Visitation Information for Continuing Care Residents
During a Respiratory Pandemic
Section 1: Policy
The facility should continue to follow CMS and CDC guidance for preventing the transmission of COVID-19 and follow state and local direction due to the vulnerability of nursing home residents. For additional guidance the facility should refer to CMS QSO Memo 20-39.
Visitation can be conducted through different means based on a facility’s structure and residents’ needs, such as in resident rooms, dedicated visitation spaces, outdoors, and for circumstances beyond compassionate care situations. Regardless of how visits are conducted, there are certain core principles and best practices that reduce the risk of COVID-19 transmission.
Core Principles of COVID-19 Infection Prevention:
- Facilities should screen all who enter for these visitation exclusions, including; having a positive viral test for COVID-19, symptoms of COVID-19, close contact with someone with SARS-CoV-2 infection (visitors should not visit if they have any of the following and have not met the same criteria used to discontinue isolation and quarantine for residents as outlined by the COVID-19 Policy).
- Hand hygiene (use of alcohol-based hand rub is preferred).
- Face covering or mask (covering mouth and nose), in accordance with CDC guidance.
- Social distancing at least six feet between persons, in accordance with CDC guidance.
- Instructional signage throughout the facility and proper visitor education on COVID-19 signs and symptoms, infection control precautions, and 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 to COVID-19 care).
- Resident and staff testing was conducted as required at 42 CFR 483.80(h) (see QSO-20- 38-NH).
Facilities shall not restrict visitation without a reasonable clinical or safety cause, consistent with 42 CFR § 483.10(f) (4) (v). A nursing home must facilitate in-person visitation consistent with the applicable CMS regulations. Failure to facilitate visitation, per 42 CFR § 483.10(f)(4), which states “The resident has a right to receive visitors of his or her choosing at the time of his or her choosing, subject to the resident's right to deny visitation when applicable, and in a manner that does not impose on the rights of another resident,” would constitute a potential violation and the facility would be subject to citation and enforcement actions.
Section 2: Procedure
- The above core principles are consistent with the Centers for Disease Control and Prevention (CDC) guidance for nursing homes and should be adhered to at all times.
- The Executive Director and/or Nursing Home Administrator is responsible for ensuring the adherence to this policy.
- Additionally, visitation should be person-centered, consider the residents’ physical, mental, and psychosocial well-being, and support their quality of life.
- The risk of transmission can be further reduced through the use of physical barriers. Also, nursing homes should enable visits to be conducted with an adequate degree of privacy.
- Visitors who are unable to adhere to the core principles of COVID-19 infection prevention should not be permitted to visit or should be asked to leave.
- The facility should ensure that physical distancing can still be maintained during peak times of visitation (e.g., lunchtime, after business hours, etc.).
- During indoor visitation, the facility should limit visitor movement in the facility. For example, visitors should not walk around different halls of the facility. Rather, they should go directly to the resident’s room or designated visitation area.
- The facility may contact their local health authorities for guidance or direction on how to structure their visitation to reduce the risk of COVID-19 transmission.
Education should be available to visitors on the following:
- Visitation restrictions.
- Actions the facility is taking to protect them, the residents, and associates.
- Actions they can take to protect themselves while in the facility.
- The important role of social distancing.
- How to properly don and doff appropriate PPE.
- Hand hygiene, respiratory hygiene, and cough etiquette.
- Wearing a face covering or mask during the presence in the facility as a means of source control.
- Performing hand hygiene immediately before and after any contact with their facemask or cloth mask.
A resident, client, or patient may designate a visitor who is a family member, friend, guardian, or other individual as an essential caregiver. The facility will allow in-person visitation by the essential caregiver for at least 2 hours daily in addition to any other visitation. The facility does not require an essential caregiver to provide necessary care to a resident, client, or patient of the facility and the facility will not require an essential caregiver to provide such care.
Facilities should allow indoor visitation at all times and for all residents as permitted under the regulations.
The facility will allow in-person visitation in all of the following circumstances, unless the resident, client, or patient objects:
- End-of-life situations
- A resident, client, or patient who was living with family before being admitted to the provider’s care is struggling with the change in environment and lack of in-person family support.
- The resident, client, or patient is making one or more major medical decisions.
- A resident, client, or patient is experiencing emotional distress or grieving the loss of a friend or family member who recently died.
- A resident, client, or patient needs cueing or encouragement to eat or drink which was previously provided by a family member or caregiver.
- A resident, client, or patient who used to talk and interact with others is seldom speaking.
Although there is no limit on the number of visitors or length of the visit, that a resident can have at one time, visits should be conducted in a manner that adheres to the core principles of COVID-19 infection prevention and does not increase risks to other residents.
Visitors, regardless of vaccination status, should wear face coverings or masks and physically distance from other residents and staff when in a communal area in the facility. However, in private settings if the visitor and resident choose to remove face coverings during visitation, they should be made aware of the risks of engaging in close contact with the resident and not wearing a face covering during their visit.
Removal of face coverings is not recommended but if a resident (or responsible party) is aware of the risks of close contact and/or not wearing a face-covering during a visit, and they choose to not wear a face covering and choose to engage in close contact, the facility will not deny the resident their right to choose, as long as the residents’ choice does not put other residents at risk. This would occur only while not in a communal area.
- Compassionate care visits, and visits required under federal disability rights law, should be allowed at all times, regardless of a resident’s vaccination status, the county’s COVID-19 positivity rate, or an outbreak.
- For individuals that enter compassionate care situations, facilities should require visitors to perform hand hygiene, wear a face mask, and use other Personal Protective Equipment (PPE) according to facility policy.
- Also, in addition to family members, compassionate care visits can be conducted by any individual that can meet the resident’s needs, such as clergy or laypersons offering religious and spiritual support. Furthermore, the above list is not an exhaustive list as there may be other compassionate care situations not included.
- 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.
- Visitors should wear face coverings or masks and physically distance when around other residents or healthcare personnel, regardless of vaccination status.
- Residents, regardless of vaccination status, can choose not to wear face coverings or masks when other residents are not present and have close contact (including touch) with their visitor. Residents (or their representative) and their visitors, who are not up-to-date with all recommended COVID-19 vaccine doses, should be advised of the risks of physical contact prior to the visit.
While taking a person-centered approach and adhering to the core principles of COVID-19 infection prevention, outdoor visitation is preferred when the resident and/or visitor are not up-to date with all recommended COVID-19 vaccine doses.
Outdoor visits generally pose a lower risk of transmission due to increased space and airflow. For outdoor visits, facilities should create accessible and safe outdoor spaces for visitation, such as in courtyards, patios, or parking lots, including the use of tents, if available.
However, weather considerations (e.g., inclement weather, excessively hot or cold temperatures, poor air quality) or an individual resident’s health status (e.g., medical condition(s), COVID-19 status, quarantine status) may hinder outdoor visits. When conducting outdoor visitation, all appropriate infection control and prevention practices should be followed.
Visitors may eat with a resident if the resident (or representative) and the visitor are aware of the risks and adhere to the core principles of infection prevention. Eating in a separate area is preferred, however if that is not possible, then the meal could occur in a common area as long as the visitor, regardless of their vaccination status, is physically distanced from other residents and wears a face covering, except while eating or drinking. If the visitor is unable to physically distance from other residents, they should not share a meal with the resident in a common area. Visitors, regardless of vaccination status, must wear face coverings or masks and physically distance from other residents and staff when in a communal area in the facility.
The facility should continue to consult with state and local health departments when outbreaks occur to determine when modifications to visitation policy would be appropriate. The facility should document their discussions with the health department, and the actions they took to attempt to control the transmission of COVID-19.
When a new case of COVID-19 among residents or staff is identified, a facility should immediately begin outbreak protocols in accordance with CMS QSO 20-38-NH REVISED and CDC guidelines.
While it is safer for visitors not to enter the facility during an outbreak investigation, visitors must still be allowed in the facility.
Visitors should be made aware of the potential risk to be exposed to COVID-19, if visiting during an outbreak investigation and adhere to the core principles of infection prevention. Whether residents who are up to date with all recommended COVID-19 vaccine doses are known to be close contacts or are identified as a part of a broad-based outbreak response but not known to be close contacts, indoor visitation should ideally occur only in the resident’s room, the resident and their visitors should wear well-fitting source control (if tolerated) and physically distance (if possible).
Source control and physical distancing recommendations should also be followed for residents who are up to date with all recommended COVID-19 vaccine doses.
Outdoor visitation could be allowed, but residents should wear well-fitting source control (if tolerated), maintain physical distancing from others, and not linger in common spaces when moving from their rooms to the outdoors.
The facility may contact their local health authorities for guidance or direction on how to structure their visitation to reduce the risk of COVID-19 transmission during an outbreak investigation.
CMS strongly encourages all visitors to become vaccinated and the facility should educate and also encourage visitors to become vaccinated. Visitor testing and vaccination can help prevent the spread of COVID-19 and facilities may ask about a visitors’ vaccination status, however, visitors are not required to be tested or vaccinated (or show proof of such) as a condition of visitation. If the visitor declines to disclose their vaccination status, the visitor should wear a face covering or mask at all times. This also applies to representatives of the Office of the State Long-Term Care Ombudsman and protection and advocacy systems.
- State survey agencies and CMS are ultimately responsible for ensuring surveyors are compliant with the applicable expectations. Therefore, the facility is not permitted to restrict access to surveyors based on vaccination status, nor ask a surveyor for proof of his or her vaccination status as a condition of entry. If the facility has questions about the process a state is using to ensure surveyors can enter a facility safely, those questions should be addressed to the State Survey Agency. Surveyors should not enter a facility if they have a positive viral test for COVID-19, signs or symptoms of COVID-19, or currently meet the criteria for quarantine. Surveyors should also adhere to the core principles of COVID-19 infection prevention and adhere to any COVID-19 infection prevention requirements set by federal and state agencies (including Executive Orders).
Access to the Long-Term Care Ombudsman
- As stated in previous CMS guidance QSO-20-28-NH (revised), regulations at 42CFR 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. If an ombudsman is planning to visit a resident who is in TBP or quarantine, who is not up-to-date with all recommended COVID-19 vaccine doses, in a nursing home in a county where the level of community transmission is substantial or high in the past 7 days, the resident and ombudsman should be made aware of the potential risk of visiting, and the visit should take place in the resident’s room. We note that representatives of the Office of the Ombudsman should adhere to the core principles of COVID-19 infection prevention as described above. If the resident or the Ombudsman program requests alternative communication in lieu of an in-person visit, facilities must, at a minimum, facilitate alternative resident communication with the Ombudsman program, such as by phone or through the use of other technology. 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
Federal Disability Rights Laws and Protection & Advocacy (P&A) Programs
- Section 483.10(f)(4)(i)(E) and (F) requires the facility to allow immediate access to a resident by any representative of the protection and advocacy systems, as designated by the state, and as established under the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (DD Act), and of the agency responsible for the protection and advocacy system for individuals with a mental disorder (established under the Protection and Advocacy for Mentally Ill Individuals Act of 2000). Additionally, each facility must comply with federal disability rights laws such as Section 504 of the Rehabilitation Act and the Americans with Disabilities Act (ADA).
If the P&A is planning to visit a resident who is in TBP or quarantine, or a resident, who is not up-to-date with all recommended COVID-19 vaccine doses, in a county where the level of community transmission is substantial or high in the past 7days, the resident and P&A representative should be made aware of the potential risk of visiting and the visit should take place in the resident’s room.
Additionally, each facility must comply with federal disability rights laws such as Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. § 794 (Section 504), and the Americans with Disabilities Act of 1990, 42 U.S.C. §§ 12101 et seq. (ADA).
- For example, if communicating with individuals who are deaf or hard of hearing, it is recommended to use a clear mask or mask with a clear panel. Face coverings should not be placed on anyone who has trouble breathing or is unable to wear a mask due to a disability, or anyone who is unconscious, incapacitated, or otherwise unable to remove the mask without assistance.
- In addition, if a resident requires assistance to ensure effective communication (e.g., a qualified interpreter or someone to facilitate communication) and the assistance is not available by onsite staff or effective communication cannot be provided without such entry (e.g., video remote interpreting), the facility must allow the individual entry into the nursing home to interpret or facilitate, with some exceptions. This would not preclude nursing homes from imposing legitimate safety measures that are necessary for safe operations, such as requiring such individuals to adhere to the core principles of COVID-19 infection prevention.
Entry of Health Care Workers and Other Providers of Services
- All healthcare workers must be permitted to come into the facility as long as they are not subject to a work exclusion or showing signs or symptoms of COVID-19. In addition to health care workers, personnel educating and assisting in resident transitions to the community should be permitted entry consistent with this guidance. We note that EMS personnel do not need to be screened, so they can attend to an emergency without delay. We remind facilities that all staff, including individuals providing services under arrangement as well as volunteers, should adhere to the core principles of COVID-19 infection prevention and must comply with COVID-19 testing requirements.
- CMS Memo QSO-20-39-NH – Nursing Home Visitation rev 11.12.21
- Nursing Home Visitation FAQs 12.23.21
- Nursing Home Visitation FAQs 01.06.22
- CDC – Interim Infection Prevention and Control Recs to Prevent SARSCoV-2 Spread in Nursing Homes 2.02.22
- CDC – Interim IPC Recommendations for HCP During the COVID-19 Pandemic 2.02.22
- Nursing Home Visitation FAQs 02.02.22
- CMS Memo QSO-20-39-NH – Nursing Home Visitation rev 03.10.22
- FL – SB 988 – 04.04.22