Visitation FAQs

Visitation Considerations

From CMS “Frequently Asked Questions (FAQs) on Nursing Home Visitation (June 23, 2020) 

Necessary steps before having visitors?

What steps should nursing homes take before reopening to visitors? 

Nursing homes should continue to follow CMS and CDC guidance for preventing the transmission of COVID-19, and follow state and local direction. Because nursing home residents are especially vulnerable, CMS does not recommend reopening facilities to visitors (except for compassionate care situations) until phase three (defined by White House, see “Phase 3” definition below) when: 

  • There have been no new, nursing home onset COVID-19 cases in the nursing home for 28 days (through phases one and two) 

  • The nursing home is not experiencing staff shortages 

  • The nursing home has adequate supplies of personal protective equipment and essential cleaning and disinfection supplies to care for residents 

  • The nursing home has adequate access to testing for COVID-19 

  • Referral hospital(s) have bed capacity on wards and intensive care units


Compassionate care situations

The reopening recommendations maintain that visitation should only be allowed for “compassionate care situations.” Do compassionate care situations only refer to end-of-life situations? 

While end-of-life situations were used as examples of compassionate care situations in previous CMS memoranda, the term “compassionate care situations” does not exclusively refer to end-of-life situations. 

Examples: 

  • A resident who was living with their family before recently being admitted to a nursing home, the change in their environment and sudden lack of family can be a traumatic experience. Allowing a visit from a family member in this situation would be consistent with the intent of the term “compassionate care situations.” 

  • Allowing someone to visit a resident whose friend or family member recently passed away, would also be consistent with the intent of these situations. See CMS “Frequently Asked Questions (FAQs) on Nursing Home Visitation for more details. CMS cannot define each situation that may constitute a compassionate care situation.


Outside visits or other creative means

Can facilities use creative means, such as outside visits, to begin to allow for visitation within the CMS and CDC guidelines; even before reaching phase three (defined by White House, see “Phase 3” definition below)?


Yes, the reopening guidance does allow for some flexibility for controlled visitation prior to phase three. CMS recognizes the toll of separation from family and other loved ones while at the same time recognizing the need to balance the safety of residents and staff. 


For example, there may be safe ways for families to see their loved ones outside the facility. Facilities can create spaces for residents without COVID-19, including those who have fully recovered, to participate in outdoor visitation sessions with their loved ones, such as in courtyards, on patios, or even in parking lots. 


Facilities should still ensure all actions for preventing COVID-19 transmission are followed. 


These actions include:

  • screening all visitors for symptoms and fever;

  • asking both residents and visitors to wear a cloth face covering or face mask; 

  • performing hand hygiene (e.g., use alcohol-based hand rub); 

  • maintaining social distancing at all times; and 

  • ensuring the items in visitation spaces are cleaned and disinfected routinely 


If outdoor visitation is conducted, facilities should:


  • limit the number and size of visits occurring simultaneously to support safe infection prevention actions (e.g., maintaining social distancing). 

  • limit the number of individuals visiting with any one resident (e.g., two visitors for one resident visit).

Communal Activities

Can nursing home residents participate in communal activities before reaching phase 3 of the nursing home reopening plan?

The current CMS guidance is not intended to completely restrict communal activities, except in the case of a resident with symptoms consistent with COVID-19 or a confirmed case. The May 18, 2020 reopening recommendations notes that residents may eat in the same room with social distancing (limited number of people at tables and spaced by at least 6 feet).

Group activities may also be facilitated (for residents who have fully recovered from COVID-19, and for those not in isolation for observation, suspected or confirmed COVID-19 status) with social distancing among residents, appropriate hand hygiene, and use of a cloth face covering or facemask.

Facilities may be able to offer a variety of activities while also taking the necessary precautions. For example, book clubs, crafts, movies, and Bingo are all activities that can be facilitated with alterations to adhere to the guidelines for preventing transmission.

CMS sponsors partnership calls in which a number of nursing homes from across the country have shared creative activities that engage residents while still observing infection control practices.

Residents or visitors who have tested positive for COVID-19

Should residents or visitors who have tested positive for COVID-19 participate in visits?
Residents who are in isolation for observation, for having symptoms consistent with COVID-19, or having been confirmed with COVID-19, should not have in-person visits. Similarly, any visitor that has tested positive or has symptoms consistent with COVID- 19, should not come to the facility and refer to CDC guidance for when they can be around others.

If a visitor has tested negative for COVID-19, that reduces some of the risks for allowing creative visitation. However, since the time between a negative test and a visit can vary, all actions to prevent the transmission of COVID-19 should still be followed for visitors that have tested negative (e.g., social distancing, face coverings, hand hygiene, etc.).

For residents who are unable to participate in outdoor visits, including residents with symptoms consistent with COVID-19, or who have tested positive for COVID-19, there are still ways to connect with loved ones. For example, CMS notified state survey agencies that Civil Money Penalty (CMP) reinvestment funds may be used for programs that provide residents with adaptive communicative technologies so that they may enjoy virtual visits. Also, facilities can have staff assist residents with sending or reading texts or emails with family. Lastly, we remind facilities and families to leverage the Long- Term Care Ombudsman Program to help families stay connected with their loved ones. More information on these items can be found in a Frequently Asked Questions (FAQ) document published on April 24, 2020 (see questions 2 and 3 of the FAQ attached to CMS memorandum QSO-20-28-NH). The CDC also has recommendations for how individuals can support their loved ones in a nursing home.

Ombudsman visitation

Are nursing homes required to allow visits from the ombudsman when requested by a resident?

Under sections 1819(c)(3)(A) and 1919(c)(3)(A) of the Social Security Act (the Act), and implementing regulations at 42 CFR 483.10(f)(4)(i)(C), a nursing home is re required by law to provide the state ombudsman immediate access to any resident. In CMS memorandum QSO-20-14-NH, we stated that residents still have the right to access the Ombudsman program. If in-person access is not available due to infection control concerns, facilities need to facilitate resident communication (e.g., by phone or other format) with the Ombudsman program or any other individual listed in 42 CFR 483.10(f)(4)(i). Since ombudsmen are critical resources for residents and their families, nursing homes should facilitate their in-person access as soon as is practicable.

Nursing homes are also required under 42 CFR 483.10(h)(3)(ii) to allow the ombudsman to examine the resident’s medical, social, and administrative records as otherwise authorized by State law.

Also, while CMS waived certain requirements related to discharging a resident, such as notifying the Office of the State Long-Term Care Ombudsman prior to discharge, those waivers are only to be used for the purposes of cohorting residents to prevent transmission of COVID-19.1 For all non-cohorting discharges, facilities must comply with all discharge requirements. For example, per 42 CFR 483.15(c)(3), before a facility transfers or discharges a resident, the facility must notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. Facilities that do not comply with these and all other requirements that have not been waived under section 1135 of the Act are subject to deficiency citation and enforcement action.

1“COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers” is located at https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf. CMS memorandum QSO-20-25-NH, “2019 Novel Coronavirus (COVID-19) Long-Term Care Facility Transfer Scenarios” is located at https://www.cms.gov/files/document/qso-20-25-nh.pdf.

White House

From “Guidelines for Opening Up America Again” (Accessed June 13, 2020)

Gating Criteria

Proposed State or Regional Gating Criteria (Satisfy Before Proceeding to Phased Opening) 


SYMPTOMS

CASES

HOSPITALS

Downward trajectory of influenza-like illnesses (ILI) reported within a 14-day period, 


AND


Downward trajectory of COVID-like syndromic cases reported within a 14-day period

Downward trajectory of documented cases

within a 14-day period, 


OR


Downward trajectory of positive tests as a percent of total tests within a 14-day period (flat or increasing volume of tests)

Treat all patients without crisis care, 


AND


Robust testing program in place for at-risk healthcare workers, including emerging antibody testing



*State and local officials may need to tailor the application of these criteria to local circumstances (e.g., metropolitan areas that have suffered severe COVID outbreaks, rural and suburban areas where outbreaks have not occurred or have been mild). Additionally, where appropriate, Governors should work on a regional basis to satisfy these criteria and to progress through the phases outlined below.


Phase One

Phase one is for states and regions that satisfy the gating criteria (see table above). Visits to senior care facilities and hospitals should be prohibited. Those who do interact with residents and patients must adhere to strict protocols regarding hygiene.

Phase Two

Phase two is for states and regions with no evidence of a rebound and that satisfy the gating criteria a second time. Visits to senior care facilities and hospitals should be prohibited. Those who do interact with residents and patients must adhere to strict protocols regarding hygiene.

Phase Three

Phase three is for states and regions with no evidence of a rebound and that satisfy the gating criteria a third time. Visits to senior care facilities and hospitals can resume. Those who interact with residents and patients must be diligent regarding hygiene.
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