by Timothy McQuiston, Vermont Business Magazine Governor Scott on Wednesday is expected to announce new visitation guidelines for long-term care facilities (nursing homes, etc). He indicated the new guidelines were coming at his press briefing on Monday.
In his State of Emergency declaration on March 13, 2020, the governor prohibited visitation into nursing homes. Two long term care facilities in Burlington witnessed early outbreaks and several deaths because of COVID-19.
His first four orders in the State of Emergency were related to visitation to Long Term Care facilities and hospitals. (See orders below).
Scott has reopened the economy incrementally after his initial “Stay Home” order from March 24. He can be expected to take similar steps in allowing visitation to nursing homes and other long term care facilities.
Nursing homes in some other states are allowing for outside visits with one guest with strict health protocols, including social distancing, facial covering and testing of patients and guests before the meeting. The testing might include a full PCR and/or temperature.
The guidance in those states is to ensure not only the safety of the resident, but crucially also to the staff.
Even if inside visitation is allowed, it likely will not include visitation in the main part of the facility or residential areas.
Below are the guidelines issued by the federal CMS last month.
CMS (Centers for Medicare & Medicaid Services)
Nursing Home Reopening Recommendations for State and Local Officials
Memorandum Summary May 18, 2020
• CMS is committed to taking critical steps to ensure America’s nursing homes are prepared to respond to the Coronavirus Disease 2019 (COVID-19) Public Health Emergency (PHE).
• Recommendations for State and Local Officials: CMS is providing recommendations to help determine the level of mitigation needed to prevent the transmission of COVID-19 in nursing homes. The recommendations cover the following items:
o Criteria for relaxing certain restrictions and mitigating the risk of resurgence: Factors to inform decisions for relaxing nursing home restrictions through a phased approach.
o Visitation and Service Considerations: Considerations allowing visitation and services in each phase.
o Restoration of Survey Activities: Recommendations for restarting certain surveys in each phase.
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, requires aggressive efforts to limit COVID-19 exposure and to prevent the spread of COVID-19 within nursing homes.
Recommendations for States
This memorandum provides recommendations for State and local officials to help them determine the level of mitigation needed for their communities’ Medicare/Medicaid certified long term care facilities (hereinafter, ‘nursing homes”) to prevent the transmission of COVID-19. We encourage State leaders to collaborate with the state survey agency, and State and local health departments to decide how these and other criteria or actions should be implemented in their state. Examples of how a State may choose to implement these recommendations include:
• A State requiring all facilities to go through each phase at the same time (i.e., waiting until all facilities have met entrance criteria for a given phase).
• A State allowing facilities in a certain region (e.g., counties) within a state to enter each phase at the same time.
• A State permitting individual nursing homes to move through the phases based on each nursing home’s status for meeting the criteria for entering a phase.
Given the critical importance in limiting COVID-19 exposure in nursing homes, decisions on relaxing restrictions should be made with careful review of a number of facility-level, community, and State factors/orders, and in collaboration with State and/or local health officials and nursing homes. Because the pandemic is affecting communities in different ways, State and local leaders should regularly monitor the factors for reopening and adjust their plans accordingly. Factors that should inform decisions about relaxing restrictions in nursing homes include:
• Case status in community: State-based criteria to determine the level of community transmission and guides progression from one phase to another. For example, a decline in the number of new cases, hospitalizations, or deaths (with exceptions for temporary outliers).
• Case status in the nursing home(s): Absence of any new nursing home onset1 of COVID-19 cases (resident or staff), such as a resident acquiring COVID-19 in the nursing home.
• Adequate staffing: No staffing shortages and the facility is not under a contingency staffing plan.
• Access to adequate testing: The facility should have a testing plan in place based on contingencies informed by the Centers for Disease Control and Prevention (CDC). At minimum, the plan should consider the following components: o The capacity for all nursing home residents to receive a single baseline COVID-19 test. Similarly, the capacity for all residents to be tested upon identification of an individual with symptoms consistent with COVID-19, or if a staff member tests positive for COVID-19. Capacity for continuance of weekly re-testing of all nursing home residents until all residents test negative;
o The capacity for all nursing home staff (including volunteers and vendors who are in the facility on a weekly basis) to receive a single baseline COVID-19 test, with re-testing of all staff continuing every week (note: State and local leaders may adjust the requirement for weekly testing of staff based on data about the circulation of the virus in their community);
o Written screening protocols for all staff (each shift), each resident (daily), and all persons entering the facility, such as vendors, volunteers, and visitors;
o An arrangement with laboratories to process tests. The test used should be able to detect SARS-CoV-2 virus (e.g., polymerase chain reaction (PCR)) with greater than 95% sensitivity, greater than 90% specificity, with results obtained rapidly (e.g., within 48 hours). Antibody test results should not be used to diagnose someone with an active SARS-CoV-2 infection.
o A procedure for addressing residents or staff that decline or are unable to be tested (e.g., symptomatic resident refusing testing in a facility with positive COVID-19 cases should be treated as positive).
• Universal source control: Residents and visitors wear a cloth face covering or facemask. If a visitor is unable or unwilling to maintain these precautions (such as young children), consider restricting their ability to enter the facility. All visitors should maintain social distancing and perform hand washing or sanitizing upon entry to the facility.
• Access to adequate Personal Protective Equipment (PPE) for staff: Contingency capacity strategy is allowable, such as CDC’s guidance at Strategies to Optimize the Supply of PPE and Equipment (facilities’ crisis capacity PPE strategy would not constitute adequate access to PPE). All staff wear all appropriate PPE when indicated. Staff wear cloth face covering if facemask is not indicated, such as administrative staff.
• Local hospital capacity: Ability for the local hospital to accept transfers from nursing homes.
1 A “new, nursing home onset” refers to COVID-19 cases that originated in the nursing home, and not cases where the nursing home admitted individuals from a hospital with a known COVID-19 positive status, or unknown COVID-19 status but became COVID-19 positive within 14 days after admission. In other words, if the number of COVID-19 cases increases because a facility is admitting residents from the hospital AND they are practicing effective Transmission-Based Precautions to prevent the transmission of COVID-19 to other residents, that facility may still advance through the phases of reopening. However, if a resident contracts COVID-19 within the nursing home without a prior hospitalization within the last 14 days, this facility should go back to the highest level of mitigation, and start the phases over.
From Governor Scott’s Emergency Order, March 13, 2020
NOW THEREFORE, I, Philip B. Scott, by virtue of the authority vested in me as Governor of Vermont and Commander-in-Chief, Vermont National Guard, by the Constitution of the State of Vermont, Chapter II, Section 20 and under 20 V.S.A. §§ 8, 9 and 11 and Chapter 29, hereby declare a State of Emergency for the State of Vermont.
IT IS HEREBY ORDERED:
1. All State licensed nursing homes (as defined in 33 V.S.A. § 7102(7)), the Vermont Psychiatric Care Hospital (VPCH) and Middlesex Therapeutic Community Residence shall prohibit visitor access to reduce facility-based transmission. This prohibition shall not apply to medically necessary personnel or visitors for residents receiving end of life care. Any visitors will be screened in accordance with recommendations by the Commissioner of the Vermont Department of Health.
2. All State licensed assisted living residences (as defined in 33 V.S.A. § 7102(1)), Level III residential care homes (33 V.S.A. 7102(10)(A)), and intermediate care facilities for individuals with intellectual disability (ICF/ID) (42 C.F.R. § 440.150), shall prohibit visitor access to reduce facility-based transmission. This prohibition shall not apply to two designated visitors, medically necessary personnel or visitors for residents receiving end of life care. Any visitors will be screened in accordance with recommendations by the Commissioner of the Vermont Department of Health.
3. All State therapeutic community residences (as defined in 33 V.S.A. § 7102 (11)), and Level IV residential care homes (33 V.S.A. § 7102 (10)(B)), shall restrict visitor access as necessary to reduce facility-based transmission. This restriction shall not apply to medically necessary personnel or visitors for residents receiving end of life care. Any visitors will be screened in accordance with recommendations by the Commissioner of the Vermont Department of Health.
4. All hospitals (as defined in 18 V.S.A. § 1902), except VPCH, shall develop visitation policies and procedures that conform to a minimum standard which shall be developed by the Agency of Human Services to restrict visitor access to reduce facility-based transmission.