Key Visitation and Communal Activity Reminders for Nursing Homes

With winter holidays fast approaching, nursing homes would be wise to review and update their visitation and activities policies and refresh their staff training. All three standard-setting bodies for nursing homes – the Centers for Medicare and Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC), and the New York State Department of Health (DOH) – have updated their COVID-19 infection prevention guidance for nursing homes in recent weeks. The current guidance documents often do not provide clear rules, but in many respects require facilities to strike a delicate balance between infection prevention and quality of life. Nursing homes are encouraged to work with their infection preventionist, medical director, local public health authorities, and others involved in resident care to develop policies that comply with the guidance, in light of conditions in their facilities and their communities. Nursing home leaders should weigh the following factors in developing their policies:

• Resident quality of life, rights, and preferences;
• COVID-19 community transmission levels;
• The existence of an outbreak in the facility;
• The acuity and level of vaccination uptake of the resident population;
• The physical space available; and
• The ability of residents and visitors to adhere to masking and physical distancing recommendations during large gatherings.

Homes should keep family members and residents informed of their policies, community transmission levels, outbreaks, and the circumstances in which policies might change.

Given recent guidance changes, the following is a brief refresher on some of the key elements of the various guidance documents to help members prepare for upcoming holiday events and anticipated increases in visitation. Nursing homes are urged to read the guidance documents linked below in their entirety.

Screening at Nursing Home Entrance

DOH requires screening at facility entrances for confirmed COVID-19, symptoms of COVID-19, and known close contact with someone who has COVID-19. Individuals with confirmed COVID-19 must meet the health care criteria for ending isolation (at least 10 days). New York also requires facilities to "make every effort to verify" that visitors have received a negative COVID-19 test result no more than one day prior to the visit for antigen tests or two days prior for polymerase chain reaction (PCR) tests.

Masking and Visitors

DOH guidance requires all visitors two years of age and older and able to medically tolerate a face covering to wear a mask in health care facilities. This guidance appears to have been written for health care settings generally, and DOH may not have contemplated its implications for residents who live permanently in a nursing home. CMS guidance, by contrast, states: "Regardless of the community transmission level, residents and their visitors when alone in the resident’s room or in a designated visitation area, may choose not to wear face coverings or masks. If a roommate is present during the visit, it is safest for the visitor to wear a face covering or mask." When a facility is experiencing an outbreak, CDC guidance recommends that visits take place in residents' rooms and that visitors wear masks during visits.

The most cautious approach from an infection prevention standpoint would be to require masking at all times, including in resident rooms. However, given resident rights implications and communication challenges for visitors and residents when masks are worn, the CMS guidance provides regulatory support for visitors to unmask in resident rooms when there is no outbreak in the facility.

Meals and Visitors

During holidays and special occasions, visitors and residents may want to share a snack or a meal. The DOH guidance on masking would preclude eating together, as visitors would have to remove masks while eating. By contrast, the CMS guidance includes the following question and answer:

Can a visitor share a meal with or feed the resident they are visiting?
A: Visitors may eat with a resident if aware of the risks and adhere to the core principles of infection prevention. Eating in a separate area is preferred, however if that is not possible, then the meal could occur in a common area as long as the visitor wears a mask (in accordance with CDC recommendations), except while eating or drinking.

Again, the more cautious approach for infection prevention purposes would be to prohibit visitors from unmasking to eat with a resident. However, the CMS guidance provides support for unmasking while eating, especially in a separate area.

Communal Activities

Nursing homes may resume communal activities, including large gatherings. However, under both DOH and CMS guidance, residents and visitors should wear masks and physically distance during large gatherings. CMS Frequently Asked Questions (FAQs) provide that in a memory care unit where residents may have difficulty wearing masks and physically distancing, the size of activities and gatherings should be limited.

A recent DOH FAQ notes that physical distancing is required only during peak visitation and large gatherings:

Do nursing homes need to continue enforcing social distancing in common areas?
Facilities should follow CMS requirements that recommend encouraging physical distancing during peak times of visitation and large gatherings (e.g., parties, events). CDC also recommends taking measures to limit crowding in communal spaces.

Ventilation and Air Quality Strategies

According to CMS FAQs, nursing homes are encouraged to work with their facilities and engineering staff to optimize their ventilation to reduce the risks of infection transmission. There may even be low-cost air filtration devices that provide some benefit.

Visits Outside of the Facility

CMS guidance indicates that residents and their families should be reminded of core infection prevention principles when they leave the facility. Upon the resident’s return, nursing homes should screen the resident for signs or symptoms of COVID-19. If the resident or family member reports possible close contact with an individual with COVID-19, or develops symptoms of COVID-19, the facility should follow the applicable CDC guidance.

According to the CDC guidance, empiric use of transmission-based precautions is generally not necessary when residents leave the facility, unless they meet certain criteria outlined in the CDC guidance. Residents who leave the facility for 24 hours or longer should generally be managed as an admission. They generally do not require transmission-based precautions, but testing is recommended upon return and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. Residents returning after visits of 24 hours or more should also be advised to wear source control for the 10 days following their return.

Recent DOH FAQs confirm this approach:

1. Do new admissions to a nursing home and/or residents who return to the nursing home after 24 hours or longer need to be quarantined?

Facilities should follow CDC guidance for managing admissions and residents who leave the facility. If the resident is asymptomatic and does not otherwise meet criteria for Transmission-Based Precautions outlined in Section 2 of the CDC guidance, quarantine is not required. Such residents should be tested according to CDC guidance and should be encouraged to use source control as appropriate.

 

2. Do residents who had close contact with someone confirmed to have COVID-19 but who are not symptomatic require quarantine?

Facilities should follow CDC guidance for duration of empiric Transmission-Based Precautions for asymptomatic patients following close contact with someone with SARS-CoV-2 infection. In general, asymptomatic residents do not require empiric use of Transmission-Based Precautions while being evaluated for SARS-CoV-2 following close contact with someone with SARS-CoV-2 infection. These patients should still wear source control and those who have not recovered from SARS-CoV-2 infection in the prior 30 days should be tested per CDC guidance.

Bivalent Vaccine Reminder

This is a good time to remind residents, families, and staff of the new bivalent COVID-19 vaccine. Nursing homes are required by federal and state regulations to offer the vaccine and any recommended boosters to staff and residents. With rising rates and increased social interaction, the vaccine is a relatively simple step to reduce the risk of serious illness and death from COVID-19.

Contact: Karen Lipson, klipson@leadingageny.org