The past year has brought a multitude of changes for everyone, but especially those in nursing homes. While the public health emergency (PHE) situation continues to evolve, the Centers for Medicare & Medicaid Services (CMS) initiated more changes when they updated the guidelines in QSO-20-38-NH and QSO-20-39-NH. Based on new CDC recommendations that were released April 27,2021, these changes bring hope and happiness to fully vaccinated residents who long to hug their loved ones or socialize at the same table as fellow residents during mealtimes. The days of social isolation for residents are nearing an end. This article discusses how the new guidance impacts visitation, dining and group activities, quarantining of new admissions, and staff testing and provides tips to help get into compliance.
The QSO memo 20-38-nh includes new definitions for “fully vaccinated” and “unvaccinated” individuals under F886. “Fully vaccinated” refers to a person for whom more than two weeks have elapsed following receipt of the second dose in a two-dose series, or more than two weeks following receipt of one dose of a single-dose vaccine.
“Unvaccinated” refers to a person who does not fit the definition of “fully vaccinated,” including people whose vaccination status is not known, for the purposes of this guidance.
QSO Memo 20-39-nh revises visitation guidance. Although CMS continues to require facilities and visitors to follow the Core Principles of COVID-19 Infection Prevention below, it has added the change in red:
- Screening of all who enter the facility for signs and symptoms of COVID-19 (e.g., temperature checks, questions about and observations of signs or symptoms) and denial of entry of those with signs or symptoms or those who have had close contact with someone with COVID-19 infection in the prior 14 days (regardless of the visitor’s vaccination status)
- Hand hygiene (use of alcohol-based hand rub is preferred)
- Face covering or mask (covering mouth and nose) and social distancing of 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, hand hygiene, and specified entries, exits, and routes to designated areas)
- Cleaning and disinfecting frequently 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 conducted as required at 42 CFR § 483.80(h) (see QSO20-38-NH Revised)
CMS also states that facility leaders should follow the Centers for Disease Control and Prevention (CDC) recommendations for indoor visitation, which are:
- Indoor visitation for unvaccinated residents should be limited solely to compassionate care situations if the COVID-19 county positivity rate is >10% and <70% of residents in the facility are fully vaccinated.
- Indoor visitation should be limited solely to compassionate care situations, for:
- Vaccinated and unvaccinated residents with SARS-CoV-2 infection until they have met criteria to discontinue Transmission-Based Precautions.
- Vaccinated and unvaccinated residents in quarantine until they have met criteria for release from quarantine.
- Facilities in outbreak status should follow guidance from state and local health authorities on when visitation should be paused.
- Visitors should be counseled about their potential to be exposed to SARS-CoV-2 in the facility if they are permitted to visit.
The major change in the QSO memo 20-39-nh centers around vaccination status. CMS states that facilities should follow the updated CDC recommendations for fully vaccinated residents and their fully vaccinated visitors as follows:
- While alone in the patient/resident’s room or the designated visitation room, patients/residents and their visitor(s) can choose to have close contact (including touch) and not wear source control.
- Visitors should wear source control and physically distance from other healthcare personnel (HCP) and other patients/residents/visitors that are not part of their group at all other times while in the facility
Unvaccinated residents and visitors must continue to follow the previous guidelines, including maintaining social distancing (six feet or more apart from others) and wearing source control during visitation.
Here are four steps to ensure immediate and ongoing compliance with the revised visitation guidance:
- Have a process to determine vaccination status/needs upon admission. When new patients/residents admit, have a process to identify their COVID-19 vaccination status. Is the person fully vaccinated or do they need a second dose? If a second dose is needed, what vaccine is needed and when is it due? If the individual has not been vaccinated, have a process in place to provide education to the patient/resident and their representative.
- Provide visitor education on the do’s and don’ts of visiting. Family members are excited to come in and hug their loved one, but they need education on how CMS guidance impacts visitation. For example, family members need to understand why they still need to be screened for COVID-19 if they are vaccinated. Furthermore, they need to understand how visitation must change in the event a facility has an outbreak. By proactively educating visitors, they know what to expect before the visit.
- Have a plan to manage visitors. You need to determine where and when visitors can enter the facility and where they will visit with their loved ones. It is possible this could be in the resident’s room, but QSO Memo 20-39-nh uses the CDC guidance on visitation. It clarifies that if a vaccinated resident has an unvaccinated roommate and the roommate is unable to leave for the visit, then alternative places for the visitation may be needed. If you use a specified area for these visits, determine how many people are able to visit at any given time. If space is limited, the facility may need to schedule visitations.
- Review the facility policies and procedures to ensure compliance with the revised CMS guidance. Facilities may have established their current policies and processes based on prior CMS guidance. These policies may require updating as a result of the new language. After reviewing policies and updating as necessary, provide staff education on revised policies.
Communal dining and activities
QSO Memo 20-39-nh also includes new guidance regarding communal dining and activities for fully vaccinated residents.
While adhering to the core principles of COVID-19 infection prevention, communal activities and dining may occur. Book clubs, crafts, movies, exercise, and bingo are all activities that can be facilitated with alterations to adhere to the guidelines for preventing transmission. The CDC has provided additional guidance on activities and dining based on resident vaccination status. For example, residents who are fully vaccinated may dine and participate in activities without face coverings or social distancing if all participating residents are fully vaccinated; if unvaccinated residents are present during communal dining or activities, then all residents should use face coverings when not eating and unvaccinated residents should physically distance from others. See the CDC guidance Updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccination for information on communal dining and activities.
Residents who are in isolation or quarantine will not be allowed to participate in communal dining and activities until they have met the criteria for discontinuation. Here are four tips to consider when implementing guidance related to dining and group activities:
- Determine resident vaccination status. Establish a process to inform staff of each resident’s vaccinations status. Resident vaccination status can change over time, and new residents will be admitted. Staff need to be able to easily identify residents who are and who are not able to participate in communal dining and group activities without social distancing and source control.
- Maintain vaccination privacy. Maintaining privacy, as required by the Health Insurance Portability and Accountability Act (HIPAA), is a must, but doing so might be challenging given the fact that vaccinated residents will be easily identifiable by their participation in activities without social distancing and source control. It is still important to educate and inform staff that they cannot release this information to others. If a visitor asks why Mr. Smith can participate in that activity without a mask while my dad cannot, staff cannot say it is because Mr. Smith is vaccinated.
- Educate and address family and resident questions regarding dining and activities. It might be easy to separate vaccinated residents from unvaccinated residents, but that may not be in line with a resident’s choice. For example, if resident Bill always sat with Joe for meals and now Bill is vaccinated and Joe is not, they may still want to sit together. This would require Bill to social distance and use source control to sit at Joe’s table. If that is the case, Bill’s choice should be accommodated. Education for group activities is also a must. It is likely that group activities will require infection prevention and control measures, including masks and social distancing, because there will be vaccinated and unvaccinated residents present. Also be sure to include education for families too.
- Policy changes. The revised guidelines likely impact policies or procedures for dining and activities. Be sure to consider how a resident’s choice impacts the policy as well. While it might be easy to implement a policy that states only vaccinated residents can come to the dining room or group activities, it would be a violation of their rights.
The above guidance from CMS implements numerous CDC recommendations. The CDC guidance, Updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccination, has also issued recommendations regarding the quarantining of residents upon admission. Residents with prolonged close contact (within 6 feet for a cumulative total of 15 minutes or more over a 24-hour period) with someone with SARS-CoV-2 infection should quarantine, even if vaccinated; outpatients should be cared for using recommended Transmission-Based Precautions. They also state that “Although not preferred, healthcare facilities could consider waiving quarantine for fully vaccinated patients and residents following prolonged close contact with someone with SARS-CoV-2 infection as a strategy to address critical issues (e.g., lack of space, staff, or PPE to safely care for exposed patients or residents) when other options are unsuccessful or unavailable. These decisions could be made in consultation with public health officials and infection control experts.”
Fully vaccinated residents that have not had prolonged close contact with someone with SARS-CoV-2 infection no longer need to be quarantined for 14 days upon admission. Here are two tips to consider when implementing the new recommendations.
- Review and update admission policy and procedure. If your facility will be waiving the quarantining of new residents who are fully vaccinated, the admission policy should be reviewed and revised if needed to ensure compliance with the guidelines. If quarantine will be waived for fully vaccinated residents with prolonged exposure, ensure the policy and procedure specifically lists under what circumstances quarantine may be waived and what experts should be consulted prior to waiving. If policies and procedures are revised, educate staff.
- Review and revise the preadmission process. The pre-admission process will need to be revised to include obtaining information about vaccination status from a discharging provider. As mentioned above, to be “fully vaccinated,” the person must have received both vaccines (if receiving a two-dose vaccination) at least two weeks ago. Knowing the vaccine status isn’t enough; you must also know what vaccine and when they received it.
QSO Memo 20-38-nh revises guidelines for routine testing of staff based on county positivity rates (note that routine testing of asymptomatic residents is neither required nor recommended). Facility leaders must only test unvaccinated staff per the county positivity rate. CMS states that a facility should test all unvaccinated staff at the frequency prescribed in the table below, which is based on county positivity rate.
|Community COVID-19 Activity||County Positivity /rate in the past week||Minimum Testing Frequency of Unvaccinated Staff|
|Low||<5%||Once a month*|
|Medium||5%-10%||Once a week*|
|High||>10%||Twice a week*|
+Vaccinated staff do not need be routinely tested.
*This frequency presumes availability of point of care testing on-site at the nursing home or where off-site testing turnaround time is less than 48 hours.
The CDC also states that asymptomatic HCP with high-risk exposure and residents with prolonged close contact with someone with SARS-CoV-2 should be tested immediately and then again five to seven days after exposure, regardless of vaccination status. Individuals who have had the SARS-CoV-2 infection in the last 90 days do not need to be tested if they remain asymptomatic.
When implementing these revised guidelines regarding staff testing, facility leaders should consider the following:
- Encourage unvaccinated staff to receive the vaccination. There are still a number of staff who are hesitant about getting the vaccine. Continue to follow up with staff and ask them what information might motivate them to become vaccinated. The new testing requirements allow vaccinated staff to forego routine testing, which might incentivize some staff to become fully vaccinated.
- Review testing policy and procedures. The new testing requirements likely impact current policies that will need to be revised. Make sure all staff are aware of policy revisions.
- Ensure unvaccinated staff do not feel isolated or discriminated against for their choice to remain unvaccinated. Staff who have elected to remain unvaccinated may see the updated guidelines as being discriminatory; simultaneously, other staff members may single out unvaccinated staff for their choice. Ensure staff are not treated differently based on their vaccination status.
For additional information and to review all the changes, refer to QSO Memo 20-38-nh, QSO Memo 20-39-nh and the CDC’s “Updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccination.”
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