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 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

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. For example, for 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.” Similarly, allowing someone to visit a resident whose friend or family member recently passed away, would also be consistent with the intent of these situations.

CMS cannot define each situation that may constitute a compassionate care situation. We encourage facilities to consult with state leadership, families, and ombudsman, to help determine if a visit should be conducted for compassionate care. Also, while CMS acknowledges that compassionate care situations may extend past end-of-life situations, we still believe these visits should not be routine, and allowed on a limited basis as an exception to restricting visitation. We also remind facilities and visitors that all actions to prevent the transmission of COVID-19 should be taken when these visits are allowed. These actions include screening all visitors for symptoms of COVID-19, practicing social distancing, performing hand hygiene (e.g., use alcohol-based hand rub upon entry), and both residents and visitors wearing a cloth face covering or facemask for the duration of their visit.

To help with these visits, nursing homes may decide to create safe spaces within the facility, such as see-through separation walls or other such areas so that residents may physically see their family members (if outside visitation is not conducted). Nursing homes may also consider setting up appointment times to ensure control of the number of visitors at any given time. Additionally, when facilitating visits, facilities should continue to limit the number of visitors allowed in the building at the same time, and limit the number of individuals visiting with any one resident (e.g., two visitors for one resident visit)

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?

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. CMS encourages creative means of connecting residents and family members. 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 have a process to limit the number and size of visits occurring simultaneously to support safe infection prevention actions (e.g., maintaining social distancing). We also recommend limiting the number of individuals visiting with any one resident (e.g., two visitors for one resident visit).

As more information becomes available at the national, state and local levels, facilities are encouraged to work with their state officials to determine the appropriate level of visitation restrictions within available guidelines from the CDC.

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.

What factors should nursing homes consider when making decisions about visitation?

CMS encourages that any decisions to relax requirements or conduct creative alternatives within nursing homes be made in coordination with state and local officials after a careful review of facility-level, community, and state factors/orders. Additionally, state and local officials should consider the following as a part of a comprehensive reopening plan:

• Case status in surrounding community
• Case status in the nursing home(s)
• Staffing levels
• Access to adequate testing for residents and staff
• Personal protective equipment supplies
• Local hospital capacity

These factors should help guide reopening decisions, and decisions related to creative ways to facilitate visitation. For example, a facility with multiple COVID-19 cases should still use caution when deciding to facilitate outdoor visitation. As facilities explore these options, they are still responsible for preventing the transmission of 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 LongTerm 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.

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.

Where can I find more information?

More information about CMS’ reopening recommendations can be found in CMS memorandum QSO-20-30-NH. Facilities should also contact their state or local health department for questions related to preventing the transmission of COVID-19. The CDC website continues to offer guidelines for managing and preventing the transmission of COVID-19 in nursing homes.