CMS Updates Nursing Home Guidance with Revised Visitation Recommendations

Nursing homes have been severely impacted by COVID-19, with outbreaks causing high rates of infection, morbidity, and mortality. [1] The vulnerable nature of the nursing home population, combined with the inherent risks of congregate living in a healthcare setting, have required aggressive efforts to limit COVID-19 exposure and to prevent the spread of COVID-19 within these facilities.

Since the beginning of the pandemic, the Centers for Medicare & Medicaid Services (CMS) has recognized that physical separation from family and other loved ones has taken a physical and emotional toll on residents and their families. Today, CMS is announcing guidance on expanding indoor visitation in nursing homes, in response to significant reductions in COVID-19 infections and transmission resulting from ongoing infection control practices, and high vaccination rates in the nursing home population following the authorization of COVID-19 vaccines by the U.S. Food and Drug Administration (FDA’s) authorization of COVID-19 vaccines for emergency use.

Visitation can be conducted through various means based on a facility’s’ structure and residents’ needs, including in resident rooms, visitation spaces, and outdoors. Given the ongoing risk of COVID-19 transmission, CMS continues to recommend facilities, residents, and families adhere to the core principles of COVID-19 infection control, including maintaining physical distancing and conducting visits outdoors whenever possible. This continues to be the safest way to prevent the spread of COVID-19, particularly if either party has not been fully vaccinated.

Starting March 10, 2021, the following visitation guidance recommends:

Indoor Visitation

• Facilities should allow responsible indoor visitation at all times and for all residents, regardless of vaccination status of the resident, or visitor, unless certain scenarios arise that would limit visitation for:
  • Unvaccinated residents if; 1) the COVID-19 county positivity rate is greater than 10 percent; and 2) less than 70 percent of residents in the facility are fully vaccinated;
  • Residents with confirmed COVID-19 infection, whether vaccinated or unvaccinated until they have met the criteria to discontinue transmission-based precautions; or
  • Residents in quarantine, whether vaccinated or unvaccinated, until they have met criteria for release from quarantine.

  Indoor Visitation During an Outbreak

  • While outbreaks increase the risk of COVID-19 transmission, a facility should not restrict visitation for all residents as long as there is evidence that the transmission of COVID-19 is contained to a single area (e.g., unit) of the facility. Facilities should continue to adhere to CMS regulations and guidance for COVID-19 testing, including routine staff testing, testing of individuals with symptoms, and outbreak testing.
  • When a new case of COVID-19 among residents or staff is identified, a facility should immediately begin outbreak testing and suspend all visitation until at least one round of facility-wide testing is completed. Visitation can resume based on the following criteria:
    • If the first round of outbreak testing reveals no additional COVID-19 cases in other areas (e.g., units) of the facility, then visitation can resume for residents in areas/units with no COVID-19 cases. However, the facility should suspend visitation on the affected unit until the facility meets the criteria to discontinue outbreak testing.
    • If the first round of outbreak testing reveals one or more additional COVID-19 cases in other areas/units of the facility (e.g., new cases in two or more units), then facilities should suspend visitation for all residents (vaccinated and unvaccinated), until the facility meets the criteria to discontinue outbreak testing.

    Compassionate Care Visits

    Visits for compassionate care, such as an end-of-life situation or a residents in decline or distress should be allowed at all times for any resident (vaccinated or unvaccinated), regardless of the above scenarios. In addition, facilities and visitors should continue all infection prevention and control practices.

    Ombudsman

    As always, federal regulations 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.

    Vaccination for Visitors and Surveyors

    • • We encourage visitors to facilities to become vaccinated when they have the opportunity. While visitor testing and vaccination can help prevent the spread of COVID-19, visitors should not be required to be tested or vaccinated (or show proof of such) as a condition of visitation.
      • Federal and state surveyors are not required to be vaccinated and must be permitted entry into facilities unless signs or symptoms of COVID-19 are present. Surveyors should also adhere to infection prevention and control practices.

      Note: CMS and CDC continue to recommend facilities, residents, and families adhere to the core principles of COVID-19 infection, including physical distancing (maintaining at least 6 feet between people). This continues to be the safest way to prevent the spread of COVID-19, particularly if either party has not been fully vaccinated. However, we acknowledge the toll that separation and isolation has taken. We also acknowledge that there is no substitute for physical contact, such as the warm embrace between a resident and their loved one. Therefore, if the resident is fully vaccinated, they can choose to have close contact (including touch) with their visitor while wearing a well-fitting facemask. Regardless, visitors should physically distance from other residents and staff in the facility.

      Background

      In March 2020, CMS issued memorandum QSO-20-14-NH providing guidance to facilities on restricting visitation of all visitors and non-essential health care personnel, except for certain compassionate care situations, such as an end-of-life situation. In May 2020, CMS released Nursing Home Reopening Recommendations , which provided additional guidance on visitation for nursing homes as their states and local communities progress through the phases of reopening. In June 2020, CMS also released a Frequently Asked Questions document on visitation, which expanded on previously issued guidance on topics such as outdoor visits, compassionate care situations, and communal activities.

      In September 2020, CMS issued revised guidance encouraging nursing homes to facilitate outdoor visitation and allowed for indoor visitation if there has been no new onset of COVID-19 cases in the past 14 days and the facility was not conducting outbreak testing per CMS guidelines. The guidance also clarified additional examples of compassionate care situations.