New Visitation Guidance for Nursing Homes and HWS/AL Takes Effect October 17

Posted on October 14, 2020 by Jonathan Lips

Both nursing homes and housing with services/assisted living settings will be hard at work this week preparing for implementation of new visitation guidance that takes for effect for both of these provider groups this Saturday, Oct. 17.

The MN Department of Health (MDH) rollout of these new standards has been confusing for some, and we hope the following information will clear up some of the uncertainty.

Background

In August 2020 MDH released visitation and activities guidance that gave separate recommendations for “Level 1” and “Level 2” scenarios. That guidance applied to both nursing homes and HWS/AL providers and indicated as follows:

• A facility was in Level 1 if there has been a COVID-19 exposure at the facility in the past 28 days, or if certain risk factors placed the facility in Level 1 due to risk of COVID-19 exposure.
• A facility was eligible to move to Level 2—and could loosen visitation restrictions—if there had not been a COVID-19 exposure at the facility in the past 28 days.

MDH has withdrawn that August guidance and it no longer applies, regardless of your provider type.

What Visitation Guidance Now Applies to My Setting and Where Do I Find It?

For nursing homes the core visitation guidance document is now CMS memo QSO 20-39-NH, released on Sept. 17, 2020. It identifies ways in which CMS believes nursing homes can safely facilitate in-person visitation, including both outdoor and indoor visitation, to address the psychosocial needs of residents. Nursing homes can work directly from this federal document.  (Side note: QSO 20-38-NH continues to guide nursing homes on issues relating to testing.)  Just today (Oct. 14) MDH posted this document - COVID-19 Guidance: Nursing Home Visitation and Activity Restriction Modifications –to confirm that nursing homes should follow QSO-20-39-NH.

For housing with services/assisted living, the core guidance document is now Minnesota Home Care Provider/Assisted Living Visitation and Activities Guidance Throughout the COVID-19 Pandemic, which MDH released this past Monday, Oct. 12. Because MDH wants to have consistency across provider types, this guidance closely follows the structure and content of the memorandum CMS released for nursing homes. It identifies core principles of infection prevention and control and directs providers to facilitate both outdoor and indoor visitation in accordance with those principles.

This Long-term Care Visitation and Activities Guidance Update Summary (PDF) covers key topics relating to the new visitation guidance for nursing homes and HWS/AL. Revision date: 10/12/2020. An explanation is in order, though. Given the title of this document and the way it reads, some members have asked if this is MDH’s new core guidance document for nursing homes. The answer is no. The core guidance document for nursing homes is CMS memo 20-39-NH. While the summary gives an accurate overview of key visitation topics for both nursing homes and HWS/AL, you should read it together with the core guidance document listed above that applies to your setting.

Also, an important technology note: When clicking on the link above, some LeadingAge MN staff have found that it leads to an August 10 summary that is now obsolete.  This appears to be because MDH is using the same URL to link the new document as it used for the old.  You may need to clear out the “cookies” and refresh your page. You can also hit ctrl F5 to do a hard refresh of the page and it should show up correctly. (The updated date shows up at the end of the document.) 

Other visitation-related guidance and considerations include:

• Providers may continue to allow essential caregiver visits in both nursing homes and HWS/AL, and MDH has updated the Essential Caregiver Guidance for Long-term Care Facilities to confirm this. Revision date: 10/13/2020.

• Outdoor Visitation Guidance for Long-term Care Facilities continues to be in place, unchanged from earlier this summer. Revision date: 6/17/2020.  See also Guidance for Temporary Tent Structures and Clear Dividers for Long-term Care Visitation (PDF) Revision date: 9/30/2020.

• MDH’s Guidance for Window Visits at Long-Term Care Facilities remains in place as well, and is unchanged.  Revision date: 6/12/2020.

What are key differences between the prior Level 1/Level 2 guidance and the new guidance?

Three issues stand out when reviewing the new guidance:

(1) Under the new guidance for both nursing homes and HWS/AL, in-person visits must be allowed when both of the following criteria are met, unless the provider has a reasonable or clinical safety cause to restrict visitation:

• There has not been a new facility onset COVID-19 case (resident or staff) in the last 14 days, and  
• The 14-day COVID-19 county positivity rate is ≤10%, placing the facility in the low-risk or medium-risk category.  

In the prior guidance, providers could choose whether or not to resume visitation if they had been 28 days without a COVID exposure.

(2) Under the new guidance for both nursing homes and HWS/AL, the key community risk factor is the 14-day COVID-19 positivity rate and not the 14-day county case rate. The positivity rate is the percent of COVID-19 tests conducted that have positive results, while the case rate is the number of COVID-19 cases per 10,000 people. Under the prior guidance, we had trained ourselves to monitor the county case rate for purposes of deciding whether to relax visitation restrictions, but the positivity rate is now the applicable factor.

(3) MDH has raised its minimum testing expectations for HWS/AL. In the prior guidance, the minimum requirement for HWS/AL providers was to have a testing plan and to test all residents or staff with symptoms consistent with COVID-19. Under the new guidance, MDH is requiring HWS/AL to test all symptomatic residents and staff and to conduct outbreak testing. “Upon identification of a new COVID-19 infection in any staff or residents,” the guidance states, “as a health standard of care, all staff and residents should be tested, and all staff and residents that test negative should be retested every three days to seven days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result.”

Tools to Support Implementation

To help both nursing homes and HWS/AL providers understand and operationalize the new core guidance documents, the LeadingAge MN team developed a comprehensive Toolkit for Visitation Guidance Implementation including implementation resources, communications templates, and reference document. See the related article in this week’s newsletter for more details. As always, our technical assistance team is here to help. Please contact Kari Everson or Jonathan Lips anytime for assistance with visitation related questions.