Updated Policy & Procedures for Visitation at Washington, updated 7/18/23: 

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Purpose: This facility will implement heightened surveillance activities for communicable diseases during periods of transmission in the community, an outbreak in the facility, and/or during a declared public health emergency for the illness. 

Policy: This facility will allow visitation of all visitors and non-essential health care personnel and can be conducted through different means based on the facility’s structure and residents’ needs, such as in resident rooms, dedicated visitation spaces, and outdoors. The visitation will be person-centered, consider the resident’s physical, mental, and psychosocial well-being, and support their quality of life. Exceptions will be in accordance with current CMS directives and CDC recommendations.

Policy Interpretation and Implementation:

1. The Infection Preventionist will monitor the status of communicable diseases in the community, maintain communication with local and state health departments, and will keep facility leadership informed of the need for heightened surveillance activities. The infection preventionist and the administrator are responsible for staff adherence to the visitation policies and procedures.

The Infection Preventionist will monitor the status of the COVID-19 situation through the CDC website and local/state health department and will keep facility leadership informed of current directives/recommendations and the need for restricting visitation if indicated. The infection preventionist and the administrator are responsible for staff adherence to the visitation policies and procedures.

2. The facility will communicate this visitation policy through multiple channels including but not limited to signage, calls, letters, social media posts, emails, and call multiplier with an updated recorded message.

Restrictions may be placed to prevent community-associated infection or communicable disease transmission to one or more residents.  A resident’s risk factors for infection (e.g., immunocompromised condition) or current health state (e.g., end-of-life care) should be considered when restricting.

3. Essential caregivers must be allowed in-person visitation in all the following circumstances unless the resident objects:

 • End-of-life situations.

• A resident who was living with family before being admitted to the provider’s care is struggling with the change in environment and lack of in-person family support.

• The resident is making one or more major medical decisions.

• A resident is experiencing emotional distress or grieving the loss of a friend or family member who recently died.

• A resident needs cueing or encouragement to eat or drink which was previously provided by a family member or caregiver.

• A resident who used to talk and interact with others is seldom speaking.

At a minimum the facility will follow the “Cores Principles of Infection Control” as noted:

1. Visitors with signs and symptoms of a transmissible infection (e.g., a visitor is febrile and exhibiting signs and symptoms of an influenza-like illness) should defer visitation until they are no longer potentially infectious (e.g., 24 hours after resolution outbreak of fever without antipyretic medication), or according to CDC guidelines, and/or local health department recommendations.

2. The facility will provide guidance (e.g., posted signs at entrances) about recommended actions for visitors with a positive viral test for COVID-19, symptoms of COVID-19, or close contact with someone with COVID-19. 

3. Visitors with confirmed COVID-19 infection or compatible symptoms should defer non-urgent in-person visitation until they meet CDC criteria for healthcare settings to end isolation.

4. For visitors who have had close contact with someone with COVID-19 infection, it is safest to defer non-urgent in-person visitation until 10 days after their close contact if they meet the criteria described in CDC healthcare guidance (e.g., cannot wear source control).

5. Visitors will be counseled about their potential to be exposed to COVID-19 or other communicable diseases in the facility.

6. Visitors, staff, and residents will be educated to perform hand hygiene at a minimum before and after visits (alcohol-based hand rub is preferred).

7. Visitors will not be required to be tested or vaccinated (or show proof of such) as a condition of visitation.

8. A face covering or mask (covering the mouth and nose) may be required in accordance with CDC guidance.

9. Instructional signage will be present throughout the facility and proper visitation education on signs and symptoms of  prevention of transmission, and other postings as applicable.

10. The facility cleans and disinfects high-touch areas frequently

11. The facility will conduct resident and staff testing as per current CMS/CDC guidance.

12. Visitors who are unable to adhere to these principles of Covid-19 and communicable infection prevention will not be permitted to visit or will be asked to leave.

Outdoor Visitation:

1. Outdoor visitation will be conducted in a manner that reduces the risk of COVID-19 or other communicable diseases transmission as follows:

1. Visits will be held outdoors whenever practicable and will be facilitated routinely barring weather conditions or a resident’s health status.

2. The facility will have an accessible and safe outdoor space in which to conduct outdoor visitation.

3. All appropriate infection control and prevention practices will be followed when conducting outdoor visitations.

Indoor Visitation:

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 infection prevention (see above) and does not increase the risk to other residents. The following guidelines will be implemented:

1. Indoor visitation will be conducted in a manner that reduces the risk of communicable diseases transmission based on the following guidelines:

2. The facility will allow indoor visitation at all times and for all residents and will not limit the frequency and length of visits, the number of visitors, or require advance scheduling of visits.

3. Visits will be conducted in a manner that adheres to the core principles of infection prevention and does not increase risk to other residents.

4. Physical distancing should be encouraged during peak times of visitation and large gatherings (e.g., parties, events, lunch time).

5. If the facility’s county COVID-19 community transmission is high, everyone in a healthcare setting should wear face coverings or masks including the visitors.

6. If the facility’s county COVID-19 community transmission is not high, the safest practice is for residents and visitors to wear face coverings or masks, however, the facility can choose not to require visitors to wear face coverings or masks while in the facility, except during an outbreak. The facility’s policies regarding face coverings and masks is based on recommendations from the CDC, state and local health departments, and individual facility circumstances.

7. Regardless of the community transmission level, resident and their visitors when alone in the resident’s room or in a designated visitation area, may choose not to wear face coverings or masks and may choose to have close contact (including touch). Residents (or their representative) and their visitors should be advised of the risks of physical contact prior to the visit. If a roommate is present during the visit, it is safest for the visitor to wear a face covering or mask.

8. For residents who are on transmission-based precautions or quarantine, visits may occur in the resident’s room and the resident should wear a well-fitted facemask (if tolerated). Visitors will be made aware of the potential risk of visiting and precautions necessary in order to visit and should adhere to the core principles of infection prevention

9. Visitors will be instructed to go directly to the resident’s room or designated visitation area. Visitors will be required to wear a well fitted face covering or mask when walking in the hall or any public area of the building to get to designated area regardless of vaccination status.

10. If a resident’s roommate is immunocompromised (regardless of vaccination status), if possible, visits will not be conducted in the resident’s room.

11.  For situations where there is a roommate and the health status of the resident prevents leaving the room, the facility will attempt to enable in-room visitation while adhering to the core principles of infection prevention. (Curtain pulled or barrier, social distance from roommate, and appropriate PPE). In this case, visitors may be limited to ensure social distancing can occur.

12. The facility will not schedule or approve large gatherings (e.g., parties, events) when large numbers of visitors are in the same space at the same time and physical distancing cannot be maintained.

13. In considering privacy the facility will not be monitoring each visit one on one, however, visitors who are observed not in compliance with the core principles of infection control will be educated and if continues will be asked to leave the facility.

14. The facility realizes with the opening of visitation the need for compassionate care visits will be rare, but in the event of limited visitation, the facility will allow compassionate visits for residents.

Visitation for residents in Transmission Based Precautions (TBP), Quarantine, or during Outbreak Investigation

• When a new case of COVID-19 among staff or residents is identified, the facility will immediately begin an outbreak investigation and adhere to CMS regulations and guidance for COVID-19 testing, including expanded screening testing, testing of individuals with symptoms and outbreak testing. (See Facility Testing Policy).

• Visits will be allowed during outbreak investigations, but visitors will be made aware of the potential risk of visiting during the outbreak investigation and adhere to the core principles of infection prevention. If visiting, during this time, residents and their visitors should wear face coverings or masks during the visits, regardless of vaccination status, and visits should ideally occur in the resident’s room. The facility may contact their local health authorities for guidance or direction on how to structure their visitation to reduce the risk of transmission during an outbreak investigation.

• While an outbreak investigation is occurring, the facility should limit visitor movement in the facility and visitors should go directly to the resident’s room or designated visitation area and physically distance themselves from other residents and staff, when possible.

• For residents who are on transmission-based precautions or quarantine, visits may occur in the resident’s room and the resident should wear a well-fitted facemask (if tolerated).

• Visitors will be notified about the potential for COVID-19 or other communicable disease exposure in the facility (e.g. appropriate signage regarding current outbreaks), and adhere to the core principles of infection and prevention, including effective hand hygiene and use of face coverings.

• Compassionate care visits will be allowed at all times.

• Before visiting residents who are on TBP, in quarantine, or during outbreak investigation visitors will be made aware of the potential risk of visiting and precautions necessary to visit the resident.

• Visitors are required to wear all necessary PPE to protect themselves from COVID during the visit regardless of vaccination status.

Residents Leaving the Facility

• Residents are permitted to leave the facility as they choose. The facility will remind the resident and any individual accompanying the resident to follow all recommended infection prevention practices such as wearing a face covering or mask, especially for those at high risk for severe illness and when community transmission is high, performing hand hygiene and to encourage those around them to do the same.

• Upon the resident’s return, the facility will screen the resident.

• If the resident or family member reports possible close contact to an individual with COVID-19 or other communicable disease while outside the nursing home, the facility will follow the current CDC guidance in regards to testing and quarantine.

• If the resident develops signs or symptoms of COVID-19 or other communicable disease after the outing, the facility will follow the current CDC guidance for residents with symptoms.

• In most circumstances, quarantine is not recommended for residents who leave the facility for less than 24 hours (e.g., for medical appointments, or community outings with family or friends) except in certain situations as per the current CDC empiric transmission-based precaution guidance.

• The facility will monitor residents for signs and symptoms of COVID-19 daily.

• Residents who leave the facility for 24 hours or longer should be managed as a new admission or readmission and follow current CDC guidance.

 Visitor Testing and Vaccination

The facility understands the importance of visitation to a residents’ physical, mental, and psychosocial well-being, and how visitation will support their quality of life.

1. The facility encourages visitors to become vaccinated when they have the opportunity. Visitor testing and vaccination can help prevent the spread of COVID-19 in our communities. However, visitors are not be required to be vaccinated (or show proof of such) as a condition of visitation.

Communal activities (including group activities, communal dining, and resident outings):

a.         Communal activities and dining may occur while adhering to the core principles of infection prevention. The safest approach is for everyone, particularly those at high risk for severe illness, to wear a face covering or mask while in the communal areas of the facility.

b.         Communal activities and dining do not have to be paused during an outbreak unless directed by the state or local health department. Residents who are on transmission-based precautions should not participate in communal activities and dining until the criteria to discontinue transmission-based precautions have been met.

c.         Residents are permitted to leave the facility as they choose. The facility will remind the resident and any individual accompanying the resident to follow all recommended infection prevention practices such as wearing a face covering or mask, especially for those at high risk for severe illness and when community transmission is high, performing hand hygiene and to encourage those around them to do the same.

 

Additional guidance for access to visitation

 In addition to health care workers, personnel educating and assisting in resident transitions to the community should be permitted entry consistent with this guidance.

1. The resident has a right to receive visitors of his or her choosing at the time of his or her choosing, subject to the resident's right to deny visitation when applicable,

and in a manner that does not impose on the rights of another resident,” would constitute a potential violation and the facility would be subject to citation and enforcement action

1.  Ombudsman Visitation – a nursing home provides 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 an unvaccinated resident in a nursing home in a county where the level of community transmission is substantial or high in the past 7 days, the resident and ombudsman should be made aware of the potential risk of visiting, and the visit should take place in the resident’s room. If an alternative means of communicating is requested by the resident or agency, the facility will assist in accommodating the request.

2. Any representative of the protection and advocacy (P&A) systems: 42 CFR §483.10(f)(4)(i)(E) and (F) requires the facility to 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). If the P&A is planning to visit a resident who is in TBP or quarantine, or an unvaccinated resident in a county where the level of community transmission is substantial or high in the past 7 days, the resident and P&A representative should be made aware of the potential risk of visiting and the visit should take place in the resident’s room.

3. Qualified interpreters or someone to facilitate communication is allowed entry if a resident requires assistance to ensure effective communication and the assistance is not available from onsite staff or effective communication cannot be provided remotely (e.g., video remote interpreting).

4. All healthcare workers must be permitted to come into the facility as long as they are not subject to a work exclusion or showing signs or symptoms of COVID-19

5. Health care workers, personnel educating and assisting in resident transitions to the community should be permitted entry consistent with this guidance.

6. Federal and State Surveyors must be permitted entry into facilities unless they exhibit signs or symptoms of COVID-19 or other communicable disease.

7. Surveyors should also adhere to core principles of infection prevention and adhere to any infection prevention requirements set by state law. LTC facilities are not permitted to 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.

Updated Policy & Procedure at Washington for Facial Coverings/Masks updated, 7/23/23: 

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The facility will utilize facial coverings/face masks only as required to prevent the spread of infection or as directed by local regulatory agencies including the local Department of Health, the CDC, or other governmental agencies as appropriate.

 

Florida Statue 59AER23-2 Emergency Rule – Standards for Appropriate Use of

Facial covering for Infection Control.

 

Procedure

(1) The facility may choose to require a resident to wear a facial covering only

when the resident is in a common area of the center and is exhibiting signs or

symptoms of or has a diagnosed infectious disease that can be spread through

droplet or airborne transmission.

 

(2) The facility may choose to require a visitor to wear a facial covering only when the

visitor is:

• Exhibiting signs or symptoms of or has a diagnosed infectious disease that can be spread through droplet or airborne transmission.

• In sterile areas of the health care setting or an area where sterile procedures are being performed

• In an in-patient or clinical room with a resident who is exhibiting signs or symptoms of or has a diagnosed infectious disease that can be spread through droplet or airborne transmission, or

• When visiting a resident whose treating health care practitioner has diagnosed the resident with or confirmed a condition affecting the immune system in a manner that is known to increase the risk of transmission of an infection from employees without signs or symptoms of infection to a resident and whose treating practitioner has determined that the use of facial coverings is necessary for the resident’s safety.

(3) Residents that require isolation based on an active infection and/or a

compromised immune system will have signage placed on the outside of the room

door identifying the type of isolation and alerting team members/providers and

visitors what PPE is required for entering the room including face masks.

 

(4) Residents with an active infection requiring droplet precautions requests to opt out of wearing the requested facial covering/face mask they may do so by

maintaining droplet precaution isolation in their room during the infectious phase of

their infection.

 

(5) Residents who are not actively infected and request to opt out of wearing the

requested facial covering/face masks they may do so once they have been educated on the risks of possible exposure. Education will be documented in the electronic medical record and the care plan will be updated with resident preferences.

 

(6) Visitors who request to opt out of wearing facial coverings/ face masks may do so if they do not present with signs/symptoms of an active infection.

• Visitors who opt-out will be informed of the risk of exposure when not wearing a facial covering/face mask.

• Visitors who are not actively exhibiting signs and symptoms of an airborne illness will be allowed to visit the resident unrestricted unless the resident is immune-comprised and per a physician’s order for all persons entering the room to have a facial covering/face mask to protect the resident.

(7) The facility staff may opt out of wearing a facial covering/face mask unless the

staff member is:

• Conducting sterile procedures,

• Working in a sterile area,

• Working with a resident whose treating health care practitioner has diagnosed the visitor or resident with or confirmed a condition affecting the immune system in a manner that is known to increase the risk of transmission of an infection from team members without signs or symptoms of infection to a guest/resident whose treating practitioner has determined that the use of facial coverings is necessary for the resident’s safety

• With a resident on droplet or airborne isolation, or

• Engaging in non-clinical potentially hazardous activities that require facial coverings to prevent physical injury or harm in accordance with industry standards.

• Staff members will wear approved medical-grade face masks – no cloth face masks will be permitted.

References:

Centers for Medicare & Medicaid Services, Department of Health and Human Services. State Operations Manual (SOM): Appendix PP Guidance to Surveyors for Long Term Care Facilities. (February 2023 Revision)  F563 – Right to Receive/Deny Visitors. 42 C.F.R. §483.10(f).

Centers for Medicare & Medicaid Services. (May 8, 2023) QSO-20-39-NH: Nursing Home Visitation-COVID-19 (REVISED).

https://www.cms.gov/files/document/qso-20-39-nh-revised.pdf

 

 

 

 

 

 

Additional Information & Resources

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Please remember the following recommendations from the CDC, as the flu virus also remains highly active across the country, putting all of us at risk for several more weeks. Get the flu vaccine and be vigilant with the appropriate hand hygiene and prevention measures:

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• Wash your hands for at least 20 seconds after using the restroom, before eating, and after blowing your nose, coughing or sneezing.

• Use an alcohol-based hand sanitizer.

• Avoid touching your eyes, nose and mouth.

• Cover your cough or sneeze with a tissue and throw it away.

• Stay home when you are ill.