A week and a half after nursing home operators across the country learned they could open their doors to visitors, many are still grappling with the nuances of new visitation guidelines issued by the Centers for Medicare & Medicaid Services.
Representatives from LeadingAge and other national stakeholders met virtually with CMS earlier this week to ask for clarification on several items, including whether to cancel visits during outbreaks and how to navigate conflicting state and federal guidance.
During a Tuesday meeting, CMS officials said they could issue additional clarification through a frequently asked question handout or schedule a national call for providers.
“But we shouldn’t expect concrete, definitive answers that cover every scenario,” according to Jodi Eyigor, director of nursing home quality and policy for LeadingAge. She told members during a Wednesday conference call with members that CMS instead would aim to explain reasoning behind guidelines.
“Armed with that understanding of the intent, we can be better at making decisions that are facing us,” Eyigor said.
When to halt visitations
Among questions Eyigor said she presented to officials in the CMS Nursing Home Division were several dealing with when to stop visitation for an outbreak. Initial guidance indicated facilities must halt visitation after a single positive test, but could resume it if a full round of outbreak testing revealed the outbreak was contained to a single area.
Providers also want to know how to respond if the outbreak is only among staff. A nursing home could resume visitation if the affected staff members all worked on the same team or in a single part of the building, Eyigor said, quoting officials. An outbreak among workers with responsibilities on multiple units would lead to a full stoppage. COVID-positive workers also must still quarantine.
Providers also pushed for more information on resuming activities that might require residents to be closer than six feet apart, including communal dining.
“Activities and dining are really important to our residents,” Eyigor explained. “Can they sit at a table actually with someone else? Unfortunately, that’s not going to happen.”
That’s because guidance from the Centers for Disease Control and Prevention still recommends social distancing, except in private homes. Nursing homes, because they depend on staff living in different homes with different families, don’t qualify, Eyigor said. Social distancing in dining rooms and activities should continue, but facilities can bring in entertainment and gather residents in a congregate room, provided they limit seating.
Leaves of absence, medical appointments and outings with family all can be considered too, but here CMS remains circumspect. It has yet to lay out details of what resident leave policies should look like or how to treat vaccinated residents on readmission.
“CMS says we really want people getting back to a more routine way of life, with the modification of those core principles of infection control,” Eyogor said.
States balance conflicting orders
Recently, the CDC reversed course and said fully vaccinated staff would no longer have to stay away from nursing homes when exposed to a COVID-positive individuals. Theoretically, that holds true for readmission too, Eyigor said, but questions remain.
In addition to tiptoeing between guidance from two federal agencies, providers in several states also must figure out how to conform to both local regulations and CMS policy. In Florida, where visitation has been allowed for months, for example, the federal guidelines forced some changes to local visitation allowances.
There, a state order requires nursing homes to stop visitation entirely if an outbreak occurs. In addition, CMS guidelines allow touch for fully vaccinated residents, something the state had not yet approved.
“We know there are some states that have more restrictive guidance in place,” Eyigor said. “If this is the case, reach out to your CMS regional office to let them know what the states are so CMS can reach out and try to address that.”
