ISDH Issues Updated “Back on Track” Guidelines – Outdoor Visitation Required & Indoor Visitation Permitted July 4, 2020
On the evening of June 29, 2020, the Indiana State Department of Health (ISDH) updated the “Back on Track” guidelines for long-term care facilities, which includes both comprehensive care facilities and residential care facilities. The updated guidelines address continuing COVID-related infection prevention and control policies, outdoor and indoor visitation, internal and external activities, and medical appointments. The entirety of the updated “Back on Track” guidelines can be found here, and more specific guidelines regarding beauty/personal services can be found here.
These guidelines are effective immediately, with indoor visitation being permitted and outdoor visitation being required starting July 4, 2020, unless there has been a new facility-onset COVID-19 case within the past fourteen (14) days. Excursions outside of the facility are also permitted under the updated guidelines, as outlined further below.
Looking ahead to July 17, 2020, ISDH will update the visitation waivers for comprehensive and residential care facilities to require at least four (4) hours of visitation daily, including evening hours, unless there has been a new facility-onset COVID-19 case within the past fourteen (14) days. The four (4) hours per day may be a mixture of outdoor and indoor visitation unless weather prevents outdoor visitation.
New Facility-Onset COVID-19 Cases
An important term in the updated guidelines is “new facility-onset COVID-19 case,” which determines when a facility may resume outdoor and indoor visitation, and when visitation must cease for a period of time. The guidelines define “new facility-onset COVID-19 case” for residents and staff as follow:
- Residents
- A new facility-onset COVID-19 resident case is defined as a resident who contracts COVID-19 within a facility without prior hospitalization or other outpatient/external facility-based health service within the last fourteen (14) days. New facility-onset COVID-19 cases in residents do not include new admissions who become positive within fourteen (14) days after admission.
- Facilities that place new admissions in transmission-based precautions for fourteen (14) days are not required to test residents upon admission in order to continue internal activities or visitation. If facilities would like to end the transmission-based precautions for new admissions prior to fourteen (14) days, they may follow the CDC’s test-based strategy for the end of transmission-based precautions. If a resident is admitted with a negative COVID-19 test, transmission-based precautions are not required.
- Staff
- The majority of positive staff likely contracted COVID-19 outside of the facility. While positive staff cases still need to be reported through the RedCaps Survey, they do not immediately count as a new facility-onset COVID-19 case.
- Positive staff members should be contact traced, and any resident or staff who spent more than fifteen (15) minutes closer than six (6) feet apart from that staff member without the use of a mask (either the resident or staff) should be quarantined for fourteen (14) days, although staff who were close contacts may continue to work in a COVID-dedicated unit.
- The quarantining of any residents and/or staff does not prohibit other residents from continuing with visitation.
- However, if a close contact of the positive staff member then tests positive for COVID-19 (i.e., a fellow staff member on the same shift or unit), the case would be considered a new facility-onset COVID-19 case, and the fourteen (14) day period would start from the time of the last contact with the positive staff member.
- Please note, the local health department or ISDH will conduct the contact tracing for external facility contacts, but the facility’s infection preventionist should conduct the internal outbreak exposure control using the LTC Respiratory Surveillance Line List and LTC Respiratory Surveillance Outbreak Summary found in the LTC Toolkit.
Visitation
Starting July 4, 2020, all long-term care facilities must allow outdoor visitation and may offer indoor visitation, if there have been no new facility-onset COVID-19 cases in the past fourteen (14) days as defined above. Visitation is limited to those residents who are COVID-negative or COVID-recovered, meaning the resident meets the CDC’s guidance for discontinuation of transmission-based precautions.
Like outdoor visitation, long-term care facilities may establish policies for indoor visitation addressing the length of visits, the number of visitors per resident, and the number of visitors at any one time. The guidelines also outline specific requirements for staff and visitors with regard to indoor visitation.
For both outdoor and indoor visitation, a facility must cease visitation if a new facility-onset COVID-19 resident case is confirmed. Fourteen (14) days must pass without a new facility-onset COVID-19 case occurring among residents prior to visitation beginning once again. If a staff member is confirmed COVID-19 positive before any confirmed new facility-onset COVID-19 resident cases are confirmed, then the facility may resume visitation after the facility has completed contract tracing related to the confirmed positive staff member and the close contacts are quarantined. If any of the close contacts test positive, visitation must cease and the fourteen (14) day period begins once again.
Internal Activities
The updated guidelines also allow for the resumption of internal activities such as gym use and beauty/personal services. For gym use, multiple individuals may use a facility’s gym at one time as long as residents are not using the same piece of equipment or therapy pool. The equipment should be wiped down after each use.
Beauty/personal services may resume within a facility as well, and any beauty/personal services staff or contractors are not required to first be tested. As noted above, ISDH issued more specific guidelines for beauty/personal services, which can be found once again here.
External Activities and Medical Appointments
The updated guidelines state that independently mobile residents may leave the facility for excursions, and residents who are not independently mobile may be escorted on outdoor excursions, provided that any residents leaving the facility take proper precautions with social distancing, hand hygiene, and mask wearing. These residents are not required to be placed in transmission-based precautions when they return, although they should be monitored for signs and symptoms of COVID-19.
Residents may also attend medical appointments, both routine and preventative, outside of the facility, and similarly, these residents are not required to be placed in transmission-based precautions when they return. However, infection control precautions (i.e., ensuring each resident wears a surgical mask while being transported and attending an appointment and performing hand hygiene before and after the appointment) should be maintained, and residents should be monitored for signs and symptoms of COVID-19 upon their return. Private or semi-private rooms are not required for dialysis patients, but that may be an added infection prevention and control policy of a facility.
New Admissions or Re-admissions
The updated guidelines also address the management of new admissions and readmissions based on the known or unknown COVID-19 status.
- For Unknown COVID-19 status admissions or readmissions, ISDH refers to CDC recommendations to either place that resident in a single-person room in the “general population” (i.e. Green Unit) or in a separate observation area to be monitored. 14 days of monitoring is required for unknown COVID-19 status residents.
- For known Negative status admissions or readmissions, residents can be placed in the general/main area of the facility without transmission based precautions, but should be monitored for signs and symptoms.
- For known Positive COVID-19 status admission or readmissions, residents must be placed in the COVID-19 Unit (i.e. Red Unit) until they meet the CDC criteria to end transmission based precautions.
The guidelines issued by ISDH are significant and please reach out to IHCA/INCAL staff for assistance and with questions as you begin to implement. Lori Davenport (ldavenport@ihca.org), Zach Cattell (zcattell@ihca.org) and Laura Brown (lbrown@ihca.org) are ready to assist.