IDH Issues Updated Visitation and Activities Guidance

On November 23, 2021, the Indiana Department of Health updated its COVID-19 guidance and toolkit to complement the most recent CMS guidance related to visitation for nursing homes and assisted living communities.

Highlights and a summary of the changes and/or additions are as follows:

Visitation and Activities Guidance for LTC Summary:

Please note that IDH is making PPE available to LTC facilities through the Langham Logistics portal to help with PPE supplies to facilitate visitation (see Indoor Visitation for residents in TBP).  Also, please note that IDH has updated suggested signage for visitation (see last item below).

Visitation Requirements:

• Failure to facilitate visitation, without adequate reason related to clinical necessity or resident safety, would constitute a potential violation of 42CFR 483.10(f)(4) and the facility would be subject to citation and enforcement of actions.
• Residents have the right to receive visitors of his or her choosing at the time of his or her choosing.
• Residents have the right to deny visitation in a manner that does not impose on the rights of another resident.

State Regulations Regarding Visitation: 

Comprehensive Care, Nursing Homes:

• Reasonable visiting hours for at least nine hours a day
• Visitation hours posted in a prominent place in the facility and available to each resident
• Provide access to the resident of immediate family or relatives – resident has right to deny or withdraw consent.

Residential Care, Assisted Living: 

• Reasonable visiting hours for at least twelve hours a day.
• Visitation hours made available to each resident.
• A policy and procedure that provides for emergency visitation at other hours.
• Restriction of visits should not occur unless requested by the resident.

Key Points: 

• Visitation cannot be denied based on vaccination status
• Visitation can be denied if a visitor is screened and found to be with COVID-19 infection, symptoms or had prolonged contact with someone with COVID-19 in the past 14 days or in quarantine for any other reason.

Family and Visitor Education:

• Letters, emails, and postings at entrances to remind visitors of importance of getting vaccinated.
• Provide educational reminders on source control and physical distancing and facility instructions related to visitation.

Outdoor Visitation – No Changes

• Create a safe and accessible spaces for outdoor visitation
• Outdoor visits are not permitted for residents with confirmed COVID-19 infection or in quarantine.

Indoor Visitation

• Always allowed with no prescheduling, limit in frequency, duration, or number of visitors.
• There is not a limit on the number of visitors a resident can have, however the space needs to be large enough to ensure physical distancing for the visitors that are in a room at a given time.
• Semi-private room with an unvaccinated and/or immunocompromised, visits should not be conducted in the resident’s room, if possible.
• When visitation must occur in a semi-private room with an unvaccinated and /or immunocompromised resident because of the health status of the resident prevents leaving the room, facilities should attempt to enable in-room visitation while adhering to the core principals of infection prevention and privacy curtain pulled.
• There is not a limit on the number of visitors a resident can have, however the space needs to be large enough to ensure physical distancing for the visitors that are in a room at a given time.
• Privacy curtain should be pulled.
• There should be no limitation of the number of visits a resident can have per day or per week, including the same visitor coming daily.
• Circumstances when visitation should be limited due to high risk of COVID-19 transmission include limiting indoor visitation for:
  • Unvaccinated residents, if the LTC facility’s COVID-19 county positivity rate is >10% and <70% 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 (TBP); or
  • Residents in quarantine, whether vaccinated or unvaccinated, until they have met criteria for release from quarantine.
• Indoor Visitation During an Outbreak (only pertains to SNF/NFs facilities required to conduct outbreak testing):
  • Upon identification of a new case of COVID-19 among residents or staff, investigate and begin outbreak testing.
  • Provide visitors with potential risks and the need to adhere to core principles of COVID-19 infection prevention if they chose to enter the facility during an outbreak situation a mask must be always worn, and visits should be in the resident room.
  • When a new case of COVID-19 is identified, a facility should begin outbreak testing and suspend all indoor visitation immediately (except for compassionate care visits required under federal disability rights law) until at least one round of facility-wide testing is completed.  Visitation can resume based on the following criteria:
    • 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. Visitors who resume visitation in the unaffected areas of the facility should be notified of potential exposure, and signage should be placed in the facility regarding the outbreak in the particular unit.
    • 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 visitations for all residents (vaccinated and unvaccinated), until the facility meets the criteria to discontinue outbreak testing, meaning every 3-7 days until no new COVID-19 case is identified in a 14-day period.
  • Indoor Visitation for residents in TBP:
    • Visitation is not recommended but allowed and visitors to be informed as such.
    • Provide visitors with potential risks associated with visitation and the need to wear a well-fitting mask (if tolerated) and adhere to core principles of infection prevention.
      • Instruct visitors entering the TBP room to wear proper PPE reg
      • Facilities may offer well-fitting masks but are not required to provide PPE for visitors however Indiana Department of Health has made PPE available for LTC SNF facilities to order specifically for visitors through the Langham portal. https://warehouse.elangham.com/Account/LogOn?ReturnUrl=%2F
        • SNF/NF facilities are encouraged to check PPE inventory weekly to ensure adequate processing and transit time for delivery of the supplies.

Privacy – No Changes

• Enable visits to be conducted with adequate degree of privacy.
• Continuous observation/supervision of each visitor is not required.

Visitors

• Community transmission is substantial to high for the facility, resident, and visitors (regardless of vaccination status) must always wear masks and physically distance.
• Community transmission low to moderate for the facility, the safest practice is for residents and visitors to wear face masks and physically distance, particularly if either is at increased risk for severe disease or is unvaccinated.
• Residents and visitors that are fully vaccinated and the resident is not immunocompromised, may choose not to wear masks and to have physical contact while visiting privately without other residents or staff around.
• Visitors should adhere to the core principals of infection prevention.
• Visitors who do not adhere to the core principals should be asked to leave the facility.
• Limit movement of visitors in the facility as much as possible.
• Visitors are not required to be vaccinated but facilities to encourage vaccination.
• Vaccinated and unvaccinated residents and visitors may choose to have physical touch based on preferences, needs and an understanding of the risks associated.
• Unvaccinated visitors should always wear a mask while in the facility.
• Visitors should adhere to Core Principals of Infection Control and should be asked to leave otherwise.
• Facilities should limit movement of visitors in the facility.
• Physical touch is allowed for resident, but both resident and visitor should wear a well-fitted face mask, social distance (6 feet between people) and practice hand hygiene before and after the visit.

Compassionate Care Visitation including Essential Family Caregiver (EFC)

• Access to Long-Term Care Ombudsman and Protection and Advocacy Programs:
  • Inform the ombudsman and or representative of risks associated with visitation as follows:
    • Status of a resident to be visited that is in TBP and risk associated with visitation in the resident room.
    • Unvaccinated resident is a county with community transmission that is substantial or high in the last seven (7) days.

  Visitation must be allowed in compassionate care circumstances regardless of the resident’s vaccination status, including during outbreak testing and when the positivity rate is more than 10%, even if the resident is in TBPs (Yellow or Red Zone).

Personal Services, Activities and Communal Dining

• Family and visitors may join communal dining during their visit while adhering to the core principle of infection prevention.
• Core principals of Infection control and sources controls should be in place and encouraged.
• HCP will continue to wear source controls so long as they are indoors. When community transmission is substantial to high HCP will wear facemasks at all times. During substantial to high community transmission, HCP must wear eye protection when providing direct care within 6 feet of a resident in the green zone, and at all times in the yellow and red zones.
• Salon:  A hairdresser may come into the facility if the hairdresser ears a mask, eye protection when indicated and serves customers following infection control measures below with environmental cleaning of the chair and instruments between clients.
  • Residents and hairdresser to wear masks that covers the mouth and nose
  • Eye protection should be used when there is risk of splash or spray for the hairdresser.
  • Consider fans and fan placement to blow air away from the hairdresser and resident.
  • One client at a time inside the salon is recommended unless space accommodates more than one fully vaccinated residents; however, all in the room must wear a mask and residents to maintain social distance.
  • Blow dryers should blow away from individuals in the same room.

Pools and Gyms

• Limit use to one individual at a time in the gym or therapy pool if space is small
• Larger gyms may allow more than one individual ( not residing on a yellow or red unit in TBP) at a time if >6 feet is maintained (equipment placement and people), masks are worn, hand hygiene and equipment is cleaned/disinfected between uses.  All residents and HCP’s regardless of vaccination status, must wear a mask.
• A newly admitted resident in a 14-day quarantine (yellow zone) because they are not fully vaccinated or a resident in 14-day quarantine in TBP for Asymptomatic COVID-19 is allowed in the gym for medical rehabilitation.  Only one resident at a time for this situation and yellow zone required PPE (N95, gown, gloves, eye protection) to be worn by the HCP and the resident to wear a procedure mask and gloves.  All equipment to be cleaned and disinfected and the gym to remain empty for an hour afterward before allowing another resident in the gym for therapy.
• Equipment and surfaces should be cleaned with approved antiviral disinfectant after each individual use.
• Masking is not required when a resident is swimming laps is the facility has free standing swimming pools.

Therapy Pets

• Therapy pets may be brought to the facility and held by residents in the green zone and/or not in TBP.
• Use of hand sanitizer before handling the pets and after is encouraged.

Communal Dining and Activities

• A resident may not participate in communal dining and activities as follows:
  • Vaccinated and unvaccinated residents with COVID-19 infection or in TBP because of suspected COVID-19 until they have met criteria to discontinue.
  • Facilities in outbreak testing until they have completed one round of testing. (SNF required – Assisted Living is not required)  If first round of testing reveals no additional COVID-19 cases in other areas of the facility, then dining and activities may resume for residents in areas with no COVID-19 cases and or in TBP. If the first round of outbreak testing reveal one or more additional COVID-19 cases in other areas of the facility, then communal dining and activities should be halted in all areas of the facility.
• Communal dining and activities can occur under these conditions:
  • Facilities can adhere to physical distancing, such as being seated at least 6 feet apart.
  • Dining area is environmentally cleaned before and after each group comes to the area.
  • Residents should be offered hand hygiene before and after activities and dining. o Residents should not share food, drinks, or other personal items during dining.
  • Caregivers in the dining area should wear masks and perform hand hygiene before assisting residents with eating and between each resident that they assist.
  • Caregivers should perform hand hygiene after leaving the resident’s room if assisting him/her there.

Church Services

• Facilities can allow church services indoors with social distancing and masks.
• Encourage medium and large services to be held outdoors.
• Singing is a high risk activity and requires a well-fitted mask and distancing greater than 6 feet.
• Indoor singing is not prohibited

Entertainment

• If singing occurs indoor, all singers should wear a well-fitted mask and be distanced greater than six feet when singing.
• Outdoor entertainment is encouraged as weather permits.
• Indoor entertainment with social distancing, masks and core principals of infection prevention.
• Shouting and singing should be avoided with indoor entertainment.

Medical Appointments

• For residents attending medical appointments and routine and preventive care outside of the facility, the following is recommended:
  • Provide the resident with a surgical mask to wear while attending the appointment and performing hand hygiene before and after the appointment.
  • Review core principals of Infection Control often and answer any questions the resident has.
  • It is not recommended to place the resident in transmission-based precautions upon return to the facility but monitor the residents for signs and symptoms of COVID-19 per protocols for all other COVID naïve residents in the facility and consider frequent COVID testing for screening for residents who go in and out of the facility routinely.
  • Consider offering a private room or a semiprivate room with a roommate who has not had high exposure risk for COVID 19 for those residents that leave the facility for dialysis.