CMS Guidance on Visitors in Long-Term Care Facilities

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. Keep on reading to learn more about the impact of this virus and how CMS has shifted their recommendations for visitation to help prevent isolation.

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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