Background
Nursing homes have been severely impacted by COVID-19, with outbreaks causing high rates of infection, morbidity, and mortality. The vulnerable nature of the nursing home population combined with the inherent risks of congregate living in a healthcare setting have required aggressive efforts to limit COVID-19 exposure and to prevent the spread of COVID-19 within nursing homes.
In March 2020, CMS issued memorandum QSO-20-14-NH providing guidance to facilities on restricting visitation of all visitors and non-essential healthcare personnel, except for certain compassionate care situations, such as an end-of-life situation. In May 2020, CMS released Nursing Home Reopening Recommendations, which provided additional guidance on visitation for nursing homes as their states and local communities progress through the phases of reopening.
While CMS guidance has focused on protecting nursing home residents from COVID-19, they recognize that physical separation from family and other loved ones has taken a physical and emotional toll on residents and their loved ones. Residents may feel socially isolated, leading to increased risk for depression, anxiety, and expressions of distress. Residents living with cognitive impairment or other disabilities may find visitor restrictions and other ongoing changes related to COVID-19 confusing or upsetting. CMS understands that nursing home residents derive value from the physical, emotional, and spiritual support they receive through visitation from family and friends. In light of this, CMS has again revised the guidance regarding visitation in nursing homes during the COVID-19 PHE. The information contained in this memorandum supersedes and replaces previously issued guidance and recommendations regarding visitation.
Since the release of QSO memorandum 20-39-NH on September 17, 2020, COVID-19 vaccines have received full approval and Emergency Use Authorization from the Food and Drug Administration. Millions of vaccinations have since been administered to nursing home residents and staff, and these vaccines have been shown to help prevent symptomatic SARS-CoV-2 infection (i.e., COVID-19).
As required by CMS, The Jamaica Hospital Nursing Home:
- Has educated residents and staff on the risks and benefits of the vaccines
- Has offered the vaccine to residents and staff
- Reports resident and staff vaccination data to CDC’s National Healthcare Safety Network. CMS now posts this information on the CMS COVID-19 Nursing Home Data website along with other COVID-19 data, such as the weekly number of COVID-19 cases and deaths. Therefore, CMS, in conjunction with the Centers for Disease Control and Prevention (CDC), updates visitation guidance accordingly, but emphasizing the importance of maintaining infection prevention practices.
- Visitation during the COVID-19 PHE is closely monitored to mitigate the opportunity for visitors to introduce COVID-19 into the nursing home. Currently as per 42 CFR § 83.10(f)(4), a resident has the right to receive visitors of his or her choosing at the time of his or her choosing, and in a manner that does not impose on the rights of another resident, such as a clinical or safety restriction (42 CFR § 483.10(f)(4)(v)).
Vaccination rates and visitation
CMS has indicated that staff vaccination rates remain significantly lower than resident vaccination rates. Therefore, there is still concern about the transmission of the virus from unvaccinated staff to residents. CMS took additional measures, such as establishing a staff vaccination requirement, to mitigate the spread of COVID-19 and protect residents.
On November 4, 2021, CMS issued a regulation requiring that all nursing home staff be vaccinated against COVID-19 as a requirement for participating in the Medicare and Medicaid programs. This requirement also applies to nearly all Medicare and Medicaid-certified providers and suppliers. They will continue to monitor vaccination and infection rates, including the effects of COVID-19 variants on nursing home residents, which have recently caused the number of cases to slightly increase. However, at this time, continued restrictions on this vital resident’s right are no longer necessary. The nursing home will adhere to the core principles of COVID-19 infection prevention and mitigate any concerns with regard to visitation. We understand that the resident has the right to make choices about aspects of his or her life in the facility that are significant to them. Residents may deny or withdraw consent for a visit at any time, per 42 CFR § 483.10(f)(4)(ii) and (iii). Therefore, 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 will be allowed to receive visitors as he/she chooses.
New Terminology: “Up-to-date” means a person has received all recommended COVID-19 vaccines, including any booster dose(s) when eligible.
Guidance
Visitation will be conducted through different means based on a facility’s structure and residents’ needs, such as in resident rooms, dedicated visitation spaces, and outdoors. Regardless of how visits are conducted, certain core principles and best practices reduce the risk of COVID-19 transmission:
Core Principles of COVID-19 Infection Prevention
- Visitors who have a positive viral test for COVID-19, symptoms of COVID-19, or currently meet the criteria for quarantine, will not be permitted to enter the facility. Jamaica Hospital Nursing Home will screen all who enter for these visitation exclusions.
- Hand hygiene (use of alcohol-based hand rub is preferred)
- Face covering or mask (covering mouth and nose) and physical distancing at least six feet between people, in accordance with CDC guidance;
- Instructional signage will be placed throughout the facility and proper visitor education on COVID19 signs and symptoms, infection control precautions, other applicable facility practices (e.g., use of face covering or mask, specified entries, exits and routes to designated areas, hand hygiene) will be given out upon arrival.
- Cleaning and disinfecting high-frequency touched surfaces in the facility often, resident room and designated visitation areas after each visit will be performed;
- Appropriate staff and visitor use of Personal Protective Equipment (PPE)
- Effective cohorting of residents (e.g., separate areas dedicated to COVID-19 care)
- Resident and staff testing conducted as required at 42 CFR § 483.80(h) (see QSO20- 38-NH)
- These core principles are consistent with the Centers for Disease Control and Prevention (CDC) guidance for nursing homes, and will be adhered to at all times.
- Additionally, visitation will be person-centered, considering the residents’ physical, mental, and psychosocial well-being, and support for their quality of life.
- The risk of transmission will be further reduced through the use of physical barriers (e.g., clear Plexiglass dividers, curtains).
- Also, the facility will enable visits to be conducted with an adequate degree of privacy.
- Visitors who are unable to adhere to the core principles of COVID-19 infection prevention will not be permitted to visit or will be asked to leave.
By following a person-centered approach and adhering to these core principles, visitation can occur safely and based on the below guidance.
Outdoor Visitation
While taking a person-centered approach and adhering to the core principles of COVID-19 infection prevention, outdoor visitation is preferred when the resident and/or visitors are not up-to-date with all recommended COVID-19 vaccine doses. Outdoor visits generally pose a lower risk of transmission due to increased space and airflow. For outdoor visits, Jamaica Hospital Nursing Home will create accessible and safe outdoor spaces for visitation, weather permitting (e.g., inclement weather, excessively hot or cold temperatures, poor air quality) or based on an individual resident’s health status (e.g., medical condition(s), COVID-19 status, quarantine status) which may hinder outdoor visits. When conducting outdoor visitation, all appropriate infection control and prevention practices will be followed.
Indoor Visitation
Jamaica Hospital Nursing Home will allow indoor visitation at all times and for all residents as permitted under the regulations. The frequency and length of visits for residents, the number of visitors, or advance scheduling of visits will no longer be dictated or required.
Although there is no limit on the number of visitors that a resident can have at one time, visits will be conducted in a manner that adheres to the core principles of COVID-19 infection prevention and does not increase risk to other residents.
Jamaica Hospital Nursing Home will ensure that physical distancing can still be maintained during peak times of visitation (e.g., lunch time, after business hours, etc.).
- Jamaica Hospital Nursing Home will avoid large gatherings (e.g., parties, events) where large numbers of visitors are in the same space at the same time and physical distancing cannot be maintained.
- During indoor visitation, the nursing home will limit visitor movement in the facility. For example, visitors will not be permitted to walk around different halls of the facility. Rather, they will be instructed to go directly to the resident’s room or designated visitation area.
- If a resident’s roommate is not up-to-date with all recommended COVID-19 vaccine doses or immunocompromised (regardless of vaccination status), visits will not be conducted in the resident’s room, if possible. For situations where there is a roommate and the health status of the resident prevents leaving the room, facilities will attempt to enable in-room visitation while adhering to the core principles of infection prevention.
- 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.
- In areas of low to moderate transmission, the safest practice is for residents and visitors to wear face coverings or masks and physically distance, particularly if either of them is at increased risk for severe disease or not up-to-date with all recommended COVID-19 vaccine doses.
- If the resident and all their visitor(s) are up-to-date with all recommended COVID-19 vaccine doses and the resident is not moderately or severely immunocompromised and no other resident present they may choose not to wear face coverings or masks and to have physical contact.
- Visitors should wear face coverings or masks when around other residents or healthcare personnel, regardless of vaccination status. Additional information on levels of community transmission is available on the CDC’s COVID-19 Integrated County View webpage.
- While not recommended, residents who are on transmission-based precautions (TBP) or quarantine can still receive visitors. In these cases, visits will occur in the resident’s room and the resident will wear a well-fitting facemask (if tolerated). Before visiting residents, who are on TBP or quarantine, visitors will be made aware of the potential risk of visiting and precautions necessary in order to visit the resident. Visitors will be required to adhere to the core principles of infection prevention.
- Jamaica Hospital Nursing Home will offer well-fitting facemasks or other appropriate PPE, if available; however, facilities are not required to provide PPE for visitors.
- CMS and CDC continue to recommend facilities, residents, and families adhere to the core principles of COVID-19 infection. This continues to be the safest way to prevent the spread of COVID-19, particularly if either party has not been up-to-date with all recommended COVID-19 vaccine doses. Separation and isolation has taken a toll on residents and there is no substitute for physical contact, such as the warm embrace between a resident and their loved one. Therefore, if the resident is up-to-date with all recommended COVID-19 vaccine doses, they can choose to have close contact (including touch) with their visitor in accordance with the CDC’s “Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic.” and Center for Clinical Standards and Quality/Survey & Certification Group Ref: QSO-20-39-NH DATE: September 17, 2020 REVISED 03/10/2022
- Residents who are not up-to-date with all recommended COVID-19 vaccine doses may also choose to have physical touch based on their preferences and needs, such as with support persons for individuals with disabilities and visitors participating in certain religious practices, including in end-of-life situations. In these situations, residents who not up-to-date with all recommended COVID-19 vaccine doses (or their representative) and their visitors will be advised of the risks of physical contact prior to the visit.
- Visitors will also be required to physically distance from other residents and staff in the facility.
Indoor Visitation during an Outbreak Investigation
An outbreak investigation is initiated when a new nursing home onset of COVID-19 occurs (i.e., a new COVID-19 case among residents or staff). To swiftly detect cases, Jamaica Hospital Nursing Home will adhere to CMS regulations and guidance for COVID-19 testing, including routine testing of staff who are not up-to-date with all recommended COVID-19 vaccine doses, testing of individuals with symptoms, and outbreak testing.
When a new case of COVID-19 among residents or staff is identified, Jamaica Hospital Nursing Home will immediately begin outbreak testing in accordance with CMS QSO 20-38-NH REVISED and CDC guidelines. While it is safer for visitors not to enter the facility during an outbreak investigation, visitors will still be allowed in the facility. Visitors will 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 will be required to wear face coverings or masks during visits, regardless of vaccination status, and visits will ideally occur in the resident’s room. Jamaica Hospital Nursing Home may contact the local health authorities for guidance or direction on how to structure their visitation to reduce the risk of COVID-19 transmission during an outbreak investigation if needed.
Visitor Testing and Vaccination
- As per the Governor’s Order, Jamaica Hospital Nursing Home will verify that visitors have received a negative SARS-CoV-2 test result one day prior to visitation for antigen tests and two days prior to visitation for NAAT (e.g. PCR) tests.
- All visitors may use either NAAT testing or antigen testing. This means, for example, that a test for a Sunday visit should be conducted no earlier than Saturday if it’s an antigen test or Friday if it’s a PCR test. Any PCR or antigen test used must either have Emergency Use Authorization by the U.S. Food and Drug Administration or be operating per the Laboratory Developed Test requirements by the U.S. Centers for Medicare and Medicaid Services.
- Jamaica Hospital Nursing Home may offer to conduct onsite testing of visitors, if practical using COVID-19 Antigen Rapid Tests, while supplies last. For visitors who visit for multiple days, including a visitor who comes every day, proof of negative testing is needed as often as feasible, at a minimum every third day (meaning at a minimum testing is done on day one, day 4, day 7, and so on).
- Jamaica Hospital Nursing Home may provide a visitor with a COVID-19 Antigen Rapid Test while supplies last if he/she does not have other valid proof of a negative test conducted. All visitors will be asked to test him/herself at the facility and present test to facility staff to verify. The results of self-testing for visitors will not need to be reported either to ECLRS or to HERDS.
Exemptions: The following are exempt from the testing requirements of this Advisory: As stated in previous Department and CMS guidance at 42 CFR § 483.10(f)(4)(i)(C) requires that a Medicare and Medicaid-certified nursing home provide representatives of the Office of the State Long-Term Care Ombudsman with immediate access to any resident. If an ombudsman is planning to visit a resident who is on transmission-based precautions or in quarantine, or resident who is not up-to-date and if Jamaica Hospital Nursing Home’s level of community transmission is substantial or high in the past 7 days, the resident and ombudsman will be made aware of the potential risk of visiting, and the visit will take place in the resident’s room. Representatives of the Office of the Ombudsman should adhere to the core principles of COVID- 19 infection prevention as described above. Emergency medical services (EMS) personnel are not subject to testing requirements.
Jamaica Hospital Nursing Home strongly encourages all visitors to become vaccinated and provide literature to educate and also encourage visitors to become vaccinated. Visitor testing and vaccination can help prevent the spread of COVID-19 and Jamaica Hospital Nursing Home may ask about a visitors’ vaccination status, however, visitors are not required to be tested or vaccinated (or show proof of such) as a condition of visitation.
If the visitor declines to disclose their vaccination status, the visitor will be required to wear a face covering or mask at all times. This also applies to representatives of the Office of the State Long-Term Care Ombudsman and protection and advocacy systems, as described below.
Compassionate Care Visits
Compassionate caregiving visitors, within the meaning of Public Health Law §2801-h, who are visiting in anticipation of the end of a resident’s life or in the instance of a significant mental, physical, or social decline or crisis of a resident.
- Compassionate care visits are allowed at all times in accordance with CMS regulations.
- In the event a scenario arises like a resident is severely immunocompromised and the number of visitors the resident is exposed to needs to be kept to a minimum, facility may limit visitation only to compassionate care visits but would still be allowed at all times and the visitor must wear any additional personal protective equipment (PPE) that facility personnel deem appropriate to the situation.
Required Visitation
Jamaica Hospital Nursing Home shall not restrict visitation without a reasonable clinical or safety cause, consistent with 42 CFR § 483.10(f)(4)(v). In previous nursing home visitation guidance during the PHE, CMS outlined some scenarios related to COVID-19 that would constitute a clinical or safety reason for limited visitation. However, there are no longer scenarios related to COVID-19 where visitation should be limited, except for certain situations when the visit is limited to being conducted in the resident’s room or the rare event that visitation is limited to compassionate care. Therefore, Jamaica Hospital Nursing Home will facilitate in-person visitation consistent with the applicable CMS regulations, which will be done by applying the guidance stated above.
There are still risks associated with visitation and COVID-19. However, the risks are reduced by adhering to the core principles of COVID-19 infection prevention. Per 42 CFR §483.10(f)(2), residents have the right to make choices about aspects of his or her life in the facility that are significant to the resident. Visitors, residents, or their representative will be made aware of the potential risk of visiting and necessary precautions related to COVID-19 in order to visit the resident. However, 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 will be allowed to receive visitors as he/she chooses.
Access to the Long-Term Care Ombudsman
As stated in previous CMS guidance QSO-20-28-NH (revised), regulations at 42 CFR § 483.10(f)(4)(i)(C) require that a Medicare and Medicaid-certified nursing home provide representatives of the Office of the State Long-Term Care Ombudsman with immediate access to any resident. If an ombudsman is planning to visit a resident who is in TBP or quarantine, or a resident who is not up-to-date with all recommended COVID-19 vaccine doses in Jamaica Hospital Nursing Home and the level of community transmission is substantial or high in the past 7 days, the resident and ombudsman will be made aware of the potential risk of visiting, and the visit will take place in the resident’s room. Representatives of the Office of the Ombudsman will be expected to adhere to the core principles of COVID19 infection prevention as described above. If the resident or the Ombudsman program requests alternative communication in lieu of an in-person visit, Jamaica Hospital Nursing Home will, at a minimum, facilitate alternative resident communication with the Ombudsman program, such as by phone or through use of other technology. The Ombudsman will be allowed to examine the resident’s medical, social, and administrative records as otherwise authorized by State law.
Federal Disability Rights Laws and Protection & Advocacy (P&A) Programs
As per 42 CFR § 483.10(f)(4)(i)(E) and (F), the Jamaica Hospital Nursing Home will allow immediate access to a resident by any representative of the protection and advocacy systems, as designated by the state, and as established under the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (DD Act), and of the agency responsible for the protection and advocacy system for individuals with a mental disorder (established under the Protection and Advocacy for Mentally Ill Individuals Act of 2000). P&A programs authorized under the DD Act protect the rights of individuals with developmental and other disabilities and are authorized to “investigate incidents of abuse and neglect of individuals with developmental disabilities if the incidents are reported to the system or if there is probable cause to believe the incidents occurred.” 42 U.S.C. § 15043(a)(2)(B). Under its federal authorities, representatives of P&A programs are permitted access to all facility residents, which includes “the opportunity to meet and communicate privately with such individuals regularly, both formally and informally, by telephone, mail and in person.”
If the P&A is planning to visit a resident who is in TBP or quarantine, or a resident who is not up-to-date with all recommended COVID-19 vaccine doses at Jamaica Hospital Nursing Home and the level of community transmission is substantial or high in the past 7 days, the resident and P&A representative will be made aware of the potential risk of visiting and the visit will take place in the resident’s room.
Additionally, Jamaica Hospital Nursing Home will comply with federal disability rights laws such as Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. § 794 (Section 504) and the Americans with Disabilities Act of 1990, 42 U.S.C. §§ 12101 et seq. (ADA).
For example, if communicating with individuals who are deaf or hard of hearing, Jamaica Hospital Nursing Home will use video remote interpreting, qualified interpreter or clear mask or mask with a clear panel. Face coverings will not be placed on anyone who has trouble breathing or is unable to wear a mask due to a disability, or anyone who is unconscious, incapacitated, or otherwise unable to remove the mask without assistance.
In addition, if a resident requires assistance to ensure effective communication (e.g., a qualified interpreter or someone to facilitate communication) and the assistance is not available by onsite staff or effective communication cannot be provided without such entry (e.g., video remote interpreting), Jamaica Hospital Nursing Home will allow an individual entry into the nursing home to interpret or facilitate, with some exceptions. This would not preclude the nursing home from imposing legitimate safety measures that are necessary for safe operations, such as requiring such individuals to adhere to the core principles of COVID-19 infection prevention. Any questions about or issues related to enforcement or oversight of the non-CMS requirements and citations referenced above under this section subject heading will be referred to the HHS Office for Civil Rights (Toll-free: 800-368-1019) (TDD toll-free: 800-537-7697), the Administration for Community Living (202-401-4634), or other appropriate oversight agency.
Entry of Healthcare Workers and Other Providers of Services
All healthcare workers will be permitted to come into the facility as long as they are vaccinated, not subject to a work exclusion or showing signs or symptoms of COVID-19. In addition to health care workers, personnel educating and assisting in resident transitions to the community shall be permitted entry consistent with this guidance. EMS personnel will not need to be screened, so they can attend to an emergency without delay. All staff, including individuals providing services under arrangement as well as volunteers, must adhere to the core principles of COVID-19 infection prevention and must comply with COVID-19 testing requirements.
Communal Activities, Dining and Resident Outings
While adhering to the core principles of COVID-19 infection prevention, communal activities and dining may occur. Book clubs, crafts, movies, exercise, and bingo are all activities that can be facilitated with alterations to adhere to the guidelines for preventing transmission. The safest approach is for everyone, regardless of vaccination status, to wear a face covering or mask while in communal areas of the facility.
Jamaica Hospital Nursing Home will permit residents to leave the facility as they choose. Should a resident choose to leave, the nursing home will remind the resident and any individual accompanying the resident to follow all recommended infection prevention practices including wearing a face covering or mask, physical distancing, and hand hygiene and to encourage those around them to do the same.
Upon the resident’s return, the nursing home will take the following actions:
- Screen residents upon return for signs or symptoms of COVID-19.
- If the resident or family member reports possible close contact to an individual with COVID-19 while outside of the nursing home, the resident will be tested for COVID-19, regardless of vaccination status. The resident will be placed on quarantine if the resident is not up-to-date with all recommended COVID-19 vaccine doses.
- If the resident develops signs or symptoms of COVID-19 after the outing, the resident will be tested for COVID-19 and place the resident on Transmission-Based Precautions, regardless of vaccination status.
- The nursing home may also opt to test residents who are not up-to-date with all recommended COVID-19 vaccine doses without signs or symptoms if they leave the nursing home frequently or for a prolonged length of time, such as over 24 hours.
- Facilities might consider quarantining residents who are not up-to-date with all recommended COVID-19 vaccine doses 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 infection prevention measures.
- Monitor residents for signs and symptoms of COVID-19 daily.
Residents who leave the facility for 24 hours or longer should generally be managed as a new admission or readmission, as recommended by the CDC’s “Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes.” Please note that there are exceptions to quarantine, including for residents who are up-to-date with all recommended COVID-19 vaccine doses
Survey Considerations
State survey agencies and CMS are ultimately responsible for ensuring surveyors are compliant with the applicable expectations. Jamaica Hospital Nursing Home will not restrict access to surveyors based on vaccination status, nor ask a surveyor for proof of his or her vaccination status as a condition of entry. Any concerns will be addressed to the State Survey Agency.
