On November 12, 2021, the Centers for Medicare & Medicaid Services (CMS) announced that visitation is now allowed for all residents at all times in nursing homes. The revised guidance becomes effective immediately.
The COVID-19 vaccination has impacted CMS decisions to provide more lenient visitation for residents in nursing homes. The guidance is a revision of QSO-20-39-NH memorandum which was originally issued on September 17, 2020. The CMS guidance allows visitation that is conducted through different means based on a facility’s structure and resident’s needs, such as in resident rooms, dedicated visitation spaces, and access to the outdoors. Regardless of how visits are conducted, there are certain core principles and best practices that must be adhered to reduce the risk of COVID-19 transmissions. The Core Principles include:
- Visitors who have a positive viral test for COVID-19, symptoms of COVID-19, or currently meet the criteria for quarantine, should not enter the facility. Facilities should screen all who enter for these visitation exclusions.
- Hand hygiene – use of alcohol-based hand rub is preferred.
- Face covering or mask (covering both 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; and hand hygiene).
- Clean and disinfect high-frequency touch 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).
The risk of transmission can be further reduced through the use of physical barriers (e.g., clear Plexiglass dividers, curtains). Nursing homes must 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 should not be permitted to visit or should be asked to leave.
Outdoor Visitations: Facilities can use accessible and safe outdoor spaces for visitation, such as 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 must be followed.
Indoor Visitation: Facilities must allow indoor visitation at all times and for all residents as permitted under the regulations. Facilities can 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, does not increase risk to other residents, and ensures that physical distancing is maintained during peak times of visitation. Facilities should avoid large gatherings (e.g., parties, events) where physical distancing cannot be maintained. During indoor visitation, limit visitor movement in the facility. For example, visitors should not walk around different halls of the facility, but should go directly to the resident’s room or designated visitation area.
Indoor Investigation during an Outbreak Investigation: An outbreak investigation must be initiated if a new nursing home onset of COVID-19 occurs (i.e., a new COVID-19 case among residents or staff). Facilities must adhere to CMS regulations and guidance for COVID-19 testing, including routine unvaccinated staff testing, testing of individuals with symptoms, and outbreak testing. If a new case of COVID-19 is identified, 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, they must still be allowed in the facility. Visitors should be informed of potential risk of visiting during an outbreak investigation, follow core principles of infection prevention, and wear face coverings or masks during visits, regardless of vaccination status. Visits should ideally be in the resident’s room.
Visitor Testing and Vaccination: CMS encourages facilities in counties with substantial or high levels of community transmission to offer testing to visitors, if feasible. If not offering testing, encourage visitors to be tested on their own before coming to the facility (e.g., within 2–3 days).
Compassionate Care Visits: Compassionate care visits are allowed at all times. During the PHE, there were 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.
Required Visitation: Facilities must not restrict visitation without a reasonable clinical or safety cause. During the PHE, CMS outlined 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 the resident’s room or the rare event that visitation is limited to compassionate care. Residents at risk (e.g., in the resident’s room) must be allowed to receive visitors as he/she chooses.
Federal Disability Rights Laws and Protection & Advocacy (P&A) Programs: 42 CFR § 483.10(f)(4)(i)(E) and (F) requires each 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). If an agency representative is planning to visit a resident who is in Transmission-Based Precautions or quarantine, or an unvaccinated resident in a county where the level of community transmission is substantial or high in the past 7 days, the resident and representative should be made aware of the potential risk of visiting, and the visit should take place in the resident’s room.
Entry of Healthcare Workers and Other Providers of Services: All healthcare workers must 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. EMS personnel do not need to be screened so they can attend to an emergency without delay.
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 can be facilitated with alterations to adhere to the guidelines for preventing transmission. Facilities must permit residents to leave the facility as they choose and remind the resident and any accompanying individual to follow 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. Screen residents upon return for signs or symptoms of COVID-19 and ask about possible exposure. If close contact occurred, test the resident for COVID-19, regardless of vaccination status, and place the resident on quarantine if he or she is not fully vaccinated. If the resident develops signs or symptoms of COVID-19 after the outing, test for COVID-19 and institute Transmission-Based Precautions, regardless of vaccination status. Monitor residents for signs and symptoms of COVID-19 daily. Residents who leave the facility for 24 hours or longer should generally be managed as a new admission or readmission.
Survey Considerations: State survey agencies and CMS are responsible for ensuring surveyors are compliant with applicable expectations. LTC facilities may not restrict access to surveyors based on vaccination status, nor ask a surveyor for proof of his or her vaccination status.
The entire CMS memo QSO-22-02-All can be accessed at QSO-20-39-NH REVISED (cms.gov).
Issue:
As we all continue to battle against COVID-19 and its variants, it is essential that each facility has the most up-to-date information in their Infection Control Plan. Masking and vaccinations are critical strategies to help decrease the spread of COVID-19 and its variants. Facilities should also provide education for residents and their visitors so that all residents, staff, and visitors adhere to the Infection Control Plan. Healthcare personnel must stay up to date on any important changes in CMS requirements and train all staff on the available information.
Discussion Points:
- Review your Infection Control Plan. Update as needed.
- Train all staff on your Infection Control Plan and how to prevent the spread of the virus. Place signed training documentation in each employee’s education file.
- Periodically audit to ensure that all staff are following your Infection Control Plan.
