New CMS and DOH Nursing Home Visitation Guidance Lift Most Restrictions

The Centers for Medicare and Medicaid Services (CMS) and the Department of Health (DOH) have issued new nursing home visitation guidelines that eliminate most restrictions on visitation. The CMS guidance states: "Visitation is allowed for all residents at all times." The DOH guidance directs nursing homes to adhere to the CMS guidance issued on Nov. 12^th and immediately implement its provisions.

The new guidance reflects CMS's consideration of the reduced risks of visitation in light of widespread vaccination of residents and the importance of visitation to residents' wellbeing. The guidance also indicates that visitors and residents or their representatives should be made aware of the potential risk of visiting and necessary precautions related to COVID-19. While recognizing that there are still risks associated with visitation, the guidance notes that "if a visitor, resident, or their representative is aware of the risks associated with visitation, and the visit occurs in a manner that does not place other residents at risk (e.g., in the resident's room), the resident must be allowed to receive visitors as he/she chooses." Adherence to core principles of infection prevention is still required in order to mitigate those risks. The guidance is effective immediately.

Nursing home leaders are encouraged to read the new guidance documents in their entirety. Some highlights of the CMS guidance are excerpted below:

Core Principles of Infection Prevention: Visitors who have symptoms of COVID-19, a positive viral test for COVID-19, or currently meet the criteria for quarantine should not enter the facility. Facilities should screen all visitors for these exclusions.
Indoor Visitation: Facilities must allow indoor visitation at all times and for all residents as permitted under the federal nursing home regulations. Facilities can no longer limit the frequency and length of visits for residents or the number of visitors, or require advance scheduling of visits.
Outdoor Visitation: Outdoor visitation is preferred when the resident and/or visitor are not fully vaccinated.
Outbreaks: While it is safer for visitors not to enter the facility during an outbreak investigation, visitors must still be allowed in the facility.
- Visitors should be made aware of the potential risk of visiting during an outbreak investigation and adhere to the core principles of infection prevention.
- If residents or their representative would like to have a visit during an outbreak investigation, they should wear face coverings or masks during visits, regardless of vaccination status, and visits should ideally occur in the resident’s room.
Physical Distancing and Masking: Facilities should ensure that physical distancing can still be maintained during peak times of visitation (e.g., lunch time, after business hours).
- Facilities should avoid large gatherings where there may be many people in the same space at the same time.
- If the nursing home’s county COVID-19 community level of transmission is substantial to high, all residents and visitors, regardless of vaccination status, should wear face coverings or masks and physically distance, at all times.
- If a resident’s roommate is unvaccinated or immunocompromised (regardless of vaccination status), visits should not be conducted in the resident’s room, if possible.
- Visitors should wear face coverings or masks when around other residents or health care personnel, regardless of vaccination status. If the nursing home’s county COVID-19 community level of transmission is substantial to high, all residents and visitors, regardless of vaccination status, should wear face coverings or masks and physically distance, at all times.
- If the resident and all their visitor(s) are fully vaccinated, and the resident is not moderately or severely immunocompromised, they may choose not to wear face coverings or masks and to have physical contact. Unvaccinated residents may also choose to have physical touch based on their preferences and needs. In these situations, unvaccinated residents (or their representative) and their visitors should be advised of the risks of physical contact prior to the visit.
Transmission-Based Precautions: While not recommended, residents who are on transmission-based precautions (TBP) or quarantine can still receive visitors. In these cases, visits should occur in the resident’s room, and the resident should wear a well-fitting face mask (if tolerated). Before visiting residents who are on TBP or quarantine, visitors should be made aware of the potential risk of visiting and precautions necessary in order to visit the resident.
Testing of Visitors and Vaccination: Facilities are encouraged to offer COVID-19 testing to visitors in counties with substantial or high levels of community transmission. If they do not offer testing, facilities should encourage visitors to be tested on their own within two to three days prior to visiting. Facilities may ask about vaccination status, but may not require vaccination or testing or require proof of either. If a visitor declines to disclose their vaccination status, they should wear a mask at all times.
Compassionate Care Visits: While always allowed, there are very few scenarios where residents should have only compassionate care visits. One example of a situation in which compassionate care visitation might be needed is when a resident is severely immunocompromised, and the number of visitors that he or she receives must be kept to a minimum.
Outings: Residents must be permitted to leave the facility. They and the person accompanying them should be reminded to follow recommended infection prevention practices. Upon their return, they should be screened for symptoms. If they report an exposure, they should be tested for COVID-19, and if not fully vaccinated, they should be quarantined. They should also be monitored for signs and symptoms daily upon their return. Residents who leave for 24 hours or more should be managed as new admissions or readmissions, as recommended by the Centers for Disease Control and Prevention's (CDC) “Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes."
Communal Dining and Activities: The safest approach is for everyone to wear a mask in communal areas. The CMS guidance refers readers to the "Implement Source Control" section of the CDC guidance, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 Pandemic ("Interim Infection Prevention guidance"). It recommends, for nursing homes in areas of low to moderate transmission: "[Q]uality of life should be balanced with risks for transmission. In light of this, consideration could be given to allowing fully vaccinated residents to not use source control when in communal areas of the facility; however, residents at increased risk for severe disease should still consider continuing to practice physical distancing and use of source control."

The communal dining and activities section of the CMS guidance, which is repeated in the DOH guidance, does not provide facilities with a great deal of direction. The CDC Interim Infection Prevention guidance, which is referenced by both DOH and CMS visitation guidance, consolidates and modifies earlier CDC guidance (dated April 27, 2021) on post-vaccination infection prevention measures. The updated version omits prior guidance that explicitly recommended source control and physical distancing when engaging in communal dining or group activities if unvaccinated residents were present. The updated version appears to apply only to nursing homes in areas of low to moderate transmission and does not appear to require fully vaccinated residents in those facilities to practice distancing or masking, even if unvaccinated residents are present. The updated guidance is silent on the proper practices for nursing homes in areas of substantial to high community transmission.

The DOH guidance adopts the CMS guidance and highlights certain sections of the CMS guidance as important. They are:

Ombudsman Program: This section requires facilities to provide immediate access to any resident by the ombudsman, consistent with the core principles of infection prevention.
State Survey Agency Responsibilities: This section notifies facilities that they may not restrict access to surveyors based on vaccination status or ask a surveyor for proof of vaccination status as a condition of entry. However, surveyors are not permitted to enter if they have a positive test for COVID-19 or if they exhibit signs or symptoms of COVID-19.
Communal Activities, Dining, and Resident Outings: This section echoes the CMS guidance and reminds nursing homes to routinely visit and familiarize themselves with updated guidance on the CDC website. Key CDC guidance documents include:

Contact: Karen Lipson, klipson@leadingageny.org, 518-867-8838