CMS Updates Nursing Home Visitation Guidance – Again

On September 23, 2022, the Centers for Medicare & Medicaid Services (CMS) updated the QSO Memo, “Nursing Home Visitation – COVID-19 (REVISED)” (Ref: QSO-20-39-NH), which was originally issued September 17, 2020 and has seen several revisions ( March 2021, April 2021) throughout the COVID-19 Public Health Emergency (PHE).

Let’s look at what’s been updated.

New Core Principle of COVID-19 Infection Prevention

The QSO Memo includes a new “core principle” for facilities to implement regarding guidance for visitors, including providing guidance, including through posted signage at entrances regarding recommended actions for visitors who have:

• A positive viral test for COVID-19
• Symptoms of COVID-19
• Had close contact with someone with COVID-19

This means:

• Visitors with a confirmed COVID-19 infection or COVID-19 symptoms should defer not-urgent in-person visitation until they meet CDC criteria for healthcare settings to end their isolation.
• Visitors who have had close contact with someone with COVID-19 should be advised that it is safest to defer non-urgent, in-person visitation until 10 days after their close contact, if they meet the criteria included in CDC guidance for healthcare settings.

Outdoor Visitation Update

The revised QSO Memo also includes an update for outdoor visitation planning. The Memo notes that during “peak” visitation times and when there are large gatherings at the facility, providers should encourage physical distancing.

Indoor Visitation During an Outbreak Investigation

The revised guidance now states that an outbreak investigation must be initiated when a “single new case” of COVID-19 occurs among residents or staff “to determine if others have been exposed,” If a new case of COVID-19 is identified, the facility should immediately begin outbreak testing, “but not earlier than 24 hours after the exposure, if known.”

Visitation, as we know, is still allowed during an outbreak investigation. However, the updated guidance now includes that while an outbreak investigation is occurring:

• Visitor movement in the facility should be limited.
• Visitors should physically distance themselves from other residents and staff

Face Coverings and Masks During Visitation Updated

In the updated guidance, CMS has clarified two terms that important visitation and mask use – Community Transmission vs. COVID-19 Community Level.

Community Transmission differs from the COVID-19 “Community Level” in that the community level is used for non-healthcare settings. Nursing Homes are expected to use the Community Transmission Level, not the Community Level metric.

Now let’s look at the revised guidance related to mask use. It is as follows:

• When county COVID-19 transmission is high: Everyone in the facility should wear face coverings or masks
• When county COVID-19 transmission is not high: The safest practice is to require residents and visitors to wear face coverings/masks. The guidance states that the facility could choose not to have visitors wear face coverings/masks in the facility except during an outbreak.

Facilities must base their policies regarding face masks/coverings on recommendations from the CDC, State and local health departments and individual facility circumstances. It is important to note that there may be different guidance from the health department in a locality or state that is more stringent than what is in this Memo.

There is additional updated guidance related to in-room visits or visits in designated visitation areas. This includes:

• Residents and their visitors may choose not to wear face coverings/masks and may choose to have close contact when they are alone in the resident’s room or a designated visitation area, regardless of the community transmission level. The resident and/or representative should be advised of the risks of physical contact prior to the visit.
• If a roommate will be present during an in-room visit, the safest practice is for the visitor to wear a face covering/mask.

Communal Activities, Dining and Resident Outings

The updated guidance recommends that during communal/group activities, the safest approach is for everyone, especially those who are high-risk, wear a face covering/mask while in communal areas of the facility. If a resident chooses to leave the facility for an outing, the facility should remind the resident and escort that they should follow all recommended infection prevention practices. This includes wearing a face mask/covering, especially when the resident is at high risk for severe illness and the community transmission rate is high.

Nursing Home Visitation – Frequently Asked Questions (FAQs)

The FAQs attachment of the revised Memo has been updated and is dated September 23, 2022, so ensure you have the current version (original version is from September 2020). Several tweaks have been made and one question has been added.

View the Revised CMS QSO Memo (Ref: QSO-20-38-NH) here.