State releases new guidance for nursing home visitation

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State releases new guidance for nursing home visitation

Tue, 10/13/2020 - 4:37pm -- tim

Long Term Care Guidance for Operations During COVID-19 Health Emergency

Effective Date: 10/12/20
Core Principles of COVID-19 Infection Prevention

Background

The information contained in this guidance supersedes and replaces previously issued guidance and recommendations in the July 14th Restart Guidance.

On March 13, 2020, Governor Scott issued an Executive Order prohibiting most visitation at nursing homes and other residential care facilities in Vermont, recognizing the particularly vulnerable, congregate populations at such facilities.

On August 26, 2020, CMS (Centers for Medicare & Medicaid Services) issued a memo to nursing homes (QSO-20-38-NH) setting new requirements around resident/staff testing and providing guidance. On September 16, 2020, CMS issued a memo to nursing homes (QSO-20-39-NH) superseding and replacing former CMS guidance/recommendations regarding visitation and allowable activities.

These recent CMS memos prompted this replacement of the former COVID-19 Re-Start Plan.

The guidance below was developed using CMS’s most recent guidance, and should be used by licensed long term care facilities to guide operations and easing of restrictions, based on county positivity rates; essentially re-starting modified visitation and activities unless a facility is in an active outbreak situation or just emerging from an outbreak. 

Each facility is unique in its layout, geography, resident population, and needs. 

Recognizing the toll that separation has taken on residents and families and the equally important need to maintain safety in facilities, the phases outlined below include recommendations designed to provide for the safety of residents, staff, and visitors alike, while allowing facilities the flexibility to determine the best implementation strategy for their specific operations.

Skilled Nursing Facilities should consider this guidance in addition to CMS issued requirements.

Additionally, many aspects of COVID-19 and its properties remain unknown. This framework is based on current knowledge and may be revisited from time to time as knowledge of the virus changes.

Easing of restrictions can be conducted through different means based on a facility’s structure, staffing, supplies, and residents’ needs and abilities. As licensed long-term care facilities ease restrictions and continue to operate during this public health emergency, the following core principles and best practices, which reduce the risk of COVID-19 transmission, should be maintained at all times, throughout each phase.

• Screening of all who enter the facility for signs and symptoms of COVID-19 (e.g., temperature checks, questions or observations about signs or symptoms), and denial of entry of those with signs or symptoms;
• Hand hygiene;
• Face covering or mask (covering mouth and nose) – for all staff, all visitors (outdoor or indoor), and as tolerated by residents during visits or congregate meals/activities;
• Physical distancing at least six feet between persons;
• Instructional signage throughout the facility and proper visitor education on COVID-19 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);
• Cleaning and disinfecting frequently touched surfaces in the facility often, and designated visitation areas after each visit;
• Appropriate staff use of Personal Protective Equipment (PPE);
• Effective cohorting of residents (e.g., separate areas dedicated COVID-19 care); and cohorting and assigning of staff as feasible
• Resident and staff testing conducted as required by CMS or as recommended by the state of
Vermont

Phases of Operation

The Phases and their accompanying screening requirements, visitation guidance, congregate activity limits and testing requirements are applied to ALL long-term care residential facilities, which include nursing homes (also known as Skilled Nursing Facilities), residential care homes, assisted living residences, therapeutic community residences, the home for the terminally ill and the intermediate care facility for individuals with intellectual disabilities.

The Phases now correspond to county positivity rates instead of consecutive days without COVID-19 infections. Facilities should monitor their county positivity rate at least every other week. Use this link to obtain county positivity rates. The Division of Licensing and Protection will also be sending out a weekly list of county positivity rates via email. County positivity rates dictate the phase of each facility, but as allowable activities/visitation are implemented, each facility should have policies and procedures guiding their practices. Facilities may also monitor other factors to understand the level of COVID-19 risk, such as the percent of emergent care visits for COVID-19-like illness and influenza-like illness in Vermont, as well as at the national and regional-level.

Phase Zero: Facilities with new COVID-19 infection in any healthcare personnel (HCP) or any nursing homeonset COVID-19 infection in a resident

Screening

Screen 100% of all persons entering the facility

Screen 100% of residents at least daily

Increase monitoring of all ill residents to at least three times daily

Visitation

Compassionate Care only

Non-essential personnel

Personnel providing direct care to residents must be permitted entry (unless excluded due to exposure or symptom screening) per the below guidance. Consult with VDH and DAIL to discuss additional situations/details.

Trips outside the

facility

Only medically necessary trips outside the facility

Communal Dining

Consult with VDH and DAIL to review appropriate infection prevention and control measures tailored to your situation.

Group activities

Consult with VDH and DAIL to review appropriate infection prevention and control measures tailored to your situation.

Testing*

Any symptomatic residents or staff

SNF: Facility-wide testing of all staff and residents with repeat testing of all negatives

every 3 – 7 days until no new positives identified for a period of 14 days* Non-SNF: As recommended by VDH

 

Phase One: Facilities in a county with >10% positivity rate

Screening

Screen 100% of all persons entering the facility

Screen 100% of residents at least daily

Visitation

Compassionate Care only within the facility

Outdoor visitation allowed

Non-essential

personnel

Non-essential healthcare and contractors allowed. Services should be coordinated

among residents to reduce repeated visits.

Trips outside the

facility

Only medically necessary trips outside the facility

Communal Dining

Communal dining permitted with physical distancing, cohorting encouraged

Group activities

Group activities permitted with physical distancing, cohorting encouraged

Required Testing

Any symptomatic residents or staff and outbreak response testing

Staff Testing*

Twice per week, ongoing (optional for non-SNF)

Facility-Wide Testing

Following detected positive COVID-19 case in a resident or staff as recommended by

VDH; please consult directly with the VDH team

Phase Two: Facilities in a county with 5%-10% positivity rate

Screening

Screen 100% of all persons entering the facility

Screen 100% of residents at least daily

Visitation

Visitation should occur according to the core principles of COVID-19 infection prevention and facility policies (beyond compassionate care visits)

Non-essential personnel

Non-essential healthcare and contractors allowed. Services should be coordinated among residents to reduce repeated visits.

Trips outside the

facility

Non-medically necessary trips permitted, based on risk of activity

Communal Dining

Communal dining permitted with physical distancing, cohorting encouraged

Group activities

Group activities permitted with physical distancing, cohorting encouraged

Required Testing

Any symptomatic residents or staff and outbreak response testing

Staff Testing*

Weekly, ongoing (optional for non-SNF)

Facility-Wide Testing

Following detected positive COVID-19 case in a resident or staff as recommended by

VDH; please consult directly with the VDH team

 

Phase Three: Facilities in counties with <5% positivity rate

Screening

Screen 100% of all persons entering the facility

Screen 100% of residents at least daily

Visitation

Visitation should occur according to the core principles of COVID-19 infection prevention and facility policies (beyond compassionate care visits)

Non-essential personnel

Non-essential healthcare and contractors allowed. Services should be coordinated among residents to reduce repeated visits.

Trips outside the

facility

Non-medically necessary trips permitted, based on risk of activity

Communal Dining

Communal dining permitted with physical distancing, cohorting encouraged

Group activities

Group activities permitted with physical distancing, cohorting encouraged

Required Testing

Any symptomatic residents or staff and outbreak response testing

Staff Testing*

Monthly, ongoing (optional for non-SNF)

Facility-Wide Testing

Following detected positive COVID-19 case in a resident or staff as recommended by

VDH; please consult directly with the VDH team

*SNFs (CMS-Certified Skilled Nursing Facilities) need to follow CMS requirements for resident and staff testing, as required by QSO-20-38-NH.

Facility Self-Certification of Phases

There is no longer a need to notify DAIL’s Division of Licensing and Protection regarding Phase movement, since phases are based on county positivity rates and the facility not being in an active outbreak or outbreak recovery situation. Each facility shall have documentation and policies/procedures regarding how the facility is safely implementing the allowable activities listed in each phase and their testing strategy, which shall be readily available per request of DAIL or VDH.

Screening

Active screening involves three components: physical screening, risk assessment, and information.

1. Physical Screening: Recommendations for screening and triage of those entering a healthcare facility, in part, include:

Screen everyone entering the healthcare facility for symptoms [cdc.gov] consistent with COVID-19.
Actively take their temperature and document absence of symptoms consistent with COVID-19.
Fever is either measured temperature ≥100.0°F or subjective fever.
Ask them if they have been advised to self-quarantine because of exposure to someone with COVID-19.
According to the CDC, COVID-19 symptoms [cdc.gov] may include, but are not limited to the following:

• Fever

• Cough

• Shortness of breath

• Headache

• New loss of taste or smell

• Congestion or runny nose

• Sore throat

• Diarrhea

• Myalgia (muscle aches, body aches)

• Tiredness or fatigue

2. Risk Assessment: The general areas that could be addressed/considered during screening as risk factors include:

Latest COVID test (not required for visitation) History of contact with exposed individuals
Travel to or from out of state – refer to ACCD travel guidance

3. Information: The information to communicate to visitors should include the following:

PPE wear and use
Hand hygiene expectations
Where to go and where is off limits in the facility, and how those are marked. What to do at the conclusion of the visit and how to exit the building

Entry of Health Care Workers and Other Providers of Services

Health care workers who are not employees of the facility but provide direct care to the facility’s residents, such as hospice workers, Emergency Medical Services (EMS) personnel, dialysis technicians, laboratory technicians, radiology technicians, social workers, clergy etc., must be permitted to come into the facility as long as they are not subject to a work exclusion due to an exposure to COVID-19 or show signs or symptoms of COVID-19 after being screened. Note that EMS personnel do not need to be screened so they can attend to an emergency without delay. We remind facilities that all staff, including individuals providing services under arrangement as well as volunteers, should adhere to the core principles of COVID-19 infection prevention and must comply with COVID-19 testing requirements (testing required in SNF- only).

Access to the Long-Term Care Ombudsman and/or Disability Rights Vermont

In-person access to residents may not be limited without reasonable cause. Representatives of the Office of the Ombudsman should adhere to the core principles of COVID-19 infection prevention. If in-person access is not advisable, such as the Ombudsman or Advocate having signs or symptoms of COVID-19 or the facility being in an active outbreak situation, facilities must, at a minimum, facilitate alternative resident communication with the ombudsman and/or advocate, such as by phone or through use of other technology.

Outdoor Visitation

Outdoor visits pose a lower risk of transmission due to increased space and airflow. Therefore, visits should be held outdoors whenever practicable. Facilities should create accessible and safe outdoor spaces for visitation, such as in courtyards, patios, or parking lots. When conducting outdoor visitation, facilities should have a process to limit the number and size of visits occurring simultaneously to support safe infection prevention actions (e.g., maintaining social distancing). We also recommend reasonable limits on the number of individuals visiting with any one resident at the same time.

“Window visits” may occur, following the below guidance, as long as the facility is able to

accommodate this type of visit while ensuring core principles are followed.

• Visits must be arranged in advance and scheduled with the facility

• Visitors are screened for symptoms of COVID-19 immediately prior to any visitation with staff or residents of a facility. Those with symptoms must be excluded from visitation;

• All visitations must be documented and tracked, including maintaining a log of times and dates of all visitors, and their contact information.

• Visitors must have completed quarantine following high risk travel according to ACCD

guidance prior to any visits.

• Visitors must be able to adhere to the core principles (including face coverings/masks) and staff should provide monitoring for those who may have difficulty adhering to core principles

• Residents will also be encouraged to wear facemasks or cloth face coverings during visits if they can tolerate them.

• Facilities shall provide visitors with an alcohol-based hand rub/hand sanitizer prior to interaction with any staff members or residents.

• Facilities shall provide staff supervision as needed to ensure social distancing of at least six feet between people, and that other infection prevention measures are maintained at all times during the visit.

• Facilities should develop and provide advance notice about facility-specific policies and procedures for safe visitation to scheduled visitors.

• Physical contact between the visitor(s) and residents, including the passing of items directly to the resident and vice versa, is prohibited.

• Any gifts or items to be delivered to the resident shall be handled per the facility policy for receiving and sanitizing items.

• Facilities may limit times, dates, and lengths of stays by visitors based on available resources to ensure the proper care and safety of staff and patients.
• Homes may place physical barriers or visual reminders/signage to ensure proper distancing during visits.

Indoor Visitation

When outdoor visits are not feasible due to weather conditions, facilities should accommodate and support indoor visitation, including visits for reasons beyond compassionate care situations, based on the following guidelines:
a) There has been no new onset of COVID-19 cases in the last 14 days and the facility is not currently conducting outbreak testing;
b) Visitors must be able to adhere to the core principles and staff should provide monitoring for those who may have difficulty adhering to core principles, such as children;
c) Facilities should limit the number of visitors per resident at one time and limit the total number of visitors in the facility at one time (based on the size of the building and physical space). Facilities should consider scheduling visits for a specified length of time to help ensure all residents are able to receive visitors; and
d) Facilities should limit movement in the facility. For example, visitors should not walk around different halls of the facility. Rather, they should go directly to the designated visitation area; and
e) The county percent positivity for facility is 10%.
Visitation should be person-centered; consider the residents’ physical, mental, and psychosocial well-being, and support their quality of life. The risk of transmission can be further reduced through the use of physical barriers (e.g., clear Plexiglas dividers, curtains). Also, facilities
should enable visits to be conducted with an adequate degree of privacy when possible or requested. Visitors who are unable to adhere to the core principles of COVID-19 infection prevention should not be permitted to visit or should be asked to leave.

Indoor Visitation Recommendations

Indoor visitation poses increased risk to residents, outdoor visitation remains the preferred method for enabling contact between residents and visitors. The recommendations below are designed to create the safest possible environment to mitigate the enhanced risk posed by indoor visits.
Each facility must have a policy for indoor visitation that incorporates the following:

• A demonstrated mechanism to assess that all visitors can and do comply with core principles throughout the entire visit.

• All visitors must be screened for symptoms of COVID-19 prior to entering the facility.

Visitors must have completed quarantine following high risk travel according to ACCD
guidance prior to any visits.

• Hand sanitizer must be made available for immediate use prior to the visit; upon entry to the facility and in the visitation area.

• Face coverings or masks must be worn at all times.

• Use of signage and clear visual reminders of all core principles, best practices and infection prevention and control procedures, which are easily seen and understood by visitors.

• Names and contact information of all visitors must be documented for each visit, to enable any necessary contact tracing. Duration of visits must also be recorded.

• Visits should be scheduled in advance and limited to 2 visitors per visit.

• Visits should be of limited duration to decrease risk; current guidance indicates that anything over 15 minutes constitutes prolonged exposure. Please take this into account when developing policies and scheduling the length of visits, especially when using a small enclosed space with poor ventilation. Compassionate care situations may call for a more flexible approach.

• Physical distancing should be maintained at all times, and whenever possible, barriers should be used to increase safety.

Physical touch as part of these visits is not consistent with the core principles.
For instances in which this is a concern, please contact VDH for individual
guidance.

• Visits should be conducted in a designated area, as separate from patient care areas as possible (dependent on the physical layout of the facility). Preferably, using entrances and exits that do not require visitors to travel through patient care areas. Compassionate care situations may call for a more flexible approach.

• The designated visitor area must be cleaned and disinfected between each visit.

• The designated area should not have its HVAC system, if one is in place, disabled. Effort should be taken to increase area ventilation to the outdoors and air filtration, as feasible in the space.

• Visitors should be directed to a designated visitor bathroom whenever possible within the facility or encouraged not to use the bathrooms in the facility. If a resident/staff bathroom must be used, ensure it is cleaned and disinfected between use.

• Staff should be prepared to end visits if visitors demonstrate an unwillingness or inability to comply with the core principles.

Communal Activities and Dining

While adhering to the core principles of COVID-19 infection prevention, communal activities and dining may occur. Residents may eat in the same room with social distancing (e.g., limited number of people at each table and with at least six feet between each person). Facilities should consider additional limitations based on status of COVID-19 infections in the facility. Additionally, group activities may also be facilitated (for residents who have fully recovered from COVID-19, and for those not in quarantine for observation, or in isolation with suspected or confirmed COVID-19 status) with social distancing among residents, appropriate hand hygiene, and use of a face covering. Facilities may be able to offer a variety of activities while also taking necessary precautions.

Documentation and Reporting of COVID-19 Test Results

Any positive COVID-19 test results need to be reported to the Vermont Department of Health immediately.

Any facilities using Point of Care testing devices through a CLIA certificate of waiver are
required by federal CLIA regulations to report all results to the Vermont Department of Health. The Department of Health’s secure fax number is: 802-951-4061. Additional guidance addressing result reporting is forthcoming.
For symptomatic residents and staff, document the date(s) and time(s) of the identification of signs or symptoms, when testing was conducted, when results were obtained, and the actions the facility took based on the results.
Upon identification of a new COVID-19 case in the facility (i.e., outbreak), document the date the case was identified, the date that all other residents and staff are tested, and the dates and results of subsequent re-testing per VDH guidance.

Refusal of Testing

Facilities must have procedures in place to address staff who refuse testing. Procedures should ensure that staff who have signs or symptoms of COVID-19 and refuse testing are prohibited from entering the building until the return to work criteria are met. If outbreak testing has been triggered and a staff member refuses testing, the staff member should be restricted from the building until the procedures for outbreak testing have been completed.
Residents (or resident representatives) may exercise their right to decline COVID-19 testing in accordance with the requirements around resident rights to refuse treatment. In discussing testing with residents, staff should use person-centered approaches when explaining the importance of testing for COVID-19. Facilities must have procedures in place to address residents who refuse testing. Procedures should ensure that residents who have signs or symptoms of COVID-19 and refuse testing are placed on transmission-based precautions (TBP) until the criteria for discontinuing TBP have been met.
If outbreak testing has been triggered and an asymptomatic resident refuses testing, that resident should be placed on TBP.
Document the facility’s procedures for addressing residents and staff that refuse testing or are unable to be tested, and document any staff or residents who refused or were unable to be tested and how the facility addressed those cases.

New Admissions

Testing of new admissions can be considered along with other infection control interventions such as quarantine but is not required. It is not required to have a negative COVID-19 test to be admitted to a long-term care facility. Some people who are fully recovered from COVID-19 may test positive for several weeks after the initial positive test.
New facility admissions should not participate in communal dining, group activities, or non- medically essential services like salon services for at least 14 days due to recommendations for quarantine. New admissions may be able to safely participate in visitation, if visitation can be accommodated while maintaining quarantine (e.g. without coming in close contact with other residents/staff, outdoor visits via an entrance directly to the quarantine area, window visits, or a designated indoor visitation space within the quarantine area).

Other Testing Considerations

In keeping with current CDC recommendations, staff and residents who have recovered from COVID-19 (previously tested positive) and are asymptomatic do not need to be retested for COVID-19 within 3 months (12 weeks) after symptom onset or date of specimen collection for persons remaining asymptomatic.
Collecting and handling specimens correctly and safely is imperative to ensure the accuracy of test results and prevent any unnecessary exposures. The specimen should be collected and, if necessary, stored in accordance with the manufacturer’s instructions for use for the test and CDC guidelines.
During specimen collection, facilities must maintain proper infection control and use recommended personal protective equipment (PPE), which includes an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown, when collecting specimens.
Inquiries to the Vermont Department of Health for supplies, testing and processing assistance, as required by CMS guidance in QSO-20-38-NH, should be made to Shayla Livingston at shayla.livingston@vermont.gov.

Personal Protective Equipment

Proper use of PPE, as determined or recommended by CDC and CMS guidelines, must be maintained throughout all Phases.
PPE Resources:
Department of Health PPE Guidance
Infection Control Guidance
Use of PPE for COVID-19
PPE Optimization

Definition:

“Facility staff” includes employees, consultants, contractors, volunteers, and caregivers who provide care and services to residents on behalf of the facility, and students in the facility’s nurse aide training programs or from affiliated academic institutions. For the purpose of testing “individuals providing services under arrangement and volunteers,” facilities should prioritize those individuals who are regularly in the facility (e.g., weekly) and have contact with residents or staff. We note that the facility may have a provision under its arrangement with a vendor or volunteer that requires them to be tested from another source (e.g., their employer or on their own).