In its efforts to control and prevent the spread of Coronavirus Disease 2019 (COVID-19), the Centers for Medicare & Medicaid Services (CMS) released revised guidance on March 9, 2020 to advise healthcare facilities.1 COVID-19 is transmitted between people in close contact (within about six feet) and through respiratory droplets, and is more likely to present in adults than children.2 Individuals at highest risk for severe disease and death include people aged 60 years and older and those with underlying conditions.3 The highest mortality rate occurs in people over 80 years of age.4 Facilities must be able to respond to this challenge and protect their patients and workforce.
CMS is now recommending that facilities should actively screen and restrict visitation by individuals who meet any of the following criteria:
- Signs or symptoms of a respiratory infection, such as fever, cough, shortness of breath, or sore throat.
- Within the last 14 days, has had contact with someone with a confirmed diagnosis of COVID-19, is under investigation for COVID-19, or is ill with respiratory illness.
- Has traveled within the last 14 days to countries with sustained community transmission. This currently includes China, Iran, Italy, Japan, and South Korea, though the number of countries is likely to increase.
- Resides in an area where community-based spread of COVID-19 is occurring.
Furthermore, CMS is recommending that facilities either restrict, limit, or discourage individuals from visiting patients. CMS is using the following definitions in making its recommendations:
- Restricting – the individual should not be allowed in the facility at all, until they no longer meet the criteria above.
- Limiting – the individual should not be allowed to come into the facility, except for certain situations, such as end-of life care or when a visitor is essential for the patient’s emotional well-being and care.
- Discouraging – the facility allows normal visitation practices (except for individuals meeting the restricted criteria), however the facility advises individuals to defer visitation until further notice. This can be done through signage, calls, etc.
Facilities in counties or adjacent to other counties where a COVID-19 case has occurred should limit visitation. All other facilities should discourage visitation. All facilities, regardless of their proximity to counties with cases of COVID-19 should restrict visitors who meet the above criteria.
CMS also recommends that facilities increase signage at entrances/exits, offer temperature checks, increase availability of hand sanitizer, offer personal protective equipment (PPE) for individuals entering the facility (if supply allows), and provide instruction on hand hygiene, limiting surfaces touched, and use of PPE. Individuals who are unable or unwilling to demonstrate proper use of infection control techniques should be restricted from entry.
In addition to actively screening visitors with the above criteria, facilities should also 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. If so, facilities should recommend the visit be deferred to a later date. If the visit is necessary, then PPE should be used while onsite. If PPE is not available, the facility should restrict the individual from entry. If visitation is allowed, visitors should be instructed to limit their movement within the facility to the patient’s room (e.g., reduce walking the halls, avoid the dining room/cafeteria, etc.).
Facilities should review and revise how they interact with volunteers, vendors and receiving supplies, agency staff, EMS personnel and equipment, transportation providers, and other practitioners, and take necessary actions to prevent any potential transmission. For example, have supply vendors drop off supplies at a dedicated location, rather than allowing the vendor to transport the supplies inside the facility. These visitors may enter the facility so long as they are following appropriate Centers for Disease Control and Prevention (CDC) guidelines for Transmission-Based Precautions.
In lieu of visits, facilities can consider the following:
- Offering alternative means of communication, such as virtual communication (phone, video-calls, etc.).
- Using listserv communication to update families, such as advising to not visit.
- Assigning staff as primary contact to families for inbound calls and conduct regular outbound calls to keep families up to date.
- Offering a phone line with a voice recording updated at set times (e.g., daily) with the facility’s general operating status, such as when it is safe to resume visits.
When visitation is necessary or allowable, facilities should make efforts to provide for safe visitation. For example:
- Suggest limiting physical contact with patients and others while in the facility (e.g., practice social distances with no hand-shaking or hugging, and remaining six feet apart).
- If possible, create a dedicated visiting area near the entrance of the facility where patients can meet with visitors in a sanitized environment. Such areas should be disinfected after each patient-visitor meeting.
- Nursing home residents still have the right to access the Ombudsman program. If in-person access is allowable, use the guidance mentioned above. If in-person access is not available, facilities must facilitate resident communication with the Ombudsman program or any other entity or program required by federal regulation.
Facilities should advise restricted visitors to monitor for signs and symptoms of respiratory infection for at least 14 days after last known exposure and to self-isolate at home and contact their healthcare provider if ill. All visitors should be advised to report to the facility any signs and symptoms of COVID-19 or acute illness within 14 days after visiting the facility.
Facilities should continue to monitor and restrict healthcare staff, if necessary. Human-to-human transmission of the COVID-19 virus is largely occurring in families, and preliminary data suggests that, among healthcare providers infected with COVID-19, many may have been infected within their household or while out in public rather than in a healthcare setting.5 Healthcare providers and staff who have signs and symptoms of a respiratory infection should not report to work. If signs and symptoms of a respiratory infection develop while on-the-job, the person should immediately stop work, put on a facemask, and self-isolate at home. The person should also inform the facility’s infection preventionist and include information on individuals, equipment, and locations the person came in contact with. The local health department should be notified and its recommendations should be followed.
Facilities should continue to admit any individuals that they would normally admit to their facility, including individuals who have traveled to areas where COVID-19 is/was present. If possible, facilities should dedicate a unit/wing for COVID-19 patients or suspected patients.
Additionally, CMS has stated that it is aware that there is a scarcity of some supplies in certain areas. State and Federal surveyors will not cite nursing homes for not have certain supplies if they are having difficulty obtaining these supplies for reasons outside of their control. CMS has not opined on this issue for other types of facilities. All facilities should mitigate resource shortages and take all appropriate steps to obtain the necessary supplies as soon as possible. If there is a shortage of PPE, the facility should contact the local and state public health agency to notify them of the shortage, follow national guidelines for optimizing their current supply, or identify the next best option to care for residents.
Facility staff should regularly monitor the CDC website for information and resources, and should contact their local health department if they have questions or suspect a patient has COVID-19
Please contact MMM’s healthcare group for any questions or assistance.