CMS Guidance on Visitors in Long-Term Care Facilities Blog Feature

By: Katie Senters on October 21st, 2020

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CMS Guidance on Visitors in Long-Term Care Facilities

Visitor Management | CMS | long-term care

The danger posed by COVID-19 has required swift and decisive action to protect the population — including the elderly, who are particularly susceptible to the virus and for whom COVID-19 poses a unique threat. Long-term care facilities — including nursing homes, assisted living facilities, and rehabilitation facilities — are primarily comprised of elderly residents, and as such are especially vulnerable to COVID-19.

How has COVID-19 impacted long-term care facilities?

By the end of April 2020, only about two months into the pandemic, approximately one-third of long-term care facilities in the U.S. had been directly affected by COVID-19. As of September 2020, it was reported that despite representing just 7% of all cases in the United States, long-term care facility residents accounted for 40% of COVID-19 deaths.

Even a single case of COVID-19 can have devastating effects on residents of long-term care facilities — the infection fatality rate for COVID-19 in long-term care facilities is 24.05%, more than eleven times higher than the rest of the population. As a result, CMS has recommended the implementation of especially strict disease prevention protocols in long-term care facilities.

Early CMS guidance on visitation in long-term care facilities

In March, the Centers for Medicare & Medicaid Services (CMS) issued guidance advising long-term care facilities to “restrict visitation of all visitors and non-essential health care personnel, except for certain compassionate care situations, such as an end-of-life situation.” CMS also recommended that long-term care facilities cancel communal dining and all group activities.

Halting visitation at most long-term care facilities helped limit surges in new COVID-19 cases; however, the measures put in place to protect residents’ physical health have had a significant negative impact on their mental well-being. Isolation and loneliness are key contributors to poor health outcomes in the elderly, leading to an increased risk of cardiovascular, autoimmune, neurocognitive, and mental health problems. A 2017 study found that “social isolation increases mortality risk on par with such risk factors as smoking, obesity, and lack of physical activity.”

The effect of COVID-19 on facility residents

In addition to the effects of isolation mentioned above, long-term care residents must also contend with their fears of the virus itself.

The combined effect of extended isolation and fear of COVID-19 has caused many long-term care facility residents to further retreat both physically and emotionally from others. A new survey by Altarum found that more than 75% of facility residents report feeling lonelier since visitation was halted in March, and 64% of nursing home residents no longer leave their rooms to socialize — even with other facility residents.

Before the pandemic, nearly 70% of long-term care facility residents ate in the facility’s dining room, and only 14% said they weren’t participating in organized activities. Now, however, only 13% of facility residents visit the dining room, and a staggering 54% do not participate in organized activities. Similarly, the number of facility residents who no longer leave the facility for routine activities (e.g., shopping or visiting family) has risen from 42% prior to the pandemic to 93%.

Despite the increased risk of COVID-19 transmission indoors, long-term care residents are even hesitant to go outside: only 28% of residents surveyed said they go outside for fresh air one or more times a week, a precipitous decline from the 83% of residents who reported doing so pre-pandemic. As one respondent put it, “If the virus doesn’t kill me, the loneliness will.”

New CMS guidance for visitation in long-term care facilities

The latest CMS guidance — available here — acknowledges the deleterious health effects of extended isolation among the elderly and the value of resuming social contact. To that end, the September guidance suggests long-term care facilities take a “person-centered” approach to care while adhering to the following disease-prevention protocols:

  • Screening of all facility visitors for signs and symptoms of COVID-19 (e.g., temperature checks, questions or observations about signs or symptoms)
  • Denial of entry of those with signs or symptoms of COVID-19
  • Hand hygiene requirements, preferably with alcohol-based hand sanitizers
  • Requiring face coverings or masks covering mouth and nose for all visitors
  • Enforcing social distancing of at least six feet between persons
  • Instructional signage throughout the facility
  • Visitor education on COVID-19 symptoms and infection control precautions
  • Specified entries, exits and routes to designated areas where applicable
  • Cleaning and disinfecting frequently touched surfaces in the facility and in designated visitation areas after each visit
  • Appropriate staff use of Personal Protective Equipment (PPE)
  • Effective cohorting of residents (e.g., establishing a separate area of the facility dedicated to COVID-19 care)

September’s CMS guidance also suggests limiting the number of visitors at one time and, where possible, holding visits in outdoor areas. Long-term care facilities are also advised to take into account the COVID-19 positivity rate in their county (found here) as a guideline and adjust their visitation policies accordingly:

  • Low/Medium (up to 10% positivity rate): Visitation should be allowed, provided the facility adheres to the above guidelines.
  • High (>10% positivity rate): Visitation should only be allowed in compassionate care situations, and COVID-19 prevention guidelines should be strictly followed.

The new guidance also expands the definition of “compassionate care,” which now includes (but is not limited to) the following scenarios:

  • Residents who lived with family before being admitted to a long-term care facility and are struggling with the new environment.
  • Residents who recently experienced the loss of a friend or family member.
  • Residents displaying marked behavioral change; e.g., a formerly outgoing resident has become withdrawn and seldom speaks, or sudden emotional outbursts in a resident who is usually composed.

The COVID-19 pandemic is unlikely to end anytime soon, and residents in long-term care facilities desperately need social interaction and a return to some form of normalcy. The new CMS guidance offers a way to resume social interactions, and symplr Visitor Management can help long-term facilities implement the procedures necessary to keep residents safe, healthy, and happy.


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About Katie Senters

As the National Director of Sales at symplr, Katie Senters leads the business development team. She is passionate about listening to clients and helping them reach their credentialing, compliance, and safety goals. Katie has a unique and comprehensive healthcare SaaS background. Her experience includes implementing solutions and successfully managing client relationships with large, complex organizations such as the federal government, integrated delivery networks, pharmacies, and colleges. Prior to joining symplr, she lead the National Accounts team at the National Healthcareer Association, which is a division of Ascend Learning. Katie received a Bachelor of Science degree in Speech-Language Pathology and Audiology from West Virginia University.