CMS Releases Updated Nursing Home Visitation QSO Memo

On September 17, 2020, the Centers for Medicare & Medicaid Services (CMS) released a new QSO memo, “Nursing Home Visitation – COVID-19.” The purpose of the document is to provide “reasonable” ways for nursing homes to facilitate in-person visitation at nursing homes in a safe manner that will also address the psychosocial needs of their residents. At many facilities, it has been difficult for residents to not feel socially isolated from their families and loved ones due to the visitation restrictions.  The Memo also provides information on the use of Civil Monetary (CMP) funds for facilitating this visitation safely.

Throughout the COVID-19 Public Health Emergency (PHE), CMS issued information related to visitation restrictions, including a March 2020 QSO Memo, the May 2020 Nursing Home Reopening Recommendations and in June 2020, a Frequently Asked Questions (FAQ) document covering visitation. The new Memo, issued yesterday, supersedes and replaces the prior guidance and recommendations. The QSO Memo highlights a list of core principles of infection prevention for COVID-19 that are consistent with existing Centers for Disease Control and Prevention (CDC) guidance.

Core Principles of COVID-19 Infection Prevention

These principles should be adhered to at all times. Per the QSO Memo, visitors who do not adhere to these principles should be prohibited from visiting or be asked to leave.

  • Screening  – All individuals who enter the facility must be screened for signs and symptoms of COVID-19 and anyone who exhibits those signs/symptoms should be denied entry.  Remember temperature taking is part of the screening process.
  • Hand hygiene – Use of alcohol-based hand rub is considered preferable
  • Source Control  – Face coverings or masks that cover the mouth and nose should be worn
  • Social Distancing – Social distancing measures that create at least six feet of distance between people should be used
  • Signage – Instructional signage should be placed throughout the facility. Proper visitor education on COVID-19 signs and symptoms, infection control precautions and other facility practices in place should be completed. This includes education on appropriate hand hygiene, wearing masks/face coverings, restrictions to entries/exits and other procedures the facility has put in place for infection prevention during visitation.
  • Cleaning and Disinfecting – After each visit, the facility should ensure that the designated visitation areas are cleaned and disinfected. High-touch areas throughout the facility also require a more frequent cleaning and disinfecting schedule.
  • Personal Protective Equipment – Facility staff must utilize appropriate PPE
  • Cohorting – Residents should be separated into cohorts through the use of dedicated areas/wings in the facility
  • Testing – As set out under the new regulation at F886, nursing homes staff and residents must be tested for COVID-19. (View CMSCG Ftag of the Week for F886 here – Pt. 1 and Pt. 2)

The QSO Memo also outlines many existing Resident Rights regulations to highlight nursing homes’ responsibility to provide access to the resident under a variety of circumstances.

Facilities are Expected to Facilitate In-Person Visitation

CMS has turned the corner from restricting visitation to reminding facilities of their obligation to facilitate in-person visitation so long as there is no reasonable clinical or safety cause, consistent with the requirements at F563 Visitation Rights (view our CMSCG Ftag of the Week for F563 here). The QSO Memo states that except for the on-going use of virtual visitation means, facilities can still restrict visitation due to:

  • County COVID-19 positivity rate
  • Facility COVID-19 status
  • Resident’s COVID-19 status
  • Visitor symptoms
  • Lack of adherence to proper infection control practices
  • “Other” relevant factor related to the COVID-19 PHE

This means that a facility must facilitate in-person visitation consistent with regulations by applying the guidance that is provided in the QSO Memo. If a facility fails to facilitate visitation without adequate reason related to resident safety or clinical necessity, this will be considered a potential violation of F563 and the facility would be subject to a citation and enforcement actions.

Outdoor Visitation

The QSO Memo states that outdoor visitation is the preferred method for visitation because it reduces the risk of transmission due to increased space and airflow. All visits should be held outdoors whenever practicable. Considerations that could limit outdoor visitation include:

  • Inclement weather or extreme temperatures or other weather-related issues
  • Resident’s health status, including COVID-19 status
  • Facility’s outbreak status

The county positivity rate does not need to be considered for outdoor visitation.

Facilities are expected to create safe and accessible outdoor spaces for visitation and have a process in place to limit the number of visitors and size of visits that simultaneously occur. CMS also recommends “reasonable limits” be placed on the number of visitors each resident has at the same time.

Indoor Visitation

Indoor visits that go beyond compassionate care situations should be accommodated and supported by the facility, but the following guidelines should be followed:

  • The facility has had no new onset of COVID-19 cases in the last 14 days and the facility is not currently conducting outbreak testing
  • Visitors are able to adhere to the core principles of COVID-19 infection prevention and staff are able to provide monitoring for any visitors who may have difficulty adhering to those principles (i.e. children).
  • The number of visitors per resident at one time is limited and the total number of visitors in the facility at one time is limited based on the size of the building and the physical space available. Facilities should considering putting limits on the length of time visits can occur to ensure all residents can receive visitors.
  • Visitor movement in the facility should be limited, such as going directly to the resident’s room or designated indoor visitation area and not move throughout the facility.
  • Visits for residents who share a room should not be conducted in the resident’s room.
    • For situations where there is a roommate and the resident’s health status prevents the resident from leaving his/her room, the facility should try to enable in-room visitation while adhering to the core principles.

To facilitate indoor visitation, facilities should use the county positive rate that CMS recently started using to track nursing home testing frequency needs. This data, per the QSO Memo, can also be used to facilitate indoor visitation through the following:

  • <5% – “Low” county positivity rates – Indoor visitation should occur and the core principles should be followed, as well as facility policies (beyond compassionate care)
  • 5%-10% – “Medium”  county positivity rates – Visitation should occur according to facility policies (beyond compassionate care situations) and the core principles of COVID-19 infection prevention
  • >10% – “High” county positivity rates – Visitation should be limited to compassionate care situations according to the core principles and facility policies

Facilities can also monitor other factors to determine the level of COVID-19 risk.

Expanding the Definition of “Compassionate Care”

In prior guidance, CMS has stated that end-of-life situations have been utilized as the primary example of a compassionate care situation where visitation would be allowable, but this is not the only type of situation that meets the definition of compassionate care. Instead, CMS provides several examples of scenarios that would be considered compassionate care, noting that these are not the only situations that could qualify. Facilities are expected to take a person-centered approach to visitation and work with residents, their caregivers, their family and/or resident representatives and the Long-Term Care Ombudsman to identify when there is a need for a compassionate care visit.

CMS provides several examples of compassionate care scenarios, including:

  • A resident who used to be socially engaged with others is currently experiencing emotional distress, seldom speaks or has begun crying more frequently than he/she ever did in the past
  • A resident is who struggling with adjustment to living in the facility and the lack of family support he/she received prior to entering the facility
  • A resident who is experiencing grief after the loss of a friend or family member
  • A resident who is experiencing weight loss or dehydration now that he/she is not receiving encouragement/cueing from a caregiver/family member who previously provided this assistance

The QSO Memo notes that compassionate care visits need not only be conducted with family members, but can include anyone who is able to offer the appropriate support to the resident, such as a member of the clergy.

Social distancing during a compassionate care visit is expected, just as with all other forms of visitation, but if the facility and visitor have identified a manner in which personal contact could be allowed, this would be acceptable so long as all appropriate infection prevention guidelines have been included in the process and time-restrictions should be placed on this type of contact. CMS does not provide examples of what formats this type of personal contact could be.

Visitor Testing

  • It is not required to test visitors; however, CMS encourages facilities in medium or high-positivity counties to test visitors if it is feasible.
  • If it is feasible to test, visitors that visit regularly should be prioritized.
  • Facilities may encourage visitors to be tested prior to their visit (2-3 days) and provide proof of negative test results and the test date.
  • Facilities are also responsible to conduct visitor testing if there is a directive from the State Department of Health.

Long-Term Care Ombudsman Access/Visitation

  • Facilities are expected to provide the LTC Ombudsman with immediate access to residents, and although there may be limitations to in-person access during the COVID-19 PHE, in-person access cannot be limited without reasonable cause.
  • LTC Ombudsman must adhere to the core principles listed above.
  • If a situation arises where in-person access should be restricted for safety, such as the LTC Ombudsman showing signs/symptoms of COVID-19, the facility is still expected to provide the residents with alternate means to communicate with the representative.
  • Per the regulation at F583 Personal Privacy/Confidentiality of Records, the LTC Ombudsman must be allowed to review the resident’s records in accordance with State law. (View CMSCG Ftag of the Week for F583 here).

Access to Residents by Representatives of Protection and Advocacy Systems

Per the regulation at F562 Immediate Access to Resident, any representative of a protection and advocacy system designated by the State and established under the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (DD Act) or a representative from the protection and advocacy system for individuals with a mental disorder that has been established by the Protection and Advocacy for Mentally Ill Individuals Act of 2000 should also receive immediate access to the resident. (View CMSCG Ftag of the week – F586 Resident Contact with External Entities here).

Compliance with Federal Disability Rights Laws

Facilities are also expected to comply with Federal disability rights laws, such as the Americans with Disabilities Act (ADA). This means that residents who require assistance to ensure effective communication and there is not a facility staff member available to facilitate and effective communication cannot be provided without entry of outside assistance, the facility is required to allow an individual into the nursing home who can interpret or facilitate effective communication. CMS notes that there are some exceptions to this (not defined), and that facilities can impose “legitimate” safety measures necessary for safe operations on the individual who would be providing assistance.

Allowing Non-Employee Health Care Workers and Service Providers into the Facility

The QSO Memo states that health care workers who provide direct care to residents but are not employees of the facility must be permitted to enter the facility so long as they are not subject to a work exclusion due to COVID-19 exposure or exhibit signs/symptoms of COVID-19 upon screening. These workers include dialysis technicians, social workers, clergy, hospice workers and EMS personnel.

CMS notes that:

  • EMS personnel do not require screening so they are not delayed in attending to an emergency.
  • All health care workers, as well as volunteers, should adhere to the core infection prevention principles
  • All health care workers must comply with COVID-19 testing requirements

Communal Activities and Dining

The QSO Memo states that communal activities and dining may occur so long as the core principles are being adhered to. This means:

  • Residents may eat in the same room so long as they are socially distanced by limiting the number of residents at a table to keep them a minimum of six feet apart from each other
  • Additional limitations may be considered by the facility depending on the COVID-19 status of the facility
  • Group activities may be facilitated with social distancing among residents, appropriate hand hygiene and use of a face covering for:
    • Residents who have fully recovered from COVID-19
    • Residents not in isolation for observation
    • Residents who do not have suspected or confirmed COVID-19 status
  • The types of activities that can be offered will depend on how the facility is able to ensure necessary precautions are taken. CMS provides the examples of bingo, exercise, crafts, movies and book clubs as being activities that can be facilitated while still adhering to infection prevention guidelines.

Civil Monetary Penalty Funds Available to Aid Visitation Efforts

In response to the COVID-19 PHE, CMS had approved the use of Civil Monetary Penalty (CMP) funds to facilitate the purchase of communication devices to enable residents to communicate with their families and loved ones.

Facilities may now also apply to use CMP funds to facilitate in-person visits. CMP funds will be approved for purchases of tents and/or clear dividers that create a physical barrier between residents and visitors to reduce transmission risk during in-person visits. Funding is limited to $3000 per facility. Of course, there is a caveat – the QSO Memo reminds providers that they must ensure appropriate Life Safety Code (LSC) requirements are followed when tents are being installed.

Read the full QSO Memo, “Nursing Home Visitation – COVID-19” (Ref: QSO-20-39-NH) here.


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