provided;

3. The practice must conduct symptoms checks for all patients, decline to provide services to anyone who has symptoms, and refer them to their primary care physician. A sample form can be found here ; and

4. The practice must provide contactless payment options whenever possible;

5. The practice must follow social distancing protocols of maintaining at least a 6-foot distance between individuals wherever possible such as in waiting rooms and other small spaces, and should use physical barriers within patient care areas when possible.

6. The practice must appropriately schedule patients, so that providers have sufficient time to change PPE and ensure rooms and equipment can be cleaned and disinfected between each patient.

7. The practice should continue to maximize the use of telehealth and virtual office or clinic visits.

8. The practice should use virtual waiting rooms when possible, with patients who are able to wait in their cars not entering the office until they can be moved immediately to an exam room.

9. The practice should implement source control for everyone entering the office or clinic, including requiring all patients and visitors to wear a cloth mask when entering any healthcare building, and if they arrive without a mask, one should be provided.

 

D. As best practice, it is recommended that once voluntary and elective surgeries and procedures resume, Limited Healthcare Settings reassess their operations every two weeks, in order to ensure:

1. All of the above approaches and criteria are being met;

2. Procedures are prioritized based on whether their continued delay will have an adverse health outcome.

a. Voluntary and elective surgeries and procedures should be prioritized based on indication and urgency3 ;

3. Strong consideration is given to the balance of risks versus benefits for patients in

higher-risk groups such as those over age 65 and those with compromised immune systems or lung and heart function;

4. All patients are pre-screened for COVID-19 risk factors and symptoms prior to delivering care, via telehealth when applicable; and

5. Compliance with the guidance and directives for maintaining a clean and safe work environment issued by the CDPHE and any applicable local health department for critical businesses is maintained, including compliance with Social Distancing Requirements and all PHOs currently in effect to the greatest extent possible.

 

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DORA's FAQs regarding Safer at Home

Click here to review DORA's FAQs

 

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UPDATED STAY-AT-HOME ORDERS - MOVING TO SAFER AT HOME PHASE [UPDATED 05/08/2020 2:30PM]

4.28.2020 - We encourage everyone to also review DORA's FAQs regarding Safer at Home - Find DORA's FAQs regarding Safer at Home here.

 

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Interactive Safer At Home Map for Colorado

http://counties.coloradogeodev.com/safer.html

  Check out the updated map here including any county that has applied for a variance:

http://counties.coloradogeodev.com/saferside.html

 

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CDC GUIDANCE FOR HEALTH CARE PRACTITIONERS WHO HAVE BEEN EXPOSED TO COVID-19 [UPDATED 4/9/2020]

The CDC has taken a conservative approach to work restrictions in health care settings, because, by the nature of their work, health care professionals (HCP) often have extensive and close contact with vulnerable individuals in the office setting.  The CDC must balance the need for essential health care with the risk of exposure to patients, staff, and others.  The CDC’s approach is to quickly identify early symptoms and prevent transmission from potentially contagious HCP to patients, HCP, and visitors, and to err on the side of early evaluation and testing of symptomatic HCP, particularly those who fall into the high-and medium-risk categories described in the guidanceCDC does not include secondary exposure (i.e. spouse of a patient tests positive) in its risk assessment, because the tool focuses only on possible direct exposure of a HPC to an infected person. 

The recommended action for monitoring and work restrictions will depend on whether the HCP’s exposure is considered low, medium, or high risk.  CDC has provided a detailed chart for multiple scenarios, incorporating epidemiologic risk factors, exposure category, recommended monitoring for COVID-19 (until 14 days after last potential exposure), and work restrictions for asymptomatic HCP.

Additionally, on April 7, 2020, the CDC changed their recommendations for Critical Infrastructure Workers Who May Have Had Exposure to a Person with Suspected or Confirmed COVID-19 and now allows exposed workers to return to work sooner. Although this new guidance is primarily for non-healthcare related essential workers, it provides additional guidance for your office. The guidance indicates the following:

“Critical Infrastructure workers who have had an exposure but remain asymptomatic should adhere to the following practices prior to and during their work shift:

  • Pre-Screen: Employers should measure the employee’s temperature and assess symptoms prior to them starting work. Ideally, temperature checks should happen before the individual enters the facility.
  • Regular Monitoring: As long as the employee doesn’t have a temperature or symptoms, they should self-monitor under the supervision of their employer’s occupational health program.
  • Wear a Mask: The employee should wear a face mask at all times while in the workplace for 14 days after last exposure. Employers can issue facemasks or can approve employees’ supplied cloth face coverings in the event of shortages.
  • Social Distance: The employee should maintain 6 feet and practice social distancing as work duties permit in the workplace.
  • Disinfect and Clean workspaces: Clean and disinfect all areas such as offices, bathrooms, common areas, shared electronic equipment routinely.”

Steps to Take Following Primary Exposure:

  • Notify the local county health department of the exposure,
  • Work through the CDC Risk Assessment tool,
  • Review and follow the ADDITIONAL guidance from the CDC regarding Critical Infrastructure Workers,

Healthcare providers, in consultation with public health authorities, should use clinical judgment to assign risk and determine need for work restrictions.

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SIGNIFICANT HELP IN CARES ACT VIA SBA FORGIVABLE LOANS – [UPDATED 5/5/2020]

Note: Some details have changed in the final ruling: the interest has increased to 1% (instead of 0.5%), references to employees appear to be consideration of full-time equivalent employees, and some more confusion regarding those who are attempting to obtain both the PPP and the EIDL loans. Please see the information below for more explanation. Additionally, note the information at the end of this section regarding banks.

 

There was an important section in the “Coronavirus Aid, Relief, and Economic Security Act” (CARES Act) passed by Congress last Friday (3/27/2020) that provides for SBA loans that ultimately can be forgivable. Most people refer to this section as the “Paycheck Protection Program.” At this point, the Small Business Administration (SBA) has until April 11 to establish the regulations or rules for this act, which will be necessary to answer some additional questions and to begin the loan application process.

These loans will have different requirements than those found in most SBA rules. Some requirements are more restrictive, and some are significantly loosened. The information below is based on our understanding of the law now and may be adjusted based on new information and the release of regulations by SBA.

How the CARES loan different than typical SBA loans and the basic CARES loan requirements:

· Do NOT have to prove that you cannot receive credit from other sources. This is a typical SBA requirement, but it appears this has been removed for these loans.

· NO personal guarantee will be required.

· 100% guaranteed by the federal government.

· No federal government guarantee fees or prepayment fees.

· The borrower MUST make good faith certifications that they have been impacted by COVID-19 AND will use the funds to maintain payroll and other debt obligations. This language includes, i) “that the uncertainty of current economic conditions makes necessary the loan request to support the ongoing operations of the eligible recipient; (ii) acknowledging that funds will be used to retain workers and maintain payroll or make mortgage payments, lease payment, and utility payments”; and no other SBA loans applications are pending.

· Must have fewer than 500 employees.

Loan details:

· Funds must be used to cover payroll costs, benefits and leave, mortgage interest, rent, and utilities.

· Interest is capped at 4%, although SBA has indicated that the interest will be only 1.0%. (they previously indicated only .5%, but increased it in the final rule)

· The borrower can defer payments (including the low interest) between 6-12 months. However, SBA has fixed the deferral timeframe to 6 months.

· The loans will be for 2 years.

· The amount of the loan can be up to the average monthly payroll from 2019 times 2.5 (i.e. 2019 total payroll expenses are $240,000, then 240,000/12 = 20,000 x 2.5 = $50,000 maximum). However, the loan amount is reduced by any amounts paid to individuals greater than $100,000.
· $1 million loan amount maximum.

Loan Forgiveness:

· Section 1106 of the Act, titled “Loan Forgiveness,” provides that the Government will forgive up to the original principal amount of a loan under the Act that a recipient can document was used to pay: (1) payroll costs; (2) mortgage interest; (3) rent and (4) utilities—in each case for up to eight weeks following the issuance of the loan. Additional details:

· Like the loan amount, the forgiveness will be proportionately reduced for salaries greater than $100,000.

· Each of these documented expenditures for utilities, lease payments, mortgage interest must have been in place prior to 2/15/2020 (i.e. no mortgage interest can be included if the mortgage began on 2/25/2020).

· Employees must remain employed through the end of June.

· Employee pay cuts greater than 25% will reduce the forgiveness proportionately.

· [Updated 5/5/2020] The SBA recently changed their information sheet and removed the specific information regarding full-time equivalent hours. See the next bullet for that information. According to the SBA, forgiveness requires the following:

· “Number of Staff: Your loan forgiveness will be reduced if you decrease your full-time employee headcount.

· Level of Payroll: Your loan forgiveness will also be reduced if you decrease salaries and wages by more than 25% for any employee that made less than $100,000 annualized in 2019.

· Re-Hiring: You have until June 30, 2020 to restore your full-time employment and salary levels for any changes made between February 15, 2020 and April 26, 2020. “

· The CARES Act provision regarding full-time employees references previous IRS code (26 U.S. Code § 4980H(c)(4)(a)) that states “The term ‘full-time employee’ means, with respect to any month, an employee who is employed on average at least 30 hours of service per week.”

[Updated 5/4/2020] SBA and the Treasury Department released more information on the PPP loan forgiveness on 5/3/2020 and they answered questions that many of our doctors have. The clarification came in the form of a FAQ:

 

“Question: Will a borrower’s PPP loan forgiveness amount (pursuant to section 1106 of the CARES Act and SBA’s implementing rules and guidance) be reduced if the borrower laid off an employee, offered to rehire the same employee, but the employee declined the offer?

Answer: No. As an exercise of the Administrator’s and the Secretary’s authority under Section 1106(d)(6) of the CARES Act to prescribe regulations granting de minimis exemptions from the Act’s limits on loan forgiveness, SBA and Treasury intend to issue an interim final rule excluding laid-off employees whom the borrower offered to rehire (for the same salary/wages and same number of hours) from the CARES Act’s loan forgiveness reduction calculation. The interim final rule will specify that, to qualify for this exception, the borrower must have made a good faith, written offer of rehire, and the employee’s rejection of that offer must be documented by the borrower. Employees and employers should be aware that employees who reject offers of re-employment may forfeit eligibility for continued unemployment compensation.”


Based on this information, it appears that employees that refuse to return to work will not count against an employer for PPP loan forgiveness if the offer to return to work was:

· Made in good faith,

· In writing, and

· Employee’s rejection is documented by the employer (does not indicate signature required from the employee, just documented).

Other FAQ:

· If you have already laid-off employees, you can re-hire them once the loan is disbursed and count them toward the calculation.

· The loan forgiveness is not taxable income.

· SBA has indicated they would have a process in place by Friday, April 3, 2020.

PPP + EIDL:

·  It appears that you can apply NOW for an Economic Injury Disaster Loan Assistance (EIDLA) and then later apply for the Payroll Protection Program loan. If you choose this option, it appears you have two options:

· Re-finance the EIDLA loan into the PPP loan, or

· Use the EIDL loan (including $10,000 “advance”) for expenses NOT used to account for the forgiveness of the PPP loan.

· It is unclear if both will be available after April 3, 2020, or if only the borrower would have to choose between the two programs. We anticipate this will be addressed soon by SBA and the Treasury Department.

Remaining Questions:

What can you do now while waiting for the process to be finalized (i.e., for applications to be made available)?

· Start gathering documentation for application while waiting for the process to finalize. This would include payroll information for 2019. This includes ALL payroll expenses, such as health benefits, retirement benefits, etc. Include everything, and you can negotiate with the bank as to what, if any, they will exclude. In addition to payroll information, gather documents showing mortgage interest, rent, and utilities in place prior to 2/15/2020. See the information and links below.

SBA released more information on this program on their dedicated site. Additionally, they released the application that could be used to get ready for the actual release and start date which they have indicated will be Friday, April 3, 2020:

· Main PPP site

· Fillable application for use in preparation

· Find a bank here


If you are considering this loan, please speak with your local bank NOW to determine your next steps and proper timing for your situation and practice. Remember, this program begins on April 3, 2020, and has limited funds.


Some local banks are ONLY assisting current banking customers. Please check with your local bank soon to determine their policies and allow for time to find another potential lender to work with on the PPP.

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PROVIDER RELIEF FUND PROVIDING $30 BILLION AND INCLUDES CHIROPRACTORS UNDER CARES ACT – [UPDATED 5/11/2020 3:00 PM]

Yet another provision of the “Coronavirus Aid, Relief, and Economic Security Act” (CARES Act) will directly impact doctors who billed Medicare in 2019. Although initial indications were this provision would focus on hospitals, the federal government has allocated $30 billion in “relief funds” that will include individual providers including chiropractic physicians. This is NOT a loan. Instead, it is an automatic grant.

To determine your portion of the funds, you would take your Medicare reimbursable billings (i.e. Medicare allowed charges for 98940, 98941, 98942) divided by $484 billion (total Medicare billings in 2019) and multiply by $30 billion. A doctor who had $32,250 in Medicare allowed charges billings in 2019 would receive approximately $2,000 (32,250 / 484,000,000,000 x 30,000,000,000 = 1,999).

Beginning Friday, April 10, the funds will be automatically deposited into your bank account via Optum Bank (CMS partner in this project) with “HHSPAYMENT” as the payment description. If you are typically paid by Medicare via check, then your funds will arrive in the next 2 weeks.

[Updated 5/11/2020] HHS has placed “terms and conditions” on the funds that must be accepted within 45 days (was 30 days) of receipt through the HHS portal starting sometime in the week of April 13 which will be located on the provider relief fund page. Included in those conditions:

  • “Providers must agree not to seek collection of out-of-pocket payments from a COVID-19 patient that are greater than what the patient would have otherwise been required to pay if the care had been provided by an in-network provider;”
  • “The Recipient certifies that it will not use the Payment to reimburse expenses or losses that have been reimbursed from other sources or that other sources are obligated to reimburse.” This would include funds for PPP loans or EIDL loans;
  • “shall reimburse the Recipient only for health care related expenses or lost revenues that are attributable to coronavirus.” Thus, lost revenues are a component of these funds that would NOT be included in the PPP or EIDL funds.
  • Recipient must also keep documentation regarding the use of the funds.

[Updated 5/11/2020] Additionally, HHS has indicated that if the terms and conditions are not accepted within the 45-day timeframe and the funds are not returned, they will automatically assume the provider agrees to the terms and conditions.

HHS gives further clarification of intent on the main relief page:

  • “This quick dispersal of funds will provide relief to both providers in areas heavily impacted by the COVID-19 pandemic and those providers who are struggling to keep their doors open due to healthy patients delaying care and cancelled elective services.
  • If you ceased operation as a result of the COVID-19 pandemic, you are still eligible to receive funds so long as you provided diagnoses, testing, or care for individuals with possible or actual cases of COVID-19. Care does not have to be specific to treating COVID-19. HHS broadly views every patient as a possible case of COVID-19.” [emphasis added]

More information is available on the HHS provider relief site.

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CDC Symptoms for COVID-19

Watch for symptoms

People with COVID-19 have had a wide range of symptoms reported – ranging from mild symptoms to severe illness.

Symptoms may appear 2-14 days after exposure to the virus. People with these symptoms or combinations of symptoms may have COVID-19:

  • Cough
  • Shortness of breath or difficulty breathing

Or at least two of these symptoms:

  • Fever
  • Chills
  • Repeated shaking with chills
  • Muscle pain
  • Headache
  • Sore throat
  • New loss of taste or smell

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CONSIDERATIONS FOR EXPIRING CERTIFICATIONS AND/OR DIPLOMATES [UPDATED 5/13/2020 6:30 PM]


In the middle of times like this, we tend to let some things move to the back burner, but chiropractors may want to take a moment and review the expiration dates (or renewal dates) of your certifications and diplomates. Here is some examples:

  • CPR Certification – In Colorado, we are required to maintain an active CPR card to practice. At this time (5.13.2020) we have not heard of an exemption. Further, some health care certifications (i.e. CCSP) and some PPO agreements require that holders maintain an active CPR certification. You should check your expiration date on your CPR card to determine if you need to update it. If you hold a CPR certification from the American Heart Association, they have extended the expiration of all cards from March 1, 2020 forward by 120 days. The American Red Cross requires a very short online training (no actual training takes place, it only requires you to agree to simple terms and conditions) after which students are emailed a 120 day extension certificate. However, given the extension, the entity that requires the certification has to accept that extension. As a reminder, Colorado requires an in person practical for your CPR card. The CCA is working on future CPR classes that will comply with all public health orders to be able to provide the CPR practical to those whose CPR cards are set to expire.

  •  CCSP (Certified Chiropractic Sports Physician) – The American Chiropractic Board of Sports Physicians has indicated that they are extending some CCSP expirations to September 30, 2020. However, they also indicated that they require hands-on CPR certification and recertification and thus a hands-on course will be required by September 30th. Once we are closer to that date and you find problems updating your CPR certification (or other CCSP courses), we are recommending that you reach out directly to ACBSP. The CCA has two CPR classes scheduled in the fall and there is a potential to add more if there is a need.

 

Other Certifications and Diplomates – If you review your renewal dates and expirations of other certifications and find that you will not be able to meet the deadline as a direct result of governmental orders, CDC group guidelines, or other issues related to COVID-19, the CCA recommends reaching out directly to the governing body of the certification or diplomate to determine your best course of action.

 

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TELEHEALTH ENCOURAGED DURING THESE TIMES [UPDATED 4/14/2020 10:00AM]

 

Missed our telehealth webinar?? View our Telehealth OnDemand with Dr. Tim Bertelsman by clicking here!

 

Governor Polis issued Executive Order D 2020 020 Ordering the Temporary Suspension of Certain Statutes to Expand the Use of Telehealth Services Due to the Presence of COVID-19 on April 1, 2020. The Department of Regulatory Agencies subsequently sent an email on April 13, 2020 further clarifying this executive order.

 

DORA’s email states:

 

"1. Which DORA-regulated professions fall under Executive Order D 2020 020?

 

Executive Order D 2020 020 explicitly mentions suspension of statutes related only to mental health and veterinary services providers. Nevertheless, the following healthcare professions also are able and encouraged to use telehealth in treatment of patients for the duration of this health emergency. Please note that, with the exception of veterinarians, providers must meet the definition outlined in Colorado Revised Statutes §10-16-102(56), which includes those “licensed or otherwise authorized to furnish healthcare services” as defined in §10-16-102(33). (emphasis added)

[…]

·      Chiropractic […]"

 

The full email is at the bottom of this page.

 

We encourage everyone to review the provider-related guidance regarding telehealth created by the Colorado Department of Public Health and Environment here. Be sure to check with each insurance company you are in network with to ensure coverage and if each insurance company has their own requirements.

 

Should a provider feel telehealth is not sufficient to address the needs of your patients, you must still adhere to Executive Order D 2020 027 (the amended version of Executive Order D 2020 009) as well as the social distancing requirements in Amended Public Health Order 20-24.

 

 

UnitedHealthcare’s Telehealth Services Outpatient for Chiropractic Services 

 

“Must use live video-conferencing that involves the presence of both parties at the same time and a communication link betwee
n them that allows a real-time audio and visual interaction to take place.”

 

UHC Specific code list for chiropractors

 

We are currently researching other insurance networks and will post when more information becomes available.

 

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HIPAA REMINDER - COVID-19 FROM NCMIC [UPDATED 3/17/2020 10:00AM] 

Original article here from NCMIC

While social media is blowing up with so called “facts” about the Coronavirus, something that every clinician needs to remember is that following HIPAA  guidelines is paramount.

As an example, when an Ohio case was announced yesterday, I received a call from a friend telling me that the man testing positive lives about three miles from a family member.  Unless that individual or his family member shared that information, this type of information should not be out in “air waves”. Let’s be clear, the 18 Protected Health Information (PHI) identifiers include:

•             Names

•             Dates, except year

•             Telephone numbers

•             Geographic data

•             FAX numbers

•             Social Security numbers

•             Email addresses

•             Medical record numbers

•             Account numbers

•             Health plan beneficiary numbers

•             Certificate/license numbers

•             Vehicle identifiers and serial numbers including license plates

•             Web URLs

•             Device identifiers and serial numbers

•             Internet protocol addresses

•             Full face photos and comparable images

•             Biometric identifiers (i.e. retinal scan, fingerprints)

•             Any unique identifying number or code

HIPAA has a special guidance section for what information and to whom that information can be released during an emergency situation. You can review these guidelines at: https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/decision-tool-overview/index.html  

Office of Civil Rights

Always remember the Office of Civil Rights (OCR) is very clear in their message:  there needs to be a balance between protecting the privacy of patient PHI (protected health information) and the appropriate use and disclosure of information to protect the public.

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X-RAY REGULATORY REQUIREMENTS DURING COVID-19 [UPDATED 3/17/2020 5:15PM]

COVID-19 Extensions for Certification Evaluation of Radiation Machines and Facilities Subject to 6 CCR 1007-1 Part 02 and 06

In the interest of preventing transmission of COVID-19 the Colorado Department of Public Health and Environment is exercising regulatory flexibility and providing an extension to the requirements for select radiation machine and facility certification evaluations. 

For those radiation machines and facilities that require an initial certification evaluation within 90 days of use as per Section 6.6.1.2 the department is providing an additional 90 days for the completion of the initial evaluation.  Please note, the requirements of 2.5.1.5 and 2.5.1.6 still remain in force and an evaluation of those machines prior to being used to perform any human examination is still required.

Radiation machines and facilities that are due for a certification evaluation, as per Section 2.5 of the Regulations, during the months of March, April, May and June of 2020 shall be granted a 6 month extension to complete that evaluation.

Please feel free to contact the X-ray Certification Unit with any questions at 303-692-3448 
or via email at cdphe.hmxraycomments@state.co.us.  

 

This information is also posted on the website at: https://www.colorado.gov/pacific/cdphe/xray

 

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CORONAVIRUS SCAMS [UPDATED 4/15/2020]


Unfortunately, scammers are taking advantage of fear and anxiety to defraud the public, including health care practitioners, during the Coronavirus pandemic.  These schemes may come in the form of phishing phone calls seeking personal and financial information, or as online sales of bogus testing and “treatments” for COVID-19.  The FTC, FDA, IRS and other agencies have provided excellent information about the types of communication that should raise an immediate alert and to which you should not respond.

Stimulus Payments

One form of scam is for the caller to steal economic impact payments intended for recipients as relief money ($1,200 individual/$2,400 couple/$500 per child). The FDA has clarified that recipients don’t need to do anything, as long as they have filed taxes for 2018 and/or 2019, and that recipients should not give anyone personal information to “sign up” for the check.  For more details, see the FTC website here and IRS information on economic impact payments.

 

Of course, scammers will no doubt attempt to obtain personal information from persons who are eligible for other forms of government relief, such as payment protection money and unemployment compensation, during the pandemic.  As always, the CCA strongly recommends not giving any information during a phone call and not clicking on links contained in an email from unknown senders. There is more than sufficient information online to allow individuals to verify the steps necessary to obtain and process stimulus funds.  Any required phone contact should be initiated by the eligible person after verifying the correct phone contact information online.


Unapproved Products and False Advertising

In March, the FTC and FDA sent warning letters to seven sellers of unapproved and misbranded products, claiming they can treat or prevent the Coronavirus.  This month, the FTC sent warning letters to 10 more companies.   The unapproved products include supplements called an “ANTI-VIRUS KIT” and intravenous (IV) “therapies” with high doses of Vitamin C. The FTC says the companies have no evidence to back up their claims, as required by law.

 

Some of the FTC’s letters challenge products sold online; others challenge treatments offered in clinics or for use at home. The U.S. Food and Drug Administration (FDA) continues to say there currently are no products proven to treat or prevent the virus.   The CCA recommends that doctors be vigilant in products they purchase and advertise for use during the pandemic. For more details, see the FTC release here.

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**Resources**
 Description Link

-Governor Polis Press Releases 

 

list of all press releases 

https://www.colorado.gov/governor/news 

-Governor Polis Executive Orders 

 

list of all executive orders

https://www.colorado.gov/governor/executive-orders

-CDPHE Public Health Orders (& Executive Orders)

 

List of all public health orders 

https://covid19.colorado.gov/covid-19-in-colorado/public-health-executive-orders-resource

 -CDPHE Employee health screening form

 

sample employee health screening form - can be used for patients too!

https://drive.google.com/file/d/1uKwFlhc7wWa3OvnPw0zXWv49na_KGHdC/view

CHUSA Webinars

 

Link to CHUSA webinars for COVID-19 and more!  

https://www.chirohealthusa.com/webinars/

CCA OnDemand 

 

Previous webinars put on by the CCA now archived and available OnDemand 

https://coloradochiropractic.ce21.com/Search?displaytype=1&pagesize=10&sortby=52&producttype=4,12&sst=p&fromDuration=&toDuration=undefined&certCreditType= 

 COVID-19 Member Resources

 

Customizable content for members to download for their practice 

 https://www.coloradochiropractic.org/page/COVID-19

DORA Emails 

 

All emails DORA has sent to Chiropractors

https://www.coloradochiropractic.org/page/COVID-19DORAEmails

OR

https://www.colorado.gov/pacific/dora/covid-19-updates-licensees-and-consumers?utm_medium=email&utm_source=govdelivery


 PPP Program

 

PPP Program resumes April 27, 2020

 https://www.sba.gov/funding-programs/loans/coronavirus-relief-options/paycheck-protection-program
Economic Injury Disaster Loan Emergency Advance (EIDL)   https://www.sba.gov/funding-programs/loans/coronavirus-relief-options/economic-injury-disaster-loan-emergency-advance 
HHS Allocations of CARES Act Provider Relief Fund    https://www.coloradochiropractic.org/page/HHSAnnouncesAdditionalAllocationsofCARESActProviderReliefFund
Federal Student Loans   https://studentaid.gov/announcements-events/coronavirus 

OHSA 

 

Guidance on preparing workplaces for COVID-19

https://cdaonline.org/wp-content/uploads/2020/03/OSHA-Guidance-on-Preparing-Workplaces-for-COVID-19.pdf  

 

CDC

 

 Main CDC site 

https://www.cdc.gov/coronavirus/2019-ncov/index.html 
ChiroArmor Phone Screening Tool   https://cdn.ymaws.com/www.coloradochiropractic.org/resource/resmgr/covid_19/covid-19-phone-screening.pdf 
OSHA Workplace Risk Exposure Poster  https://www.osha.gov/Publications/OSHA3994.pdf  
-NCMIC Sample Informed Consent   https://www.ncmic.com/webres/File/coronavirus/COVID-19-DC-Informed-Consent.pdf
 COVID19 & HIPAA Notice from CMS  https://cdn.ymaws.com/www.coloradochiropractic.org/resource/resmgr/covid_19/hipaa-and-covid-19-limited-h.pdf

 

 

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