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CMS Issues Guidance on Visitation in Nursing Facilities & Use of CMP Funds - IHCA

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CMS Issues Guidance on Visitation in Nursing Facilities & Use of CMP Funds

Posted Oct 23, 20206 min Read

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Please Note:  The CMP Funds section of this article was updated on October 23, 2020, to reflect the clarifications issued by CMS on the use of CMP funds to assist with conducting in-person visitation.  As stated below, nursing facilities may submit a revised application for CMP funds for in-person visitation aids.

On September 17, 2020, the Centers for Medicare and Medicaid Services issued QSO 20-39, a memorandum detailing guidance for visitation in nursing facilities during the public health emergency.  The QSO also addresses communal activities and dining, entry of health care workers to facilities other than staff, entry of government agency investigators, and a new CMP grant related to visitation equipment (tents and plexiglass). This guidance should be utilized by nursing facilities in conjunction with the Indiana Department of Health’s (ISDH) visitation guidance.  On the whole, the new CMS memo is not a significant departure from what Indiana is already doing under IDH guidance.  IHCA/INCAL will provide additional information if ISDH’s visitation guidance is updated in response to this memorandum.

Please note that Residential Care Facilities/Assisted Living communities should proceed under ISDH’s visitation guidance as it is written currently as the CMS memo does not apply to those communities.

Even with the similarities between QSO 20-39 and existing ISDH guidance, some differences exist.  Below is a summary of key similarities and differences:

Core Principles of COVID-19 Infection Prevention

Very much like current Indiana guidance the CMS memo repeats key infection control procedures for visitors such as screening procedures, hand hygiene, face coverings, social distancing, directional signage to limit foot traffic where it should not be, cleaning procedures, cohorting, and testing.  Importantly CMS agrees that visitors must adhere to these core principles and if they cannot they are not to be permitted to visit and should be asked to leave.  In addition when discussing outdoor and indoor visitation, facilities should have a process to limit the number of and size of visits occurring simultaneously – this is very similar to the discretion that ISDH affords facilities to limit visitation based on facility judgement of facility capacity and safety.

Outdoor Visitation Preferred

While taking a person-centered approach and adhering to the core principles of COVID-19 infection prevention, CMS states that outdoor visitation is preferred.  Aside from weather considerations (i.e., inclement weather, excessively hot or cold temperatures, poor air quality), an individual resident’s health status (i.e., medical condition, COVID-19 status), or a facility’s outbreak status, outdoor visitation should be facilitated routinely, and visits should be held outdoors whenever practicable.

Indoor Visitation

Similar to ISDH’s visitation guidance, CMS states that indoor visitation can also occur when there have been no new onset of COVID-19 cases in the last 14 days, and the facility is not currently conducting outbreak testing.  However, unlike the ISDH’s guidance, CMS states that when a county has a positivity percentage above 10% based on CMS’s county positivity data, visitation should only occur for compassionate care situations.  The county positivity rate does not need to be considered for outdoor visitation.

If a facility has had no COVID-19 cases in the last 14 days and its county positivity rate is low or medium, a nursing home must facilitate in-person visitation consistent with the regulations, including the ISDH guidelines that at least four hours of visitation be provided Monday through Friday and over each weekend.

Compassionate Care Visits

Importantly, CMS clarifies that the term “compassionate care situation” does not exclusively refer to end-of-life situations and does not indicate only family members can visit for these circumstances (i.e., a clergy member offering support may be appropriate in compassionate care situations).  Examples of other types of compassionate care situations include, but are not limited to:

  • A resident, who was living with their family before recently being admitted to a nursing home, is struggling with the change in environment and lack of physical family support.
  • A resident who is grieving after a friend or family member recently passed away.
  • A resident who needs cueing and encouragement with eating or drinking, previously provided by family and/or caregiver(s), is experiencing weight loss or dehydration.
  • A resident, who used to talk and interact with others, is experiencing emotional distress, seldom speaking, or crying more frequently (when the resident had rarely cried in the past).

Essential Family Caregivers

Also of note, CMS does not distinguish between visitors and essential family caregivers.  While ISDH permits essential family caregivers regardless of whether other visitation is allowed, CMS’s memorandum indicates that when visitors are not permitted, neither are essential family caregivers.

Visitor Testing

While not required, CMS encourages facilities in medium or high-positivity counties to test visitors, if feasible.  In doing so, facilities may prioritize visitors that visit regularly and/or encourage visitors to be tested on their own prior to coming to the facility (i.e., within 2 – 3 days) with proof of negative test results and the date of the test.

CMP Funds

CMS will now approve the use of Civil Monetary Penalty (CMP) funds to purchase or rent tents or other shelters for outdoor visitation, as well as clear dividers (i.e., Plexiglas) to create physical barriers to reduce the risk of transmission during in-person visits. The CMP funds may also be used for installation, installation materials, and shipping costs for allowable items.  Please review the list of prohibited items carefully; air purifiers were recently added to the list of prohibited items.  Overall, funding to assist with visitation is limited to a maximum of $3,000 per facility for expenses incurred on or after September 17, 2020.  The application template for in-person visitation aids can be found here, and a FAQ document on utilizing CMP funds for in-person visitation aids can be found here.  Interested facilities should send their completed or revised application to Nancy Adams at NAdams1@isdh.in.gov or Lisa Hensley at lhensley@isdh.in.gov.

Please contact Zach Cattell (zcattell@ihca.org), Lori Davenport (ldavenport@ihca.org) or Laura Brown (lbrown@ihca.org) with questions.