CMS Revises Coronavirus Guidance
for Nursing Facilities

On March 9, 2020, the Centers for Medicare and Medicaid Services (CMS) revised and expanded the guidance to facilities dated March 4, 2020 (See Consumer Voice summary).  

KEY REVISIONS

1.  Facilities should:

• Restrict, limit, or discourage visitation depending on the circumstances. See section on visitation below.
• Review and revise how they interact with volunteers, vendors and receiving supplies, agency staff, EMS personnel and equipment, transportation providers, and other practitioners. 

2.  If possible, facilities should dedicate a unit/wing exclusively for any residents coming or returning from the hospital, including from a hospital where a case of COVID-19 was/is present.

3.  Surveyors are instructed not to cite facilities for failure to have supplies such as gowns, surgical masks, and hand sanitizer, if the facility is having difficulty obtaining those supplies due to circumstances outside their control.  However, in those situations, facilities are expected to:

• Take steps to obtain those supplies as soon as possible.
• Find ways to make up for the lack or shortage of supplies (such as staff washing hands with soap and water if there is not enough hand sanitizer).
• Notify the local and state public health officials of the shortage, follow national guidelines for optimizing their supply, or utilize the next best care option for residents.

4.  Facilities should check this link regularly for critical updates: https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html

CMS GUIDANCE ON VISITATION

Screening Criteria

Nursing homes have been instructed by the federal government to screen all visitors for the following revised criteria:

1. Signs or symptoms of a respiratory infection, such as fever, cough, shortness of breath, or sore throat.
2. Contact, within the last 14 days, with someone who has a confirmed diagnosis of COVID-19,  is under investigation for COVID-19, or has a respiratory illness.
3. International travel within the last 14 days to countries with sustained community transmission. For updated information on affected countries, visit:   https://www.cdc.gov/coronavirus/2019-ncov/travelers/index.html.
4. Residing in a community where community-based spread of COVID-19 is occurring.

In addition, CMS has instructed facilities to ask visitors if they took any recent trips (within the last 14 days) on cruise ships or participated in other settings where crowds are confined to a common location.  

Who can visit

• Based on the results of the screening, facilities should restrict, limit, or discourage visitors.
• For those with one or more of the criteria listed above
• The facility should restrict the individual from visiting. This means the individual should not be allowed in the facility at all, until they no longer meet the criteria.
• For those who don’t have any of the criteria
• CMS recommends that facilities in counties, or counties adjacent to other counties where a COVID-19 case has occurred, limit visitation.  This means the individual should not be allowed to come into the facility, except for certain situations, such as end-of-life situations or when a visitor is essential for the resident’s emotional well-being and care. 
• CMS recommends that all other facilities that are not in the counties described above discourage visitation. This means that the facility allows normal visitation practices, but advises individuals to defer visitation until further notice (through signage, calls, etc.)  Facilities should also suggest that visitors who travelled on cruise ships within the last 14 days or were in crowds confined to a common location defer their visit to a later date.
  

Signage

Facilities should increase signage at entrances and exits that includes language discouraging visits. For instance, the sign could recommend that the visitor defer their visit or visit only under certain limited circumstances.

Alternatives to visits

CMS states that facilities can consider the following:  

• Offering other means of communication, such as phone or video communication.
• Creating/increasing listserv communication to update families.
• Assigning staff as primary contact to families for inbound calls.
• Conducting regular outbound calls to keep families up to date.
• Providing a phone line with a voice recording updated at set times (e.g., daily) with the facility’s general operating status.  

Promoting safety when visitation is allowed

Facilities should take the following steps to keep visits safe:

• Provide visitors with personal protective equipment (PPE), such as facemasks. Visitors should use the PPE while in the facility (facilities may require visitors to do so).  
• If a visitor meets the criteria related to cruise ships or crowds, and the visit is necessary, the individual should use PPE. Facilities should restrict the individual’s visit if they cannot provide PPE, and ask the person to come back at a later date.   
• Suggest visitors limit physical contact with residents and others while in the facility (e.g. social distancing with no hand-shaking or hugging, remaining six feet apart, etc.).
• Create dedicated visiting areas (e.g., “clean rooms”), if possible, near the entrance to the facility where residents can meet with visitors in a sanitized environment. Disinfect rooms after each resident-visitor meeting. 
• Instruct visitors to limit their movement within the facility to the resident’s room. 
• Increase availability of hand sanitizer.
• Instruct visitors on hand hygiene, limiting surfaces touched, and use of PPE while in the resident’s room.

Visitor reporting

Visitors should report to the facility any signs and symptoms of COVID-19 or acute illness within 14 days after visiting the facility.

Access to the Ombudsman program

CMS states that residents still have the right to access the Ombudsman program.  If in-person access is allowed, ombudsmen should follow the guidance for visitors. If in-person access is not available due to infection control concerns, facilities need to facilitate resident communication (by phone or other format) with the Ombudsman program or any other entity listed in 42 CFR § 483.10(f)(4)(i)  (e.g, Protection and Advocacy, the resident’s physician, etc.).

Recommendations from Consumer Voice

These are truly extraordinary times as we all work to control and prevent the transmission of COVID-19. We urge everyone to review the recommendations we outlined in our previous email on the coronavirus.  However, in light of CMS’s revised guidance that significantly decreases visitation, Consumer Voice offers these additional recommendations:

• Find out how the facility plans to communicate with residents and families, including how frequently the facility will provide updates about the virus and the resident’s status.  Families should make sure the facility has correct contact information.  
• Ask how the facility will assist residents and families to connect if in-person visitation is not possible.  Request that staff actively facilitate such communication since not all residents have this technology or are able to manage it on their own. 
• Encourage residents and families to prepare now for the time when they might be unable to visit in person. Urge them to put systems in place, such as video chat (e.g. FaceTime, Skype), email, family conference calls, blogs, and Facebook, and practice using them in advance. 
• Visit our website www.theconsumervoice.org for additional information and ideas.

For more on infection prevention:  https://theconsumervoice.org/issues/other-issues-and-resources/infection-prevention