cdc guidelines for nursing home visits during covid

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CDC Updates COVID-19 Guidance for Nursing Homes

To give nursing homes a more robust strategy to protect residents and staff, CDC has updated its infection prevention guidance for long-term care settings to include tiered recommendations to address nursing homes in different phases of COVID-19 response, as well as new recommendations to designate at least one individual to manage the nursing home’s infection prevention program, and to create a plan for testing residents and healthcare personnel. This guidance also includes information about reporting COVID-19 data to the National Healthcare Safety Network (NHSN).

Additionally, CDC has developed guidance to implement facility-wide testing in nursing homes and updated the interim testing guidance to integrate testing with other core prevention strategies.

CDC has developed many resources specific to help support long-term facilities during the COVID-19 pandemic. Below you will find a summary of these resources.

• Infection Prevention and Control Assessment Tool for Nursing Homes Preparing for COVID-19 – CDC’s COVID-19 Infection Control Assessment and Response (ICAR) tool was developed to help nursing homes prepare for and respond to COVID-19. This ICAR tool should be used as one tool to develop a comprehensive COVID-19 response plan. This tool may also contain content relevant for assisted living facilities.
• Considerations for Memory Care Units in Long-term Care Facilities – Infection prevention strategies to prevent the spread of COVID-19 are especially challenging to implement in dedicated memory care units where numerous residents with cognitive impairment reside together. This guidance provides considerations for memory care units, including when residents in a memory care unit are suspected or confirmed to have COVID-19. 
• Preparedness Checklist for Nursing Homes and Other Long-Term Care Settings – Nursing homes and other long-term care facilities can take steps to assess and improve their preparedness for responding to coronavirus disease 2019 (COVID-19). This checklist should be used as one tool to develop a comprehensive COVID-19 response plan.
• Long-term Care Facility Letter to Residents, Families, Friends and Volunteers – This letter helps to communicate to residents, families and volunteers the actions your nursing home facility is taking to protect its residents and staff. 
• Preparing Nursing Homes and Assisted Living Facilities to Prepare for COVID-19 – This pre-recorded webinar will provide nursing homes, assisted living facilities and other long-term care facilities with information to prepare for COVID-19. 
• LTCF COVID-19 Module – CDC’s NHSN provides healthcare facilities, such as long term care facilities (LTCF) with a customized system to track infections and prevention process measures  in a systematic way.

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Coronavirus Updates

The coronavirus crisis, nursing homes can now lift most covid restrictions on visits.

The Associated Press

Melvin Goldstein, 90, glances at pictures of birds, left, and a fish, his 13-year-old granddaughter drew for him as a gift as his daughter Barbara Goldstein shares them with his during a family visit inside the Hebrew Home at Riverdale on March 28 in New York. On Friday, the government eased many remaining pandemic restrictions. Kathy Willens/AP hide caption

Melvin Goldstein, 90, glances at pictures of birds, left, and a fish, his 13-year-old granddaughter drew for him as a gift as his daughter Barbara Goldstein shares them with his during a family visit inside the Hebrew Home at Riverdale on March 28 in New York. On Friday, the government eased many remaining pandemic restrictions.

WASHINGTON — The government on Friday directed nursing homes to open their doors wide to visitors, easing many remaining pandemic restrictions while urging residents, families and facility staff to keep their guard up against outbreaks.

The new guidance from the Centers for Medicare and Medicaid Services instructs nursing homes to allow visits at all times for all residents. Facilities will no longer be able to limit the frequency and length of visits, or require advance scheduling. Although large groups of visitors are discouraged, nursing homes won't be allowed to limit the number of loved ones and friends who can pay a call on residents.

Many states and communities are still grappling with COVID-19 surges driven by the aggressive delta variant, but the most recent government data show that cases among residents and staff have continued to decline after rising earlier in the summer and fall.

Nationally, vaccination rates average 86% for nursing home residents and 74% for staff, although that can vary dramatically from state to state and facility to facility. Many nursing homes are rushing to provide booster shots for their residents. Staffers were recently required by the government to get vaccinated.

This "gets us the closest to pre-pandemic visitation that we've ever been since the beginning of the pandemic," said Jodi Eyigor, director of nursing home quality and policy for LeadingAge, an industry group that represents nonprofit facilities.

"But it doesn't mean that the pandemic is over and that COVID is not circulating," Eyigor added. "The nursing homes, the residents and their loved ones are all going to have to work together to make sure that visits are occurring and they are occurring safely."

The federal guidance draws a line on visits by people who have tested positive for COVID or meet the criteria for quarantine. Nursing homes should not allow COVID-positive visitors to enter.

But residents can still receive visits if their facility is in the midst of an outbreak investigation or if they themselves are under special precautions to prevent COVID transmission. In such cases, residents and visitors must wear masks and protective gear.

It was unclear Friday how the new federal guidance would work with local and state requirements that may be more restrictive.

People in long-term care facilities have borne a cruel toll from the pandemic. They represent about 1% of the U.S. population, but accounted for roughly in 3 in 10 deaths. The ravages of COVID were compounded by enforced isolation. Nursing homes went on lockdown in March of last year and residents were unable to see their loved ones in person until early this spring.

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Feds Drop Most COVID-19 Restrictions on Nursing Home Visits

Facilities are being told to open up after 20 months of lockouts.

Emily Paulin, AARP

The federal government on Friday directed the nation's 15,000 nursing homes to open up their doors and allow visits for “all residents at all times,” dropping many of the remaining COVID-19 restrictions. “At this time, continued restrictions on this vital resident’s right are no longer necessary,” the Centers for Medicare & Medicaid Services (CMS) said in the revised guidance .

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Citing a national COVID-19 vaccination rate of 86 percent among residents and “dramatically reduced” weekly COVID-19 infections, the new guidance says nursing homes can no longer limit the frequency and length of visits, limit the number of visitors, or require advance scheduling. ​

Visits must also be allowed to take place indoors for all residents, whether they’re vaccinated or not, even when a facility is experiencing a COVID-19 outbreak investigation or when a resident is on transmission-based precautions or quarantine. While visits under such conditions are “not recommended” by the CMS, they must be allowed if that’s what a resident chooses. ​

​The updated guidance represents “our most comprehensive action to bring residents and loved ones closer together,” the CMS said, but it stops short of opening facilities to visitors who have a positive COVID-19 test, who are showing symptoms of COVID-19, or who currently meet the criteria for quarantine. CMS says that facilities should screen all visitors for these exclusions.

​“We are pleased that the CMS is taking a person-centered approach to expanding visitation so that residents can exercise their rights and avoid the isolation and other challenges that too many have experienced during the pandemic,” said AARP's Rhonda Richards, a senior legislative representative. "But it’s important to remain vigilant and follow important infection prevention measures.”

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Although the new CMS guidance offers more freedoms, it reinforces that “visits should be conducted in a manner that adheres to the  core principles of COVID-19 infection prevention  and does not increase risk to other residents.” It says all residents and visitors should wear face coverings and physically distance during visits to a nursing home where the surrounding community level of transmission is high, for example. ​ ​

While the national COVID-19 death rate among nursing home residents is one-tenth of what it was during last  winter’s devastating peaks , the virus has recently killed more than 2,000 residents per month, according to  AARP’s ongoing analysis of federal nursing home data . That represents a sixfold increase in COVID-19 fatalities since early summer, when the death rate hit a low for 2021. In some states, like Montana and Wyoming, the death rate is near winter’s levels, despite a high proportion of residents being vaccinated this time around.

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​Many nursing homes are also navigating booster shots for residents and staff, as studies show waning efficacy, especially for older and immunocompromised people. As they do, more than a quarter of nursing home workers nationwide remain unvaccinated. ​ ​

The CMS says it’s “concerned about the transmission of the virus from unvaccinated staff to residents” given that staff vaccination rates remain “significantly lower” than resident rates. However, a new  federal mandate , which requires all nursing home staff be vaccinated against COVID-19 by Jan. 4 as a requirement for participating in the Medicare and Medicaid programs, aims to “ensure continued safety as facilities continue to open.”​

​The new guidance comes after 20 long months of visitation restrictions designed to reduce the risk of visitors introducing COVID-19 to a facility. Nursing homes went on lockdown in March 2020, barring residents from embracing their loved ones for an entire year. While the restrictions were designed to protect residents and staff from the virus — which has  killed more than 186,000 in long-term care facilities , including nursing homes, assisted living facilities and others — they’ve also taken a heavy toll. Besides COVID-19 deaths, 40,000 more people than usual died in U.S. nursing homes last year, many from neglect and isolation, according to an  Associated Press report  published November 2020.​

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Fact Sheets CMS Updates Nursing Home Guidance with Revised Visitation Recommendations

• Home health agencies

Nursing homes have been severely impacted by COVID-19, with outbreaks causing high rates of infection, morbidity, and mortality. [1] 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 these facilities.

Since the beginning of the pandemic, the Centers for Medicare & Medicaid Services (CMS) has recognized that physical separation from family and other loved ones has taken a physical and emotional toll on residents and their families. Today, CMS is announcing guidance on expanding indoor visitation in nursing homes, in response to significant reductions in COVID-19 infections and transmission resulting from ongoing infection control practices, and high vaccination rates in the nursing home population following the authorization of COVID-19 vaccines by the U.S. Food and Drug Administration (FDA’s) authorization of COVID-19 vaccines for emergency use.

Visitation can be conducted through various means based on a facility’s’ structure and residents’ needs, including in resident rooms, visitation spaces, and outdoors. Given the ongoing risk of COVID-19 transmission, CMS continues to recommend facilities, residents, and families adhere to the core principles of COVID-19 infection control, including maintaining physical distancing and conducting visits outdoors whenever possible. This continues to be the safest way to prevent the spread of COVID-19, particularly if either party has not been fully vaccinated.

Starting March 10, 2021, the following visitation guidance recommends:

Indoor Visitation

• Unvaccinated residents if; 1) the COVID-19 county positivity rate is greater than 10 percent;  and 2) less than 70 percent of residents in the facility are fully vaccinated;
• Residents with confirmed COVID-19 infection, whether vaccinated or unvaccinated until they have met the criteria to discontinue transmission-based precautions; or
• Residents in quarantine, whether vaccinated or unvaccinated, until they have met criteria for release from quarantine.

Indoor Visitation During an Outbreak

• While outbreaks increase the risk of COVID-19 transmission, a facility should not restrict visitation for all residents as long as there is evidence that the transmission of COVID-19 is contained to a single area (e.g., unit) of the facility. Facilities should continue to adhere to CMS regulations and guidance for COVID-19 testing , including routine staff testing, testing of individuals with symptoms, and outbreak testing .
• If the first round of outbreak testing reveals no additional COVID-19 cases in other areas (e.g., units) of the facility, then visitation can resume for residents in areas/units with no COVID-19 cases. However, the facility should suspend visitation on the affected unit until the facility meets the criteria to discontinue outbreak testing.
• If the first round of outbreak testing reveals one or more additional COVID-19 cases in other areas/units of the facility (e.g., new cases in two or more units), then facilities should suspend visitation for all residents (vaccinated and unvaccinated), until the facility meets the criteria to discontinue outbreak testing.

Compassionate Care Visits

Visits for compassionate care, such as an end-of-life situation or a residents in decline or distress should be allowed at all times for any resident (vaccinated or unvaccinated), regardless of the above scenarios. In addition, facilities and visitors should continue all infection prevention and control practices.

As always, federal regulations 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.

Vaccination for Visitors and Surveyors

• We encourage visitors to facilities to become vaccinated when they have the opportunity. While visitor testing and vaccination can help prevent the spread of COVID-19, visitors should not be required to be tested or vaccinated (or show proof of such) as a condition of visitation.
• Federal and state surveyors are not required to be vaccinated and must be permitted entry into facilities unless signs or symptoms of COVID-19 are present. Surveyors should also adhere to infection prevention and control practices.

Note: CMS and CDC continue to recommend facilities, residents, and families adhere to the core principles of COVID-19 infection, including physical distancing (maintaining at least 6 feet between people).  This continues to be the safest way to prevent the spread of COVID-19, particularly if either party has not been fully vaccinated. However, we acknowledge the toll that separation and isolation has taken. We also acknowledge that there is no substitute for physical contact, such as the warm embrace between a resident and their loved one.  Therefore, if the resident is fully vaccinated, they can choose to have close contact (including touch) with their visitor while wearing a well-fitting facemask. Regardless, visitors should physically distance from other residents and staff in the facility.

In March 2020, CMS issued memorandum QSO-20-14-NH providing guidance to facilities on restricting visitation of all visitors and non-essential health care 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. In June 2020, CMS also released a Frequently Asked Questions document on visitation, which expanded on previously issued guidance on topics such as outdoor visits, compassionate care situations, and communal activities.

In September 2020, CMS issued revised guidance encouraging nursing homes to facilitate outdoor visitation and allowed for indoor visitation if there has been no new onset of COVID-19 cases in the past 14 days and the facility was not conducting outbreak testing per CMS guidelines. The guidance also clarified additional examples of compassionate care situations. 

To read the revised nursing home visitation guidelines, visit: https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and-memos-states-and/nursing-home-visitation-covid-19-revised

To read the press release, visit:   https://www.cms.gov/newsroom/press-releases/cms-updates-nursing-home-guidance-revised-visitation-recommendations

[1] Information on outbreaks and deaths in nursing homes may be found at https://data.cms.gov/stories/s/COVID-19- Nursing-Home-Data/bkwz-xpvg.

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