Federal Infection Prevention and Nursing Home Visitation Guidance Updated as End of PHE Nears

With the end of the federal COVID-19 Public Health Emergency (PHE) approaching on May 11, 2023, the Centers for Disease Control and Prevention (CDC) has updated its COVID-19 infection prevention guidance applicable to all health care settings, and the Centers for Medicare and Medicaid Services (CMS) has updated its nursing home visitation guidance. Both guidance documents contain a few key changes, but continue many of the same infection prevention measures set forth in prior versions. CMS has also retired its nursing home testing guidance, but cautions nursing homes that it will continue to require testing for COVID-19 in accordance with CDC recommendations as part of routine infection prevention and control activities.

LeadingAge NY has contacted the NYS Department of Health (DOH) to confirm that the State will continue to follow CDC and CMS guidance. We have not yet received confirmation.

CDC’s Updated Infection Prevention and Control Recommendations for All Health Care Settings

The CDC’s Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the COVID-19 Pandemic, which apply to all health care settings, include key updates related to source control and to admission testing in nursing homes, as described below:

Source Control

The updated guidance continues to recognize source control as an important infection prevention intervention, especially during periods of higher respiratory virus transmission. However, the CDC is retiring the COVID-19 Community Transmission Level metric that has been used to guide the implementation of universal source control in health care settings. As described in more detail below, without the Community Transmission metric, the CDC recommends that health care facilities identify local metrics that could reflect increasing community respiratory viral activity and consider patient risk and stakeholder input to determine when broad-based use of source control in the facility might be warranted.

Source control refers to use of respirators or well-fitting face masks or cloth masks to cover a person’s mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. According to the CDC, source control is recommended for individuals in health care settings who:

• have suspected or confirmed SARS-CoV-2 infection or other respiratory infection (e.g., those with runny nose, cough, sneeze); or
• had close contact (patients and visitors) or a higher-risk exposure (HCP) with someone with SARS-CoV-2 infection, for 10 days after their exposure.

The CDC also recommends source control as described in its Core Infection Prevention and Control Practices in the following circumstances:

• By those residing or working on a unit or area of the facility experiencing a COVID-19 outbreak or other outbreak of respiratory infection. Universal use of source control could be discontinued as a mitigation measure once the outbreak is over (e.g., no new cases have been identified for 14 days).
• Facility-wide or, based on a facility risk assessment, targeted toward higher-risk areas or patient populations (e.g., when caring for patients with moderate to severe immunocompromise) during periods of higher levels of community SARS-CoV-2 or other respiratory virus transmission (see Appendix following guidance).
• Have otherwise had source control recommended by public health authorities (e.g., in guidance for the community when COVID-19 hospital admission levels are high).

In addition to the above circumstances, the CDC recommends that facilities implement policies that provide for broader masking, informed by the level of COVID-19 infection or other respiratory virus transmission in the community and based on consideration of the following factors:

• The types of patients cared for in the facility: Consider tiered interventions based on the population(s) served. For example, a lower threshold for universal masking might be applied in areas of the facility caring for patients at highest risk for severe outcomes or in areas more likely to provide care for patients with a respiratory infection. Except when experiencing an outbreak within the facility, facilities with residents or patients who generally do not leave the facility might consider implementing masking only for staff and visitors.
• Input from stakeholders: Review plans with stakeholders, including patient and family groups and HCP, to help determine practices that will be more broadly supported.
• The plans of other facilities caring for shared patients: Some jurisdictions might consider a coordinated approach for all facilities in the jurisdiction.
• The data available: Facilities and jurisdictions might have access to more granular data for their jurisdiction to help guide efforts locally.

The CDC is in the early stages of developing metrics that could be used to guide when to implement certain infection prevention and control practices for multiple respiratory viruses. There are some general metrics that could be used to help facilities make decisions that are listed in the Appendix following the guidance.

The CDC will also continue to collect and report SARS-CoV-2 hospital admissions data on its COVID Data Tracker. These data continue to be available at the county level and are used by the CDC to help the public decide when masking in the community should be considered, but may be less useful for informing HCP masking policies. The CDC continues to recommend that health care facilities institute facility-wide masking when masks are recommended in the community. In the absence of appropriate data, some facilities might consider recommending masking during the typical respiratory virus season (approximately October-April).

Providers are also reminded that HCP in NY are required to wear masks during flu season if they have not been vaccinated against the flu.

The CDC notes that “[e]ven when masking is not required by the facility, individuals should continue using a mask or respirator based on personal preference, informed by their perceived level of risk for infection based on their recent activities (e.g., attending crowded indoor gatherings with poor ventilation) and their potential for developing severe disease if they are exposed.”

Personal Protective Equipment

The CDC continues to recommend the use of respirators and eye protection when caring for patients or residents who have COVID-19 infection. Health care providers should consider broader use of respirators and eye protection as COVID-19 transmission in the community increases, and there is a higher likelihood of encountering patients with COVID-19 infection, as follows:

• For aerosol-generating procedures;
• For surgical procedures that might pose a higher risk for transmission if the patient has COVID-19;
• When working in other situations where additional risk factors for transmission are present, such as when the patient is unable to use source control and the area is poorly ventilated;
• When health care-associated COVID-19 transmission is identified, and universal respirator use by HCP working in affected areas is not already in place;
• To simplify implementation in counties with higher levels of COVID-19 transmission, during all patient care encounters or in specific units or areas of the facility at higher risk for COVID-19 transmission.

Nursing Home Admissions/Readmissions

The updated guidance modifies the recommendations for nursing homes concerning testing at admission and readmission. Instead of recommending a series of COVID-19 tests when Community Transmission levels are high, the updated guidance provides that admission testing is at the discretion of the facility. In general:

• Anyone with even mild symptoms of COVID-19 should be tested as soon as possible.
• Asymptomatic patients who are exposed should have a series of three viral tests (24 hours after exposure and if negative, 48 hours later, and if negative, 48 hours after the second test).
• Testing is not recommended for asymptomatic people who have recovered in the prior 30 days, and antigen testing should be considered for those who have recovered in the prior 31-90 days.
• The CDC notes that the yield of screening testing for identifying asymptomatic infection is likely lower when performed on those in areas with lower levels of COVID-19 Community Transmission.

CMS’s Updated Nursing Home Visitation Guidance

CMS has made a few modest changes to its nursing home visitation guidance, QSO-20-39-NH (changes are in red typeface). CMS reminds nursing homes that it “still expects facilities to adhere to infection prevention and control recommendations in accordance with accepted national standards.” In its list of “Core Principles of COVID-19 Infection Prevention,” CMS replaces “instructional signage throughout the facility and visitor education,” with:

Post visual alerts (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) These alerts should include instructions about current IPC recommendations (e.g., when to use source control).

It also modifies the resident and staff testing requirements to remove the regulatory reference and add a reference to CDC recommendations.

The updated guidance adds an instruction regarding indoor visitation during an outbreak:

[T]he visit should ideally occur in the resident’s room, the resident and their visitors should wear well-fitting source control (if tolerated) and physically distance (if possible) during the visit.

The guidance reiterates CMS’s encouragement of visitors to stay up-to-date with their COVID-19 vaccinations.

CMS also updated two Frequently Asked Questions (FAQs) accompanying the visitation guidance and removed several FAQs. The first modifies an FAQ about visitors sharing a meal with a resident by removing instructions to inform the resident and visitor of risks, eat in a separate area, and wear a mask except while eating. Instead, the updated FAQ says simply:

Q: Can a visitor share a meal with or feed the resident they are visiting?

A: Yes.

The second revised FAQ adds a reference to visual alerts and removes a requirement to provide reminders to maintain physical distancing during large gatherings in common areas. However, it retains references to physical distancing during large gatherings in other FAQs. The revised FAQ reads as follows:

Q: Are there any suggestions for how to conduct visits that reduce the risk of COVID-19 transmission?

A: There are ways facilities can and should take extra precautions, such as hosting the visit outdoors, if possible; creating dedicated visitation space indoors; permitting in- room visits when the resident’s roommate is not present; and the resident and visitor should wear a well-fitting mask (preferably those with better protection, such as surgical masks or KN95), in accordance with CDC recommendations, and perform frequent hand-hygiene. Some other recommendations include:

• Offering visitors face coverings or masks.
• Limiting the visitor’s movement in the facility, during an outbreak, to only the location of the visit.
• Increasing air-flow and improving ventilation and air quality.
• Cleaning and sanitizing the visitation area after each visit.
• Post visual alerts (e.g., signs, posters) that include instructions about current IPC recommendations (e.g., when to use source control).

The updated FAQs also remove questions related to precautions during periods of high-volume visitation, discouraging in-room visitation when a roommate is present, and visitation during the spike in cases due to the Omicron variant.

What Does This Mean for ACFs and Assisted Living?

In its Feb. 10^th Dear Administrator Letter (DAL) updating masking guidance, DOH states that adult care facilities (ACFs) should follow CDC community guidance and CDC guidance for congregate living settings. At the time of this writing, the CDC community guidance page was last updated on Jan. 26, 2023, and the CDC guidance for congregate living settings was last updated on Nov. 22, 2022. Thus, until this guidance is updated and/or DOH updates guidance for ACFs, LeadingAge NY recommends that you continue to follow your policies and procedures as outlined in the February guidance. We have been anticipating updated guidance for ACFs on several COVID-19 issues and will alert members once it is available.

QuickCast Videos

LeadingAge National has provided QuickCasts – brief 15-minute videos – to help members make the transition to the post-pandemic era. These are posted on the LeadingAge Learning Hub and can be accessed with a LeadingAge username and password:

• What The End of the Public Health Emergency Means for Nursing Homes
• The End of the Public Health Emergency: Considerations for Nursing Homes
• The End of the Public Health Emergency: Considerations for Hospice (members can also find Parts 1 and 2 in the Hospice & Palliative Care sections of the Learning Hub)
• The End of the Public Health Emergency: Considerations for Home Health (members can also find Parts 1 and 2 in the Home Care & Home Health Services sections of the Learning Hub)

Contact: Karen Lipson, klipson@leadingageny.org, and Diane Darbyshire, ddarbyshire@leadingageny.org