Michigan’s “Re-Opening” of Nursing Homes for Visitation Isn’t What Families Might Expect

Christina NechiporchikNews

On March 2, 2021 Governor Whitmer announced the loosening of restrictions relating to COVID-19 and stated that nursing homes would now be open to visitors. However, when reviewing the actual language in the order (full text here), the extent of visitation allowed is not as open as some family members and friends might think, which could cause further tension and strain.

A facility may only start allowing visitors when the following three requirements are met:

  1. There have been no new facility onset cases within the last 14 days and the facility is not conducting outbreak testing.
  2. The local health department or MDHSS has not prohibited the facility from having visitation.
  3. The facility must ensure that all visitors over the age of 13 who participate in indoor visitation meet/are subject to the testing requirements.

The order specifically excludes window visits from being subject to the testing requirements. Additionally, the order clarifies that if a resident was COVID-19 positive at the time of admission that that resident did not constitute a facility onset case.

We want to focus exclusively on indoor visitation as that is where the majority of limitations are imposed. The order mandates facilities comply with 19 requirements:

  1. Allow visits by appointment only. The facility has the right to use their discretion on when and how appointments are managed, however, be sure you are consistent and non-discriminatory. Visitors must log arrival and departure times, provide contact information, and attest in writing that they will notify the facility if they develop symptoms within 14 days after visiting. The rationale for this may be to assist the center in determining the number of visitors in the center at any given time. It is also helpful for contact tracing in the event a visitor develops symptoms within 14 days of the visit.
  2. Limit the number of visitors to two persons per scheduled visit. The rationale may be that Michigan continues to limit the number of people in a closed building at any given time (I.e., restaurants, entertainment venues, personal homes, etc.).
  3. Require the testing of visitors. This may include proof of a negative test result in writing versus physically testing at the entrance.
  4. Exclude visitors who are unwilling or unable to wear a mask for the entire visit or refuse to follow hand hygiene requirements. It is recommended that you post signage in a conspicuous location at or near the entrance of the center.
  5. Limit visitor entry to entrances with COVID-19 screening protocols. Most centers only allow visitors in designated entrances, however, if you allowed entrance at other locations “pre-COVID” consider posting signage that entrance is only allowed at the main entrance.
  6. Perform a health evaluation of all visitors each time a visitor enters the facility. The screenings must include temperature checks and questions about symptoms consistent with COVID-19 and known exposure to COVID-19. Any visitor who fails the screening must be denied entry. This process should be documented on a log and maintained as a “Do Not Destroy” file.
  7. Post signage at all visitor entrances about required screening and COVID-19 tests before entry.
  8. Require visitors to follow physical distancing and refrain from physical contact during entire visit. This will require continuous monitoring during visitation. Many families tend to hug when arriving and departing; educating them that visits are socially distanced will assist in meeting the requirements.
  9. Make available to visitors handwashing stations and/or hand sanitizer and post educational materials on proper handwashing and sanitization. Placing additional hand sanitizer stations throughout the center is helpful; however, soap, water and paper towels should be available in all restrooms. Establish a protocol for ensuring these supplies are available 24/7.
  10. Ensure staff are available to assist with transitioning residents, monitoring visits and cleaning visitation areas after each visit. If a resident has visitors in the privacy of their private room, ensure highly touched surfaces are disinfected after each visit. Additional staff time may be required to assist residents to common visiting areas as needed.
  11. Educate visitors on PPE required beyond a face mask, if any. The facility must provide to the visitor any missing PPE. Facemasks are the most common PPE used for visitors and if a resident is in isolation, visitation should be delayed.
  12. Prohibit visitation during respiratory specimen collecting or during any aerosol-generating procedures. This is also a privacy/dignity issue; no treatments should be provided when visitors are in the room unless the visit is for end-of-life and the treatment cannot be delayed.
  13. Restrict visitor movement within the facility. The sign in log should include where the visitor will be going (I.e., room number, common visitation area, etc.). Visitors should be instructed upon arrival (or escorted) where they are permitted to visit.
  14. Establish a visitation area for residents in a shared room. Visits cannot be conducted in a shared room. Remember the privacy and dignity of each resident. It can also be unsettling for a roommate who hasn’t had a visitor to watch another visit. Consider moving the resident being visited to a common area.
  15. A staff member or volunteer trained in infection control procedures must be available for questions during visits. Each licensed staff has been trained on infection control procedures and non-licensed staff have a basic knowledge of the facility protocols. This does not mean your infection preventionist needs to be on site at all times.
  16. Limit the number of overall visitors in the facility at a given time. This will be individual to each center depending on size, floor plan, etc. Use your space wisely and do not allow more visitors than you can safely accommodate per the order.
  17. Instruct visitors and residents to not share food. The act of consuming food or beverages requires the removal of a facemask which is not permitted during this restricted visitation period. Discourage families from bringing in food from home; however, if a family member wants to bring in grandma’s favorite pie, have them leave it covered with a staff member for the resident to enjoy after the visit.
  18. Communicate with residents and family members about updated visitation protocols. This can be done on your website, via email blasts and in newsletters.
  19. Prohibit visits to residents in isolation or under observation for COVID-19. Even if a resident hasn’t tested positive but has symptoms, do not allow visitors during isolation or observation periods.

There are exceptions to some of these limitations and testing requirements for end-of-life scenarios, visits with clergy, and some non-medical service providers.

If the facility is able, the order encourages conducting “point of entry testing.” However, if that is not possible, facilities must require visitors to be tested on their own within 72 hours of coming to the facility and require proof of a negative test before entry. This suggests that visitors are to bear any costs associated with obtaining a test. No testing is required for visitors 13 years or younger.

It is crucial to update documentation, including policies and procedures, to reflect these changes. Any and all documentation listed as required for visitation (e.g., screening requirements, testing, logs, and attestation of notification of symptoms) should be retained in the facility’s COVID-19 file and marked as “Do Not Destroy” or in some other manner as to demonstrate an exception to the facility’s record destruction policy.

It is important to note that the order states, “Visitation or visitor does not include an individual entering the facility for the purpose of performing official government functions.” This would include state surveyors. Arguably though, if this order does not apply to them, then facilities should not make any changes to their current screening and testing policies in place relating to surveyors and other vendors not specifically referenced coming into the facility. It also follows that facilities should not make any changes to screening and testing of employees and residents in light of this order.

This order was effective immediately. Right now, facilities should assess the physical space available to be able to host visitors. This should not include dining and activity rooms as the order also instructed facilities to begin resuming communal dining and group activities for non-COVID positive residents. Those spaces should be prioritized for resuming those activities. After understanding how much space is available to safely conduct visitation, policies should be developed relating to any time limitations for visits and decide what number of visitors per appointment is appropriate. Once the policies are developed, communication should be sent out to residents and families/personal representatives regarding the new visitation protocols.

Be sure to visit our Resource and Education Center for documents and resources to help your facility safely reopen.