New DOH Nursing Home Visitation Guidance Aligns with CMS Requirements

The Department of Health (DOH) issued new nursing home visitation guidance last week that aligns State requirements with guidance issued by the Centers for Medicare and Medicaid Services (CMS). The new DOH guidance supersedes and replaces previous guidance, including the Feb. 24^th visitation guidance and the November holiday guidance. It adheres to the core principles of infection control set forth by CMS and continues requirements imposed on facilities to have policies and procedures to address infection control and prevention during and after visits and outings. Like the CMS guidance, it notes that nursing homes must facilitate in-person visitation consistent with CMS requirements and that a failure to do so without a clinical or resident safety justification may trigger an enforcement action. Nursing homes are urged to read the guidance in its entirety. The following are some key highlights:

Outdoor Visitation

The DOH guidance, like the CMS guidance, generally allows outdoor visitation regardless of county positivity status or outbreak status. The outbreak provisions in the guidance are limited to the section entitled "Indoor Visitation During an Outbreak" (for the definition of "outbreak," see below). Based on the lack of any outbreak-related restrictions in the "Outdoor Visitation" section, it appears that, during an outbreak, outdoor visitation may proceed for residents who are not on transmission-based precautions. However, there is some ambiguity around the permissibility of outdoor visitation during the first round of outbreak testing after the identification of a new positive case. Under the section entitled "Indoor Visitation During an Outbreak," the guidance reads: "When a new case of COVID-19 among residents or staff is identified, nursing homes should immediately begin outbreak testing and suspend all visitation (except that required under federal disability rights law), until at least one round of facility-wide testing is completed." Although the section refers to "indoor" visitation only, it also instructs facilities to suspend "all visitation" while the first round of testing is under way.

In addition, the section of the guidance entitled "Required Visitation" provides that "[r]esidents who are on transmission-based precautions for COVID-19 should only receive visits that are virtual, through windows, or in-person for compassionate care situations." Presumably, this means that they should not participate in in-person visits, whether outdoors or indoors.

We have reached out to DOH and LeadingAge National for additional clarification on these questions.

Indoor Visitation

Indoor visitation should be allowed, except under the following limited circumstances:

Unvaccinated residents cannot have visitors indoors if the nursing home’s COVID-19 county positivity rate is >10 percent AND <70 percent of residents in the facility are fully vaccinated;
Residents with confirmed COVID-19 infection, whether vaccinated or unvaccinated, cannot receive visitors until they have met the criteria to discontinue transmission-based precautions;
Residents in quarantine, whether vaccinated or unvaccinated, cannot receive visitors until they have met the criteria for release from quarantine.

Even when indoor visitation is suspended or limited, compassionate care visits are permitted.

The new guidance eliminates the 20 percent cap on the number of visitors but cautions facilities that the number of visitors at any one time may affect their ability to adhere to the core principles of infection prevention (e.g., social distancing, screening). It encourages facilities to schedule visits for a specific duration and limit movement within the facility. It also includes recommendations for residents with roommates.

Indoor Visitation During an Outbreak

The new DOH guidance follows the CMS approach to visitation during outbreaks by allowing visitation in unaffected units when an outbreak is contained within one unit. An outbreak is triggered only by new, nursing home onset cases as referenced in CMS guidance and defined in Centers for Disease Control and Prevention (CDC) guidance:

Nursing home-onset SARS-CoV-2 infections refers to . . . infections that originated in the nursing home. It does not refer to the following:

Residents who were known to have COVID-19 on admission to the facility and were placed into appropriate Transmission-Based Precautions to prevent transmission to others in the facility.
Residents who were placed into Transmission-Based Precautions on admission and developed SARS-CoV-2 infection within 14 days after admission.

In order to determine whether an outbreak is limited to a single unit, all visitation must be suspended when a positive case is identified while an initial round of outbreak testing is conducted. If the first round of outbreak testing indicates positive cases only in one unit, visitation may proceed in unaffected units. If there are COVID-19 cases in two or more units, indoor visitation must be suspended facility-wide. Outbreak testing must continue, consistent with CMS testing guidance, until there are no new nursing home onset cases for 14 days. Visitation must be suspended on the affected units until the criteria are met for cessation of outbreak testing. Visitors should be notified of the possibility of exposure to COVID-19 in the facility and the existence of a current outbreak.

Compassionate care visitation, as described below, may proceed during an outbreak.

Visitor Testing

The new DOH guidance aligns with the CMS guidance and eliminates the requirement of a negative test result or proof of vaccination prior to visiting. In fact, both the DOH and CMS guidance prohibit facilities from requiring a negative test or proof of vaccination as a condition for visiting. Facilities are strongly encouraged to offer testing to visitors.

Exposures to Visitors Who Test Positive

The DOH guidance adds new visitor-related exposure procedures. If a visitor tests positive after a visit, and the visit took place within the period beginning two days prior to symptom onset (or two days prior to specimen collection from an asymptomatic visitor) and ending on the day that the visitor's isolation period ends, the facility must evaluate the level of exposure in the facility and take appropriate steps to mitigate the risk of infection transmission in the facility. The guidance sets forth detailed instructions for evaluating the risk of exposure and mitigation actions.

Compassionate Care Visits

The DOH guidance follows the CMS guidance in requiring facilities to allow compassionate care visits, regardless of county positivity rate or outbreak status. It reiterates the examples of compassionate care situations included in the CMS guidance, indicating that this is not an exhaustive list.

Surveyors

Facilities must permit surveyors to enter, unless they exhibit signs or symptoms of COVID-19. Federal and state surveyors are not required to be vaccinated.

Health Care Workers and Other Providers of Services

Health care providers who are not facility employees, but provide direct care to residents, including social workers and clergy, among others, must be permitted to enter the facility, unless they are subject to a work exclusion due to a COVID-19 exposure or they exhibit signs or symptoms of COVID-19. They must be screened and must adhere to the core principles of COVID-19 infection prevention and comply with COVID-19 testing requirements. EMS workers need not be screened.

Communal Dining and Activities

Communal dining and group activities may resume, consistent with COVID-19 infection prevention principles. Residents may eat together with a distance of at least six feet between them. Nursing homes are advised to consider additional limitations based on the size of the room to enable social distancing. Group activities may be facilitated (for residents who have fully recovered from COVID-19, and for those not in isolation for observation, or with suspected or confirmed COVID-19 status) with social distancing among residents, appropriate hand hygiene, and use of a face covering (except while eating).

Construction

Approved construction projects may move forward, subject to approval by DOH of a revised mitigation/prevention plan outlining, at a minimum, testing, screening, personal protective equipment (PPE) use, and distance from residents. DOH will not allow for resumption of a renovation or construction project in or adjacent to an occupied, dedicated COVID-19 unit.

Off-Site Visits/Holiday Guidance

The November holiday guidance is rescinded. The new DOH guidance states only that facilities must implement policies and procedures to address infection control and prevention during and after outings. In the absence of more specific guidance, facilities have some discretion to implement policies governing off-site visits that address the unique issues of their residents and communities, balancing infection prevention principles and resident rights to access the community. There is no specific requirement to isolate or test residents who leave the facility for a social visit and return, unless there is a known or suspected exposure.

The CDC issued new guidance yesterday for on infection preventionin nursing homes, including recommendations for managing residents who leave the facility. These recommendations include:

Residents who leave the facility should be reminded to follow all recommended infection prevention and control (IPC) practices, including source control, physical distancing, and hand hygiene and to encourage those around them to do the same.
Individuals accompanying residents (e.g., transport personnel, family members) should also be educated about these IPC practices and should assist the resident with adherence.
For residents going to medical appointments, regular communication between the medical facility and the nursing home (in both directions) is essential to help identify residents with potential exposures or symptoms of COVID-19 before they enter the facility so that proper precautions can be implemented.
In most circumstances, quarantine is not recommended for residents who leave the facility for less than 24 hours (e.g., for medical appointments, community outings with family or friends) and do not have close contact with someone with SARS-CoV-2 infection.
Quarantining residents who regularly leave the facility for medical appointments (e.g., dialysis, chemotherapy) would result in indefinite isolation of the resident that likely outweighs any potential benefits of quarantine.
Facilities might consider quarantining residents who leave the facility if, based on an assessment of risk, uncertainty exists about their adherence or the adherence of those around them to recommended IPC measures.
Residents who leave the facility for 24 hours or longer should generally be managed as new admissions or readmissions and should be placed in a 14-day quarantine, even if they have a negative test upon entry, except for:
- Residents within 3 months of a SARS-CoV-2 infection and fully vaccinated residents as described in CDC’s Updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccination.
- Facilities located in areas with minimal to no community transmission might elect to use a risk-based approach for determining which residents require quarantine upon admission. Decisions should be based on whether the resident had close contact with someone with SARS-CoV-2 infection while outside the facility and if there was consistent adherence to IPC practices in healthcare settings, during transportation, or in the community prior to admission.

Notably, these recommendations advise against quarantining residents who leave for less than 24 hours and do not have close contact with a COVID case. Residents who leave overnight should be quarantined for 14 days unless they have had COVID within the past 3 months or are full vaccinated.

CMS holiday recommendations issued last year may also be instructive. In addition, facilities may also consider the LeadingAge NY Off-Site Visit Issue Brief for suggestions, although please note that it was also written before the vaccine was available, and its references to the DOH holiday guidance are now obsolete. Nursing homes should implement policies that take into consideration factors such as positivity rates in the community or the community that the resident is visiting, the vaccination status of the resident, and the nature and duration of the visit. Indoor visits, larger gatherings, and overnight visits would call for stronger infection prevention measures upon return, such as isolation and testing.

LeadingAge Visitation Toolkit

LeadingAge National has produced a visitation toolkit to assist members in developing safe visitation practices in compliance with CMS guidance. It is available here.

Compassionate Caregiving Legislation

Finally, on March 29^th, the Governor signed into law a bill (A.1052-B/S.614-B) that requires facilities to allow visitors providing compassionate care or personal care to residents. The Governor's approval message indicated that he would be considering amendments to the bill. It is unclear how this legislation would align with the CMS and DOH guidance, and we will keep members updated as it evolves.

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