Topic: Visitation Plan and Policy during a Pandemic
Effective Date: 7/10/2020
Revised: 9/15/2020; 9/17/2020; 10/25/2020; 2/26/2020; 3/25/2021; 7/8/2021; 11/12/2021
Based on the needs of residents and the facility’s structure, visitation will be conducted through a variety of means, such as in resident rooms, dedicated visitation spaces indoors and outdoors weather permitting. Regardless of how visits are conducted, there are certain core principles and best practices that reduce the risk of COVID-19 transmission and must be followed. The facility will ensure that resident and family communication is ongoing and supported by virtual visits, whenever possible.
- Core Principals of Infection Control
- Visitors who have a positive viral test for COVID-19, symptoms of COVID-19, or currently meet the criteria for quarantine, will not be allowed to enter the facility. The facility will screen all who enter for these visitation exclusions.
- Hand hygiene (use of alcohol-based hand rub is preferred).
- Face covering or mask (covering mouth and nose) and physical distancing at least six feet between people, in accordance with CDC guidance.
- Instructional signage throughout the facility and proper visitor education on COVID- 19 signs and symptoms, infection control precautions, other applicable facility practices (e.g., use of face covering or mask, specified entries, exits and routes to designated areas, hand hygiene)
- Cleaning and disinfecting high-frequency touched surfaces in the facility often, and designated visitation areas after each visit.
- Appropriate staff use of Personal Protective Equipment (PPE).
- Effective cohorting of residents (e.g., separate areas dedicated to COVID-19 care).
- Resident and staff testing conducted as required at 42 CFR § 483.80(h) (see QSO-20- 38-NH).
These core principles are consistent with the Centers for Disease Control and Prevention (CDC) guidance for nursing homes, and is to be adhered to at all times. Additionally, visitation should be person-centered, consider the residents’ physical, mental, and psychosocial well-being, and support their quality of life. The risk of transmission can be further reduced through the use of physical barriers (e.g., clear Plexiglass dividers, curtains) when available. Also, the facility will enable visits to be conducted with an adequate degree of privacy. Visitors who are unable to adhere to the core principles of COVID-19 infection prevention will not be permitted to visit or will be asked to leave. By following a person-centered approach and adhering to these core principles, visitation can occur safely based on the below.
- Outdoor Visitation
While taking a person-centered approach and adhering to the core principles of COVID-19 infection prevention, outdoor visitation is preferred when the resident and/or visitor are not fully vaccinated against COVID-19. Outdoor visits generally pose a lower risk of transmission due to increased space and airflow. For outdoor visits, the facility will create accessible and safe outdoor spaces for visitation, such as in courtyards, patios, or parking lots, including the use of tents, if available. However, weather considerations (e.g., inclement weather, excessively hot or cold temperatures, poor air quality) or an individual resident’s health status (e.g., medical condition(s), COVID-19 status, quarantine status) may hinder outdoor visits. When conducting outdoor visitation, all appropriate infection control and prevention practices will be followed.
- Indoor Visitation
Facilities will allow indoor visitation at all times and for all residents as permitted under the current regulations. While previously acceptable during the PHE, the facility will no longer limit the frequency and length of visits for residents, the number of visitors, or require advance scheduling of visits.
Although there is no limit on the number of visitors that a resident can have at one time, visits should be conducted in a manner that adheres to the core principles of COVID-19 infection prevention and does not increase risk to other residents. The facility will ensure that physical distancing can still be maintained during peak times of visitation (e.g., lunch time, after business hours, etc.). Also, facilities should avoid large gatherings (e.g., parties, events) where large numbers of visitors are in the same space at the same time and physical distancing cannot be maintained. During indoor visitation, facilities should limit visitor movement in the facility. For example, visitors should not walk around different halls of the facility. Rather, they should go directly to the resident’s room or designated visitation area. The facility may contact their local health authorities for guidance or direction on how to structure their visitation to reduce the risk of COVID-19 transmission if necessary.
All visitors will be required to wear face masks at all times while in the facility. In areas with low to moderate transmission and both the resident and visitors are fully vaccinated may choose not to wear a mask and have physical contact if in a private room away from other residents and staff.
While not recommended, residents who are on transmission-based precautions (TBP) or quarantine can still receive visitors. In these cases, visits will occur in the resident’s room and the resident should wear a well-fitting facemask (if tolerated). Before visiting residents, who are on TBP or quarantine, visitors should be made aware of the potential risk of visiting and precautions necessary in order to visit the resident. Visitors will be required to adhere to the core principles of infection prevention. The facility will offer well-fitting facemasks or other appropriate PPE at no cost to the visitors and/or residents.
NOTE: CMS and CDC continue to recommend facilities, residents, and families adhere to the core principles of COVID-19 infection. This continues to be the safest way to prevent the spread of COVID-19, particularly if either party has not been fully vaccinated. However, they acknowledge the toll that separation and isolation has taken. They also acknowledge that there is no substitute for physical contact, such as the warm embrace between a resident and their loved one. Therefore, if the resident is fully vaccinated, they can choose to have close contact (including touch) with their visitor in accordance with the CDC’s “Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic.” Unvaccinated residents may also choose to have physical touch based on their preferences and needs, such as with support persons for individuals with disabilities and visitors participating in certain religious practices, including in end-of-life situations. In these situations, unvaccinated residents (or their representative) and their visitors will be advised of the risks of physical contact prior to the visit. Visitors will also be required to physically distance from other residents and staff in the facility.
- Indoor Visitation During an Outbreak
An outbreak investigation is initiated when a new nursing home onset of COVID-19 occurs (i.e., a new COVID-19 case among residents or staff). To swiftly detect cases, the facility will adhere to CMS regulations and guidance for COVID-19 testing, including routine unvaccinated staff testing, testing of individuals with symptoms, and outbreak testing.
When a new case of COVID-19 among residents or staff is identified, a facility will immediately begin outbreak testing in accordance with CMS QSO 20-38-NH REVISED and CDC guidelines.
While it is safer for visitors not to enter the facility during an outbreak investigation, visitors will still be allowed in the facility. Visitors will be made aware of the potential risk of visiting during an outbreak investigation and adhere to the core principles of infection prevention. If residents or their representative would like to have a visit during an outbreak investigation, they will need to wear face coverings or masks during visits, regardless of vaccination status, and visits will only occur in the resident’s room. The facility may contact their local health authorities for guidance or direction on how to structure their visitation to reduce the risk of COVID-19 transmission during an outbreak investigation.
- Visitor Testing and Vaccination
While not required, the facility will offer testing to all visitors, if feasible free of charge.
The facility strongly encourages all visitors to become vaccinated and the facility will educate and also encourage visitors to become vaccinated. Visitor testing and vaccination can help prevent the spread of COVID-19 and facilities may ask about a visitors’ vaccination status, however, visitors are not required to be tested or vaccinated (or show proof of such) as a condition of visitation. If the visitor declines to disclose their vaccination status, the visitor must wear a face covering or mask at all times. This also applies to representatives of the Office of the State Long-Term Care Ombudsman and protection and advocacy systems, as described below.
- Compassionate Care Visits
Compassionate care visits are allowed at all times. Previously during the PHE, there were some scenarios where residents should only have compassionate care visits. However, visitation is now allowed at all times for all residents, in accordance with CMS regulations. Therefore, there are few scenarios when visitation should be limited only to compassionate care visits. In the event a scenario arises that would limit visitation for a resident (e.g., a resident is severely immunocompromised and the number of visitors the resident is exposed to needs to be kept to a minimum), compassionate care visits would still be allowed at all times.
- Required Visitation
The facility will not restrict visitation without a reasonable clinical or safety cause, consistent with 42 CFR § 483.10(f)(4)(v). In previous nursing home visitation guidance during the PHE, CMS outlined some scenarios related to COVID-19 that would constitute a clinical or safety reason for limited visitation. However, there are no longer scenarios related to COVID-19 where visitation should be limited, except for certain situations when the visit is limited to being conducted in the resident’s room or the rare event that visitation is limited to compassionate care. Therefore, the facility will facilitate in-person visitation consistent with the applicable CMS regulations, which can be done by applying the guidance stated above.
As stated above, the facility acknowledges that there are still risks associated with visitation and COVID-19. However, the risks are reduced by adhering to the core principles of COVID-19 infection prevention. Furthermore, per 42 CFR §483.10(f)(2), residents have the right to make choices about aspects of his or her life in the facility that are significant to the resident. Visitors, residents, or their representative will be made aware of the potential risk of visiting and necessary precautions related to COVID-19 in order to visit the resident. However, if a visitor, resident, or their representative is aware of the risks associated with visitation, and the visit occurs in a manner that does not place other residents at risk (e.g., in the resident’s room), the resident will be allowed to receive visitors as he/she chooses.
- Access to the long-term care ombudsman
As stated in previous CMS guidance QSO-20-28-NH (revised), regulations at 42 CFR § 483.10(f)(4)(i)(C) require that a Medicare and Medicaid-certified nursing home provide representatives of the Office of the State Long-Term Care Ombudsman with immediate access to any resident. If an ombudsman is planning to visit a resident who is in TBP or quarantine, or an unvaccinated resident and the county level transmission is substantial or high in the past 7 days, the resident and ombudsman should be made aware of the potential risk of visiting, and the visit should take place in the resident’s room. We note that representatives of the Office of the Ombudsman should adhere to the core principles of COVID-19 infection prevention as described above. If the resident or the Ombudsman program requests alternative communication in lieu of an in-person visit, facilities must, at a minimum, facilitate alternative resident communication with the Ombudsman program, such as by phone or through use of other technology. The facility is also required under 42 CFR § 483.10(h)(3)(ii) to allow the Ombudsman to examine the resident’s medical, social, and administrative records as otherwise authorized by State law.
- Personal Caregiving Visitors
The personal caregiving visitation regulations for NHs, which implement the Essential Caregiver Act, remain law, and therefore the facility has policies and procedures in place regarding personal caregiving visitors, including those who provide compassionate caregiving. However, the facility need only implement these policies and procedures when there is a declared State or local public health emergency.
- Federal Disability Rights Laws and Protection & Advocacy (P&A) Programs
42 CFR § 483.10(f)(4)(i)(E) and (F) requires the facility to allow immediate access to a resident by any representative of the protection and advocacy systems, as designated by the state, and as established under the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (DD Act), and of the agency responsible for the protection and advocacy system for individuals with a mental disorder (established under the Protection and Advocacy for Mentally Ill Individuals Act of 2000). P&A programs authorized under the DD Act protect the rights of individuals with developmental and other disabilities and are authorized to “investigate incidents of abuse and neglect of individuals with developmental disabilities if the incidents are reported to the system or if there is probable cause to believe the incidents occurred.” 42 U.S.C. § 15043(a)(2)(B). Under its federal authorities, representatives of P&A programs are permitted access to all facility residents, which includes “the opportunity to meet and communicate privately with such individuals regularly, both formally and informally, by telephone, mail and in person.” 42 CFR § 51.42(c); 45 CFR § 1326.27.
If the P&A is planning to visit a resident who is in TBP or quarantine, or an unvaccinated resident in the facility and the level of community transmission is substantial or high in the past 7 days, the resident and P&A representative will be made aware of the potential risk of visiting and the visit should take place in the resident’s room.
Additionally, the facility will comply with federal disability rights laws such as Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. § 794 (Section 504) and the Americans with Disabilities Act of 1990, 42 U.S.C. §§ 12101 et seq. (ADA).
For example, if communicating with individuals who are deaf or hard of hearing, it is recommended to use a clear mask or mask with a clear panel. Face coverings should not be placed on anyone who has trouble breathing or is unable to wear a mask due to a disability, or anyone who is unconscious, incapacitated, or otherwise unable to remove the mask without assistance.
In addition, if a resident requires assistance to ensure effective communication (e.g., a qualified interpreter or someone to facilitate communication) and the assistance is not available by onsite staff or effective communication cannot be provided without such entry (e.g., video remote interpreting), the facility will allow the individual entry into the nursing home to interpret or facilitate, with some exceptions. This would not preclude the facility from imposing legitimate safety measures that are necessary for safe operations, such as requiring such individuals to adhere to the core principles of COVID-19 infection prevention.
- Entry of Healthcare Workers and Other Providers of Services
All healthcare workers will be permitted to come into the facility as long as they are not subject to a work exclusion or showing signs or symptoms of COVID-19. In addition to health care workers, personnel educating and assisting in resident transitions to the community will be permitted entry. Note that EMS personnel do not need to be screened, so they can attend to an emergency without delay. All staff, including individuals providing services under arrangement as well as volunteers, should adhere to the core principles of COVID-19 infection prevention and must comply with COVID-19 testing requirements.
- Communal Activities, Dining and Resident Outings
While adhering to the core principles of COVID-19 infection prevention, communal activities and dining may occur. Book clubs, crafts, movies, exercise, and bingo are all activities that can be facilitated with alterations to adhere to the guidelines for preventing transmission. The safest approach is for everyone, regardless of vaccination status, to wear a face covering or mask while in communal areas of the facility.
The facility must permit residents to leave the facility as they choose. Should a resident choose to
leave, the facility will remind the resident and any individual accompanying the resident to follow
all recommended infection prevention practices including wearing a face covering or mask, physical
distancing, and hand hygiene and to encourage those around them to do the same.
Upon the resident’s return, the facility will take the following actions:
- Screen residents upon return for signs or symptoms of COVID-19.
- If the resident or family member reports possible close contact to an individual with COVID-19 while outside of the facility, test the resident for COVID-19,
regardless of vaccination status. Place the resident on quarantine if the resident has not been fully vaccinated.
- If the resident develops signs or symptoms of COVID-19 after the outing, test the resident for COVID-19 and place the resident on Transmission-Based Precautions, regardless of vaccination status.
- The facility may also opt to test unvaccinated residents without signs or symptoms if they leave the nursing home frequently or for a prolonged length of time, such as over 24 hours.
- The facility may consider quarantining unvaccinated residents who leave the facility if, based on an assessment of risk, uncertainty exists about their adherence or the adherence of those around them to recommended infection prevention measures.
- Monitor residents for signs and symptoms of COVID-19 daily.
Residents who leave the facility for 24 hours or longer will generally be managed as a new admission or readmission, as recommended by the CDC’s “Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes.” Please note that there are exceptions to quarantine, including for fully vaccinated residents.