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CMS Issues Revised Guidance on Visitation in Nursing Homes

September 18, 2020

Consumer Voice is very pleased to announce that yesterday, after six months of strict visitation restrictions in nursing homes, the Centers for Medicare & Medicaid Services (CMS) released a memo significantly easing those restrictions. The new guidance, which is effective immediately, permits outdoor visitation, indoor visitation, and compassionate care visits and lays out a framework for those visits.   CMS notes that this guidance replaces all previous guidance.

Consumer Voice, along with other advocates, has been urging CMS to lift visitation limitations, noting the devastating effect being separated from their loved ones has had on residents.  We commend the agency for responding to these concerns and recognizing the value and importance of residents’ connections with family and friends.  We thank CMS for these changes, which will make a critical difference in the lives of residents, and look forward to continuing to work with CMS toward full restoration of residents’ visitation rights.

Below are key highlights from the September 17th CMS memo.

General Guidance About Visits

  • Visitation should be person-centered, consider the resident’s physical, mental, and psychosocial well-being, and support their quality of life.
  • Facilities should ensure visits are conducted with privacy.
  • Certain core principles apply to all types of visits. Among others, these include screening, hand hygiene, face covering or mask, and social distancing.

Outdoor Visitation

  • Visits should be outdoors whenever practicable.  Facilities should facilitate outdoor visits routinely except under certain circumstances.
  • Facilities should create accessible and safe outdoor spaces and a process to limit the number of visits and people visiting any one resident.

Indoor Visitation

  • Facilities should support indoor visitation adhering to the following guidelines:
    • No new onset of COVID-19 cases in the last 14 days; facility not conducting outbreak testing.
    • Only compassionate care visits if the county positivity rate is greater than 10%.
    • Visitors must follow the core principles.
    • Facilities should limit number of visitors per resident at one time; total number of visitors in the facility at one time; and movement in the facility.

CMS notes that it does not distinguish between visitors and essential caregivers, but states that such a distinction should not be necessary when a person-centered approach is used.

Compassionate Care Visitation

  • Additional examples of compassionate care situations underscore that these visits are not limited to end of life situations, but also include instances of resident decline or distress. See memo for specific examples.
  • Visits can be conducted by “any individual that can meet the resident’s needs” – for instance, clergy or lay persons offering religious and spiritual support.
  • Personal contact can be permitted for a limited amount of time if:
    • The visitor and facility agree on how that can be done.
    • Infection prevention guidelines are followed.

Required Visitation

  • A facility must facilitate in-person visitation and may only restrict visitation when there is a reasonable clinical or safety cause.
    • Examples of reasonable cause for restriction: COVID-19 county positivity rate, the facility’s COVID-19 status, a resident’s COVID-19 status, visitor symptoms, lack of adherence to proper infection control practices, other relevant factors related to the pandemic.
    • Examples of restriction without reasonable cause:  when there are no new onset COVID-19 cases for 14 days, county positivity rate is low or medium.
  • Failure to facilitate visitation without adequate reason would constitute a potential violation of a resident’s right to visitation, and the facility would be subject to citation and enforcement actions.
  • Residents who have COVID-19 or are under quarantine should only receive in-person compassionate care visitation, virtual visits, or window visits until they are COVID-19 free or out of quarantine.

Access to the Long-Term Care Ombudsman

  • In-person access to residents for Long-Term Care Ombudsmen (LTCO) may not be limited without reasonable cause, such as infection control concerns.  
  • LTCO continue to have immediate access to residents via phone and other technology.  

Federal Disability Rights Laws and Protection & Advocacy (P&A) Programs

  • Representatives of the P&A systems are permitted to access all facility residents, which includes the right to meet in person.  
  • Facilities must comply with federal disability rights laws.
    • Residents that need assistance with communication which is not otherwise available must be permitted to have an individual enter the facility to interpret or facilitate.
      • Facilities may impose legitimate safety measures necessary to adhere to COVID-19 infection prevention.

Entry of Health Care Workers (Non-Employees) and Other Providers of Services

  • Health care workers who provide direct care to facility residents, but are not employees of the facility, such as hospice workers, must be permitted to come into the facility as long as they  have not been exposed to COVID-19 or have symptoms of COVID-19.
  • EMS personnel do not need to be screened.

Communal Activities and Dining

  • Communal activities and communal dining may occur, while adhering to the principles of COVID-19 infection prevention.
  • Dining:
    • Residents may eat in a common room while social distancing.
    • Facilities should consider additional limitations based on COVID-19 infections in the facility.
  • Activities:
    • Group activities may occur for residents who have recovered from COVID-19 and for those who are not isolated for observation or do not have suspected or confirmed cases of COVID-19.
    • Residents must socially distance, use appropriate hand hygiene, and wear face coverings.
    • Examples of activities include:  book clubs, crafts, movies, exercise, and bingo.

Use of CMP Funds to Aid in Visitation

  • CMS will now approve the use of CMP funds for tents for outdoor visitation and/or clear dividers, like Plexiglass, to reduce the risk of transmission during in-person visits.
  • Facilities can apply for up to $3,000 in CMP funds for this use by contacting the person in charge of CMP funds at their state survey agency.

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