Nursing Home Visitation Restrictions Lifted in Time for Holidays

On November 12, 2021, the Centers for Medicare & Medicaid Services (CMS) issued a revision to QSO-20-39-NH, “Nursing Home Visitation – COVID-19” (originally published 9/17/2020). The new visitation guidance generally allows visitation without restrictions at nursing homes across the country. This Federal guidance does not supersede State guidance, so guidance from your home State may differ, but this information is likely to be followed by most jurisdictions.

CMS makes the following justifications for the revised guidance:

• COVID-19 vaccines are now fully approved by the FDA in addition to already being authorized for Emergency Use. Those vaccines are being widely administered to nursing home staff and residents, and have been shown to help prevent symptomatic infection. As of the publishing  date of this QSO Memo, CMS states that approximately 86% of nursing home residents and 75% of nursing home staff were fully vaccinated.
• CMS states that there has been an approximately 80% reduction in the average number of nursing home resident weekly COVID-19 cases from January 2021 vs. September 2021, which the Agency attributes to vaccine effectiveness.
• Since the number of vaccinated staff is lower than resident vaccination rates, CMS established staff vaccination requirements on November 4, 2021, for nursing homes.
• CMS regulations require that nursing homes provide education to staff and residents regarding the risks and benefits of vaccines, offer to vaccinate them and report their vaccination data to the CDC’s NHSN.
• Adherence to the Core Principles of COVID-19 infection prevention can mitigate the spread of COVID-19.

As such, CMS believes that there is no reason to restrict resident visitation but recognizes that there are some areas where visitation concerns are valid, such as visiting an unvaccinated resident in a county where there is a substantial/high level of community transmission. The Agency also notes that nursing home residents have the right to make choices and are also able to withdraw consent to have visitors at any time, so residents and their representatives can make decisions to ensure the resident can receive visitors if he/she chooses.

New Addition to the Core Principles of COVID-19 Infection Prevention

While the CMS/CDC list of core principles has basically remained the same since it was issued, the new visitation guidance includes a new addition. The newest principle is that visitors who have a positive viral test for COVID-19, symptoms of COVID-19, or who currently meet the criteria for quarantine should not enter the facility. Facilities are expected to screen prospective visitors who enter the facility for these potential exclusions.

The newest principle is that visitors who have a positive viral test for COVID-19, symptoms of COVID-19, or who currently meet the criteria for quarantine should not enter the facility.

The other principles include hand hygiene, use of a face covering/mask, physical distancing of at least six feet between people, use of instructional signage and education, cleaning/disinfecting of high touch areas, appropriate staff use of PPE, cohorting of residents and testing of residents and staff as required. CMS states that these principles must be adhered to at all times, and any visitors who are unable to adhere to these requirements should not be permitted to visit or be asked to leave.

Healthcare Worker/ Service Provider Entry

• All healthcare workers must be permitted to come into the facility as long as they are not showing signs/ symptoms of COVID-19 or subject to a work exclusion.
• EMS workers continue to not need to be screened prior to entry.
• All staff, contractors and volunteers should adhere to the core principles and must comply with COVID-19 testing requirements.
• Healthcare workers and individuals who are involved with educating and assisting resident transitions to the community should be allowed to enter the facility consistent with the guidance outlined in the updated QSO Memo.

Visitor Testing and Vaccination

While the vaccination of residents and staff has been mandated by CMS, the same requirements have not been extended to visitors, and providers do not have much ability to restrict visitors based on their vaccination status per the new guidance. The new guidance states the following:

• Testing –  CMS encourages providers to offer testing to residents, if available, in counties with substantial or high levels of community transmission. Providers can also encourage visitors to be tested 2-3 days before coming to the facility. This means that testing is not required – only encouraged – and is recommended only based on substantial/high transmission counties.
• Vaccination – CMS notes that the Agency encourages all visitors to become vaccinated before visiting the facility, and recommends that facilities also provide education and encourage visitors to become vaccinated. However, visitors are not required to be tested, or vaccinated, or show proof of vaccination as a condition of visitation. Providers continue to be allowed to ask visitors about their vaccination status, and if a visitor declines to disclose his/her vaccination status, the visitor should wear a face covering/mask at all times.

Visitors are not required to be tested, or vaccinated, or show proof of vaccination as a condition of visitation.

Visitation Areas

As per the previous visitation guidance, CMS continues to state that outdoor visitation is preferable. However, in recognition that winter is coming and that may not be feasible, CMS has greatly expanded its guidance surrounding indoor visitation. Here’s what to know:

• Indoor visitation must be allowed at all times, and for all residents as permitted under regulations.
• The length, frequency and number of visitors cannot be restricted. Facilities may not require advance scheduling of visits.
• Visits must be conducted in a way that ensures the Core Principles are adhered to so that visitation does not increase the risk to other residents.
• Facilities must still ensure physical distancing can be maintained during “peak” visitation times such as mealtimes. Large gatherings where many visitors are in the same space together and physical distancing cannot be maintained should be avoided.
• Visitors should wear face coverings/masks when around other residents or healthcare personnel, regardless of vaccination status.

Visitors should wear face coverings/masks when around other residents or healthcare personnel, regardless of vaccination status.

Unlike prior guidance, it is important to note that indoor visitation during a COVID-19 outbreak investigation does not halt indoor visitation. Instead, while the outbreak investigation is underway, indoor visitation is permissible. Facilities should advise visitors of the potential risk of visiting during an outbreak, and all visitors need to adhere to the core principles of infection prevention while in the facility. The resident should wear a face covering/mask during the visit, regarding of his/her vaccination status and the visits should be in the resident’s room, if possible.

There are also recommendations based on the county positivity rate to provide more flexibility. These include:

• Low or Moderate Transmission Areas – CMS states that the safest practice is for residents and visitors to wear face coverings/masks and physically distance, especially if either party is not vaccinated or is at increased risk for severe disease. If the resident and all their visitors are fully vaccinated and the resident is not moderately or severely immunocompromised, they may choose not to wear face coverings/masks and may have physical contact.
• Substantial or High Transmission Areas – If the nursing home is in a county of substantial or high COVID-19 transmission, all visitors and residents, regardless of vaccination status, should physically distance and wear face coverings/masks at all times. While those restrictions remain in place, indoor visits are not restricted.

Several health status-related items are included in the updated CMS guidance, including:

• If a resident has an unvaccinated or immunocompromised roommate, visits should not be conducted in the resident’s room, if possible.
• If a resident is on transmission-based precautions or quarantine, he/she may still receive visitors, even though it is not recommended by CMS. These visits should occur in the resident’s room and the resident should wear a well-fitting face mask if he/she can tolerate it. Visitors of a resident on transmission-based precautions should be made aware of the potential risk of visiting and necessary precautions before they visit. Visitors must adhere to the core principles.
• In recognition that the COVID-19 pandemic has taken on residents, the allowances regarding physical touch have been expanded. In the prior guidance, CMS allowed fully vaccinated residents to have close contact, including physical touch. The new guidance states that unvaccinated residents may also choose to have physical touch based on their preferences/ needs, such as when visitors are in the facility to participate in a certain religious ceremony, end of life situations, or touch from a support person for an individual living with a disability. If this is going to occur, the unvaccinated residents and/or their representative and visitors should be advised of the potential risks of physical contact prior to the visit.

Compassionate Care Visits

Since visitation is now allowed at all times for all residents, in accordance with CMS regulations, compassionate care visits should be allowed at all times, however, CMS expects that these will be rare scenarios given the loosening of visitation restrictions. CMS provides the example that a facility could consider limiting visitation for a severely immunocompromised resident where the number of visitors the resident would be exposed to needs to be limited.

Required Visitation

The new guidance from CMS now states that there are no longer situations where visitation should be related to COVID-19, except for when the visit is limited to being conducted in the resident’s room or is limited to compassionate care. As such, facilities are required to facilitate in-person visitation consistent with regulatory requirements. If a facility fails to facilitate visitation, this would constitute a potential violation and the facility would be subject to a citation and enforcement action.

CMS reminds providers that if a resident, his/her representative and the visitor are aware of the risks associated with visitation, and the visit will occur in a way that does not put other residents at risk, the resident must be allowed to receive visitors as he/she chooses. Other important details to note:

• Representatives of the State Long-Term Care Ombudsman are also required to be provided with immediate access to the resident. However, if the resident is in quarantine or on transmission-based precautions, or the resident is unvaccinated and residing in a nursing home where the community transmission level is substantial or high for the past 7 days, the visit should take place in the resident’s room. The resident and the Ombudsman should be made aware of the risks associated with in-person visitation. If the resident or Ombudsman request an alternate form of communication, the facility must facilitate this, such as through the use of phone or tablet.
• Any representative of the protection and advocacy systems must also be allowed immediate access to the resident. As with the guidance in the prior bullet, if the resident is in quarantine, on transmission-based precautions, or the resident is unvaccinated and living in the nursing home where the community transmission level is substantial or high over the past 7 days, the visit should take place in the resident’s room. Prior to visitation, the resident and representative should be made aware of the risk of visitation.
• Surveyors should not enter the facility if they have a positive viral test for COVID-19, have signs or symptoms of COVID-19, or meet the criteria for quarantine. However, facilities are not permitted to restrict access to surveyors based on vaccination status or ask a surveyor for proof of vaccination as a condition of entry to the facility.

Communal Activities, Dining and Resident Outings

CMS states that the safest approach is for everyone in the facility, regardless of vaccination status, to wear a face covering/ mask while in communal areas of the facility.

The facility is expected to remind the resident and anyone accompanying the resident to follow all recommended infection control practices, including physical distancing, performing appropriate hand hygiene, wearing a face covering/ mask, and encouraging everyone around them to do the same.

When a resident returns to the facility, the guidance has been expanded, but loosened.

• The facility should screen the resident for signs or symptoms of COVID-19 upon return.
• The facility has the option to opt to test unvaccinated residents who have no signs/ symptoms of COVID-19 if they leave the nursing home frequently or for a long period of time, such as overnight/ more than 24 hours.
• Residents should be monitored for signs and symptoms of COVID-19 daily.
• If the resident develops signs or symptoms of COVID-19 after leaving the facility, the resident should be tested for COVID-19 and placed on Transmission-Based Precautions, regardless of vaccination status.

Thinking About Quarantine:

• A resident who leaves the facility for 24 hours or longer should generally be managed as a new admission or readmission, in accordance with CDC guidance. There are exceptions to quarantine, including for fully vaccinated residents.
• If a facility is uncertain about a resident’s adherence to infection prevention measures, or unsure of the likely adherence of those around them, the facility may consider quarantining unvaccinated residents.
• If a resident or family member reports possible close contact to an individual with COVID-19 while outside the facility, the resident should be tested for COVID-19, regardless of vaccination status. The resident should be placed on quarantine if the resident has not been fully vaccinated.

That’s a lot of absorb, given the restrictions in place since March 2020, and opening visitation up does not absolve the provider from protecting its residents. Infection control is still a hot topic on survey, and will continue to be so for the near future, so ensure you have protocols in place to ensure adherence to the core principles. Even though everyone likely has COVID-fatigue, it is more important than ever that your staff do the right thing throughout the building when it comes to infection control – including ensuring visitors do the right thing, too.

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