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How to Implement Safe Visitation in Your Facility

It’s hard to believe that it has been a year since the first nursing home resident contracted the novel coronavirus. Our way of living changed drastically, especially in long-term care. In-person visitation ended, and residents were limited to seeing loved ones virtually or through a window—if they could at all. Feelings of isolation and depression among residents increased substantially. Fortunately, since the end of 2020, many residents have now been fully vaccinated against COVID-19. “Fully vaccinated” is considered when a person has waited two or more weeks after receiving the second dose in a two-dose series, or two or more weeks after receiving one dose of a single-dose vaccine. The Centers for Medicare & Medicaid Services (CMS) has acknowledged the toll that separation and isolation have taken on residents living in long-term care. With increased vaccination numbers making nursing facilities safer, on March 10, CMS updated the September 2020 Nursing Home Visitation – COVID-19 memo. This article will discuss steps facility leadership can take to ensure safe visitation while following the new guidelines.

Core Principles

Although CMS is relaxing visitation guidelines, it is still emphasizing maintaining strong infection prevention practices. These include the following core principles of COVID-19 infection prevention that should be followed at all times:

  • 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
  • Social distancing of at least six feet between persons
  • Instructional signage throughout the facility and proper visitor education on COVID-19 signs and symptoms, infection control precautions, other applicable facility practices (e.g., use of face covering or mask; specified entries, exits, and routes to designated areas; hand hygiene)
  • 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)

 

CMS also says that visitations should be person-centered, should consider the residents’ physical, mental, and psychosocial well-being and should support quality of life. Visitors who are unable or unwilling to comply with the above core principles of COVID-19 infection prevention should not be permitted to enter the facility or should be asked to leave.


Visitor Screening

Safe visitation starts with a strong screening process. All visitors, including volunteers, hospice, dialysis technicians, lab technicians, clergy, etc., should be screened prior to entering the facility. Leadership may wish to utilize the following tips to ensure a safe screening process.

  • Utilize only one entrance. This limits access and lessens the chance that a visitor may miss the screening process prior to entry.
  • Ensure there is enough staff to screen visitors and that the screening station is attended at all times when visitors are allowed entry.
  • Have signage posted clearly communicating the screening process and any restrictions.
  • Ensure staff know what to do when a visitor needs to be restricted from the facility due to having signs and symptoms of COVID-19, having had exposure to COVID-19, or refusing to follow the core principles.

 

Outdoor Visitation

Outdoor visitation is still preferred, regardless of visitor vaccination status, since it poses a lower risk of transmission due to space and airflow. Leadership may wish to utilize the following tips to ensure enhanced safety for outdoor visitation.

  • Continue to take a person-centered approach and follow the core principles.
  • Create accessible and safe spaces for visitation that allow for privacy.
  • Utilize areas such as patios, gazebos, courtyards, or parking areas.
  • Ensure areas are protected from the sun and other elements by utilizing tents, canopies, or large umbrellas.
  • Have a policy regarding the number of visitors allowed for each resident, the length of time for each visit, and any other restrictions the facility has in place.
  • Ensure signage is visible that communicates the outdoor visitation process and any restrictions.
  • Ensure the facility has an adequate supply of PPE for staff, residents, and visitors.
  • Consider offering COVID-19 testing to visitors.
  • If visitors and residents who are fully vaccinated want to touch, ensure they are wearing proper PPE and reinforce hand hygiene after touching.
  • Even though visitation is being conducted outdoors, visitors still need to be screened prior to seeing their loved one.

 

Indoor Visitation

Due to inclement weather, hot or cold temperatures, or medical conditions, indoor visitation may be the only option for some facilities. As of March 10, 2021, facilities should allow indoor visitation at all times and for all residents, regardless of vaccination status. However, visitation should be limited for residents who are:

  • Unvaccinated, if the county positivity rate is above 10% and less than 70% of the residents in the facility are fully vaccinated
  • Confirmed to have COVID-19. Visitation may resume once transmission-based precautions have been discontinued regardless of vaccination status.
  • Under quarantine, regardless of vaccination status, until they have met criteria for release from quarantine.


As with outdoor visitation, facility leadership also need to take certain steps to ensure the safety of their residents, staff, and visitors regarding indoor visitation. These include:

  • Continue to adhere to the core principles, including PPE, hand hygiene, and physical distancing.
  • Consider the number of visitors allowed per resident and the total number of visitors allowed into the facility at one time. This allows for better infection control practices and privacy for the resident’s visit.
  • Choose a safe location where the resident may visit with their loved ones. This may be the resident’s room or a designated visitation area.
  • Consider scheduling visitation times to allow for only a specific length of time.
  • Limit visitor movement. Visitors should not be allowed to roam the hallways but should go directly to the visitation area.
  • For residents who share a room, avoid conducting visits in the room, if possible.
  • Consider offering COVID-19 testing to visitors.
  • Ensure signage is visible that clearly communicates the indoor visitation process and any restrictions.
  • Ensure there are adequate staff and supplies for the increased cleaning and disinfecting of frequently touched surfaces in the facility and designated visitation areas after each visit.
  • If visitors and residents who are fully vaccinated want to touch, ensure they are wearing proper PPE and reinforce hand hygiene after touching.

 

Visitation During an Outbreak

An outbreak exists when either a resident or staff member is diagnosed with COVID-19. Once an outbreak is detected, the facility must suspend visitation, except what is required under federal disability rights laws, until at least one round of facility-wide testing is completed. Visitation is now allowed during an outbreak under the following circumstances:

  • If the first round of COVID-19 testing reveals the outbreak is contained to one area or unit, visitation can resume to all other areas with no COVID-19 cases. However, the facility should suspend visitation to the affected unit until criteria are met to discontinue outbreak testing.
  • If facility testing reveals one or more additional areas are affected by COVID-19, indoor visitation should be suspended for all residents, regardless of vaccination status, until the facility meets criteria to discontinue outbreak testing.

Should an outbreak occur, visitors should be notified of the potential for COVID-19 exposure in the facility.

 

Compassionate Care Visits

Compassionate care visits and visits required under federal disability rights laws should be allowed at all times, regardless of a resident’s vaccination status, county positivity rate, or outbreak status. In addition to family members, compassionate care visits can be conducted by any individual that can meet the resident’s needs, such as clergy or lay persons offering religious and spiritual support. According to CMS, examples of compassionate care situations include:

  • A resident who was living with family before recently being admitted to a nursing home is struggling with the change in environment and lack of physical family support.
  • A resident is grieving after a friend or family member recently passed away.
  • A resident who needs cueing and encouragement with eating or drinking, previously provided by family and/or caregiver(s), is experiencing weight loss or dehydration.
  • A resident, who used to talk and interact with others, is experiencing emotional distress, seldom speaking, or crying more frequently (when the resident had rarely cried in the past).

 

As with other visitors, compassionate care visitors should also adhere to the core principles when in the facility. If, during a compassionate care visit with an unvaccinated resident, a visitor and facility staff member identify a way to allow for personal contact, it should only be done following appropriate infection prevention guidelines, and for a limited amount of time. Also, as noted above, if the resident is fully vaccinated, they can choose to have close contact (including touch) with their visitor while wearing a well-fitting face mask and performing hand-hygiene before and after.

 

Communication

Clear, concise communication with residents, staff, and visitors is key to having safe visitation for all. Facility leadership should communicate on COVID-19 signs and symptoms, visitation procedures including infection control practices, any restrictions, and outbreak or risk of transmission information. This communication can and should be relayed in multiple ways, such as signage, email, on a facility website, staff in-servicing, flyers, and phone calls. When it comes to COVID-19 and safety, there is no such thing as too much communication.

 

Conclusion

Even with more vaccinations occurring, while some people feel relief, others are still hesitant. However, if facility leaders implement the updated CMS guidelines for nursing home visitation along with the additional tips discussed in this article, they should be able to have safe visitation that improves the mental health and happiness of all involved.

 


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