Advisory Memo from DPSQA/OLTC re: Guidance for Visitation/COVID-19

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On Friday, February 26, 2021, Governor Asa Hutchinson announced that all public health directives that have been issued will be converted to public health guidelines, effective immediately. This shift is due to progress in the number of cases and hospitalizations.

As a Nursing Facility, it is essential that you continue to follow the CMS Nursing Home Visitation Guidance – COVID-19. It is also important that all Nursing Facilities continue to follow the Core Principles of COVID-19 Infection Prevention by adhering to the following:

  • Screening of all who enter the facility for signs and symptoms of COVID-19 (this includes visitors)

  • Denial of entry of those with signs or symptoms

  • Hand hygiene (use of alcohol-based hand rub is preferred)

  • Face covering or mask (covering mouth and nose)

  • Social distancing at least six feet between persons

  • Instructional signage throughout the facility and proper visitor education on COVID19 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 COVID-19 care)

  • Resident and staff testing conducted, as required

These core principles are consistent with the CMS and Centers for Disease Control and Prevention (CDC) guidance for nursing homes and congregated settings such as ICF settings, ICF/IID and PRTF and should be adhered to at all times.

Outdoor Visitation. While taking a person-centered approach and adhering to the core principles of COVID-19 infection prevention, outdoor visitation is preferred and can also be conducted in a manner that reduces the risk of transmission. When conducting outdoor visitation, facilities should have a process to limit the number and size of visits occurring simultaneously to support safe infection prevention actions (e.g., maintaining social distancing). For complete details, visit CMS Visitation Guidance – Outdoor Visitation.

Indoor Visitation. Facilities should accommodate and support indoor visitation, including visits for reasons beyond compassionate care situations, based on the following guidelines: a) There has been no new onset of COVID-19 cases in the last 14 days and the facility is not currently conducting outbreak testing; b) Visitors should be able to adhere to the core principles and staff should provide monitoring; c) Facilities should limit the number of visitors per resident and should consider scheduling visits for a specified length of time; and d) Facilities should limit movement in the facility. For complete details, visit CMS Visitation Guidance – Indoor Visitation.

Visitor Testing. While not required, the guidance encourages facilities in medium or high-positivity counties to test visitors, if feasible. If so, facilities should prioritize visitors that visit regularly (e.g., weekly), although any visitor can be tested. Facilities may also encourage visitors to be tested on their own prior to coming to the facility (e.g., within 2–3 days) with proof of negative test results and date of test. For complete details, visit CMS Visitation Guidance – Visitor Testing.

Compassionate Care Visits. Compassionate Care Visits are also important for residents who are struggling with the change in environment and lack of physical family support, grieving, need encouragement, or are experiencing emotional distress. According to the guidance, compassionate care visits can be conducted using social distancing; however, if during a compassionate care visit, a visitor and facility identify a way to allow for personal contact, it should only be done following all appropriate infection prevention guidelines, and for a limited amount of time. Through a person- centered approach, facilities should work with residents, families, caregivers, resident representatives, and the Ombudsman program to identify the need for compassionate care visits. For complete details, visit CMS Visitation Guidance – Compassionate Care Visits.

Required Visitation. Except for on-going use of virtual visits, per CMS guidance, facilities may still restrict visitation due to the COVID-19 county positivity rate, the facility’s COVID-19 status, a resident’s COVID-19 status, visitor symptoms, lack of adherence to proper infection control practices, or other relevant factor related to the COVID-19 PHE. However, facilities may not restrict visitation without a reasonable clinical or safety cause. Failure to facilitate visitation, without adequate reason related to clinical necessity or resident safety, would constitute a potential violation of 42 CFR 483.10(f)(4), and the facility would be subject to citation and enforcement actions. Residents who are on transmission-based precautions for COVID-19 should only receive visits that are virtual, through windows, or in-person for compassionate care situations, with adherence to transmission-based precautions. However, this restriction should be lifted once transmission-based precautions are no longer required per CDC guidelines, and other visits may be conducted as described above. For complete details, visit CMS Visitation Guidance – Required Visitation.

Access to the Long-Term Care Ombudsman. As stated in previous CMS guidance QSO-20-28- NH, 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. For complete details, visit CMS Visitation Guidance- Access to the Long-Term Care Ombudsman.

Entry of Health Care Workers and Other Providers of Services. Health care workers who are not employees of the facility but provide direct care to the facility’s residents must be permitted to come into the facility as long as they are not subject to a work exclusion due to an exposure to COVID-19 or show signs or symptoms of COVID-19 after being screened. EMS personnel do not need to be screened so they can attend to an emergency without delay. For complete details, visit CMS Visitation Guidance – Entry of Health Care Workers and Other Providers of Services.

Communal Activities and Dining. While adhering to the core principles of COVID-19 infection prevention, communal activities and dining may occur. Facilities should consider additional limitations based on status of COVID-19 infections in the facility. Additionally, group activities may also be facilitated (for residents who have fully recovered from COVID-19, and for those not in isolation for observation, or with suspected or confirmed COVID-19 status) with social distancing among residents, appropriate hand hygiene, and use of a face covering. For complete details, visit CMS Visitation Guidance – Communal Activities and Dining.

Use of CMP Funds to Aid in Visitation Technology. Use of CMP Funds to Aid in Visitation Technology can also help improve social connections for some residents by helping to support and maintain relationships with loved ones. CMS has previously approved the use of CMP funds (See QSO-20-28-NH) to purchase communicative devices, such as tablets or webcams, to increase the ability for nursing homes to help residents stay connected with their loved ones. To ensure a balanced distribution of funds, facilities are limited to purchase one communicative device per 7– 10 residents, up to a maximum of $3,000 per facility. Additionally, facilities may apply to use CMP funds to help facilitate in-person visits. CMS will now approve the use of CMP funds to purchase tents for outdoor visitation and/or clear dividers (e.g., Plexiglas or similar product) to create a physical barrier to reduce the risk of transmission during in person visits. Funding for tents and clear dividers is also limited to a maximum of $3,000 per facility. NOTE: When installing tents, facilities need to ensure appropriate life safety code requirements found at 42 CFR 483.90 are met, unless waived under the PHE declaration.

Each facility must adhere to the federal regulations and the CMS guidance outlined in this memo. For complete details, please visit the hyperlinks in each section.