MDH, Providers Weigh Impact of CMS Revised Visitation Guidance

Posted on September 23, 2020 by Jonathan Lips

In recognition of the physical and emotional toll that separation from family and other loved ones has taken on residents, CMS has issued

revised guidance (QSO-20-39-NH) for nursing homes during the COVID-19 Public Health Emergency that expands the visitation options nursing homes must consider, including indoors. 

The information in this memo supersedes and replaces all guidance and recommendations CMS has previously issued regarding visitation, and surveyors must implement the new guidance within 30 days of the memo’s September 17 release date.

Members do not need to change visitation protocols immediately. LeadingAge MN has been in daily communication with the Minnesota Department of Health (MDH), and officials there have told us they are studying the CMS memo and are taking some time to assess carefully what changes will be needed to MDH’s own visitation-related guidance. Given the breadth of the CMS update, we believe MDH will need to revise its existing guidance on Essential Caregivers and Recommendations for Long-term Care Visitation and Activities (Level 1 and Level 2), and possibly on Outdoor Visitation as well. Our team will work closely with MDH on this analysis in the days ahead and keep members informed.

The CMS guidance applies specifically to nursing homes, and MDH has not indicated that it plans to extend the CMS principles to housing with services/assisted living settings. But this is one of many key questions we will address proactively with the State, along with others noted later in this article.

Summary of Key Elements in the New Guidance

• Indoor Visitation: The item that stands out most in CMS’s revised guidance is that facilities in counties with low or medium COVID-19 positivity rates “should accommodate and support indoor visitation, including visits for reasons beyond compassionate care situations,” when there has been no new onset of COVID-19 cases in the last 14 days and the facility is not currently conducting outbreak testing. The implication is that facilities must allow some indoor visitation, which is a departure from current MDH guidelines, and raises a question of whether “Essential Caregiver” status, as MDH defines it today, will remain relevant in nursing home settings. CMS also notes that a facility may limit the number of indoor visitors, the length of visits, and may require visitors to follow infection control protocols; but CMS notes toward the end of the memo that facilities may not restrict visitation without a reasonable clinical or safety cause.
• Positivity Rate as Key Factor: CMS says facilities should use the COVID-19 county positivity rate as additional information to determine how to facilitate indoor visitation. In counties with low or medium positivity rates (0-10%), visitation can occur consistent with core principles of infection control (see below). But in counties with >10 positivity rate, visitation should be limited to compassionate care situations. This would mean, for example, that even Essential Caregiver visits should be suspended when positivity rates are high.

• Outdoor Visitation: CMS notes that outdoor visits should be facilitated routinely, unless weather considerations, an individual’s health status, or a facility’s outbreak status makes these visits inadvisable. Most if not all Minnesota facilities are already offering outdoor visits, so we don’t believe this will be disruptive.

• Core Principles of Infection Control: Regardless of what type of visits occur, facilities must continue to follow “core principles,” including screening protocols for all who enter, hand hygiene, wearing face coverings or masks, maintain social distancing, using appropriate PPE, cleaning and disinfecting high touch surfaces and areas, cohorting of COVID positive residents and complying with CMS regulations for staff and resident testing. These are consistent with prior guidance from CMS, CDC and MDH, so should not require new learning, but if indoor visitors increase as expected, the volume of work and attention required of you and your teams will also increase. In addition, CMS outlines directions for nursing homes to alert visitors as they maneuver through the community, including instructional signage and visitor education on COVID-19, infection control and nursing home policies.
• Residents who are on Transmission-based Precautions for COVID-19: These residents 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 in the memo.
• Management of Visitor Risk: 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. While not required, CMS 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.
• Entry of Health Care Workers and Other Providers of Services: CMS also indicates that health care workers who are not employees of the facility but provide direct care to the facility’s residents, such as hospice workers, Emergency Medical Services (EMS) personnel, dialysis technicians, laboratory technicians, radiology technicians, social workers, clergy etc. 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.
• Communal Dining and Activities: Consistent with guidance CMS released earlier this year, communal activities and dining may occur, so long as facilities and residents adhere to the core principles of COVID-19 infection prevention.
• CMP Funds: CMS concludes the memo by saying it will 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. CMS notes that, 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. We are working now with the Minnesota Department of Human Services to confirm details of when and how facilities can apply for these funds, and with the MDH engineering division to confirm guidelines about life safety code standards that may affect what approaches facilities take.

The work needed to fully understand and implement these revised standards will be complex. Please know that our team will walk alongside you in this work, and we will closely collaborate with the Department of Health to ensure clear, consistent guidance is provided. We will share additional information in our daily Updates, Tuesday Clinical Coaching Rooms, and Friday Huddles, and in the meantime please contact Jon Lips or Kari Everson with comments, questions and concerns.