Update, August 20, 2021: On August 20, 2021 the Indiana Department of Health (IDH) temporarily rescinded guidance issued on August 19, 2021 (guidance was dated August 18, 2021). The rescinded guidance was the LTC Toolkit that contained a number of changes to the Visitation Guidelines and Response to COVID-19 Vaccination policy. IDH is going to work on this document over the next week and likely re-issue the LTC Toolkit. IHCA will continue to engage with IDH to request consistency in any final guidance.
In the meantime the IDH has reverted to the August 11, 2021 LTC Facility Infection Control Guidance Standard Operating Procedure (dated August 11, 2021, and issued August 13, 2021). IDH has also referenced the Adjunct IDH Guidance: LTC Facilities Guidelines in Response to COVID-19 Vaccination (dated July 29, 2021).
The LTC Facility IC Guidance SOP calls for face masks for all health care providers at all times, vaccinated and unvaccinated, but the Adjunct IDH Guidance requires face masking for all health care providers when the county positivity is above 5% (substantial or high transmission per CDC Data Tracker). Currently all counties in Indiana are in substantial or high transmission and all health care providers regardless of vaccination rate should wear a mask (and when in yellow or red it should be a N95 mask).
As a reminder, the Visitation Signage must be posted conspicuously for both residents and visitors to see (i.e., at the entrance and next to other required notices) in both nursing facilities and residential care facilities (licensed assisted living). In addition, all resident families / designated representatives must receive this signage as a notification. This can be done electronically or in line with a facility’s current family notification procedure. IDH surveyors will check to make sure each facility has posted the sign as required, along with confirming that visitation is being provided as outlined by the Visitation Guidelines.
Further highlights of IDH’s previous Visitation Guidelines are as follows:
- Outdoor Visits: As a reminder, outdoor visits must continue, except during inclement weather. Outdoor visits are not permitted for residents with a confirmed COVID-19 infection or who in quarantine. Even if a facility is in an outbreak, outdoor visits may continue for those who are not in the Yellow or Red units.
- Indoor Visitation: While outdoor visitation is still preferred, indoor visitation should occur for all residents (regardless of vaccination status), except as follows:
- If the county in which the nursing facility is located is above 10% positivity and less than 70% of the residents are vaccinated, then visitation should be limited for unvaccinated residents until the county is below 10% positivity once again;
- Visitation should be limited for residents with a confirmed COVID-19 infection, whether the resident is vaccinated or unvaccinated, until the resident meets the criteria to discontinue transmission-based precautions;
- Visitation should be limited for residents who are in quarantine, whether the resident is vaccinated or unvaccinated (i.e., a new admission in a Yellow Unit who is unvaccinated, or a new admission in a Yellow Unit who is vaccinated but was a close contact of a COVID-positive individual); and/or
- An outbreak has occurred, as outlined further below.
- Please Note: Importantly, visitation for compassionate care visits, which includes Essential Family Caregivers, should continue even if indoor visitation is otherwise restricted, regardless of a resident’s vaccination status, the county’s positivity rate, or an outbreak, even if the resident is in transmission-based precautions (i.e., Yellow or Red Unit).
- Visitation Hours: Per CMS, visitation should be allowed at all times, unless otherwise outlined below. A facility’s normal visitation hours should be visibly posted (12 hours are required of residential care facilities and 9 hours are required of nursing facilities per state regulations), but facilities should work with residents to allow visitation at all times if their visitors are not able to visit during normal visitation hours, including for compassionate care situations. Any visitation denials should be well documented regarding the reason for denial (i.e., visitor did not pass COVID-19 screening questions, resident did not want visitation at that time, etc.).
- Length of Visits: The length of visits should not be limited. Additionally, there should be no limit on the number of visits a resident can have per day or per week, including if it is the same visitor coming daily.
- Number of Visitors: The number of visitors can be restricted to allow social distancing in semi-private rooms, but at least two (2) visitors must be allowed at any one time. In other words, a visitor in a semi-private room may have more than one (1) visitor; if the roommate is present, the curtain should be pulled during the visit. In a private resident’s room, a vaccinated resident may have any number of vaccinated visitors at one time as space allows.
- In-Room Visitation: In-room visits may occur in long-term care facilities for any reason while adhering to the core principles of COVID-19 infection prevention. Long-term care facilities are not required to perform continuous supervision of each visitor. If a long-term care facility has reason to believe that a visitor may not adhere to core principles of infection control, then the facility may choose to employ periodic and frequent, or continuous, observation/supervision of the visitor. Communication by the long-term care facility to the visitor(s) and resident(s) concerning the reasons for observation/supervision is strongly encouraged.
- Physical Touch: Physical touch is permitted for residents and visitors if they are wearing a well-fitting facemask and practice hand hygiene before and after the visit. Ideally, if a resident or visitor is not fully vaccinated, both should physically distance.
- Outbreaks: This section regarding outbreaks, as it applies to visitation, only applies to nursing facilities. When one (1) new facility-onset COVID-19 case among residents or staff is identified, as defined by IDH’s Visitation Guidelines, the nursing facility should immediately begin outbreak testing and suspend all visitation (except that required under federal disability rights law, which is by definition a compassionate care visit), until at least one (1) 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/units of the facility, then visitation can resume for residents in those areas/units with no COVID-19 cases. The facility should suspend visitation on the affected unit until the facility meets the criteria to discontinue outbreak testing, meaning testing every three (3) to seven (7) days until no new COVID-19 case is identified for a 14-day period. In such a circumstance, visitors should be notified of their potential exposure to COVID-19 (i.e., when visiting residents on the non-affected units), and signage should be placed regarding the outbreak in the particular unit.
- If the first round of outbreak testing reveals one (1) or more additional COVID-19 cases in other areas/units of the facility (i.e., new cases in two (2) or more units), then facilities should suspend visitation for all residents (vaccinated and unvaccinated), until the facility meets the criteria to discontinue outbreak testing, meaning testing every three (3) to seven (7) days until no new COVID-19 case is identified for a 14-day period.
- As a reminder, IHCA/INCAL’s Outbreak Toolkit can be here, and IHCA/INCAL’s article on routine and outbreak testing can be found here.
- Staff and Visitor Screening: Staff and visitor screening can be based on two tiers:
- Tier 1: If the county positivity rate is at or below 5%, the resident vaccination rate is at or above 75%, and the staff vaccination rate is at or above 75%, signage at entrances indicating “Respiratory/Cough Etiquette” and “CDC COVID-19 Symptoms” should be posted (COVID-19 symptoms can be found here, and helpful signage can be found here), and self-screening of visitors and staff may be conducted via paper forms or kiosks. The self-screening questions should ask about being afebrile in the last 24 hours, but temperatures are not required to be physically taken.
- Tier 2: If the county positivity rate is above 5% and/or the resident and staff vaccination rates are below 75%, signage at entrances indicating “Respiratory/Cough Etiquette” and “CDC COVID-19 Symptoms” should be posted (COVID-19 symptoms can be found here, and helpful signage can be found here), and active screening of visitors and staff should be conducted. The screening can be conducted by non-licensed personnel and should include physical temperatures for staff.
- Whether in Tier 1 or Tier 2, visitors do not have to be rescreened if re-entering the facility in the same calendar day.
The guidance also addresses the CDC’s updated Infection Prevention and Control Recommendations in response to the COVID-19 vaccination as follows:
- Symptomatic: Health care personnel and residents with symptoms of COVID-19, regardless of their vaccination status, should receive a viral test (i.e., PCR or antigen test) immediately. Health care personnel should then adhere to the CDC’s Return to Work Criteria, and residents should be placed in transmission-based precautions.
- Exposure: Health care personnel with a higher risk exposure (i.e., without a mask) and residents with prolonged contact (whether wearing a mask or not), which means greater than 15 minutes of exposure over a 24 hour period, with someone with COVID-19 should have a viral test immediately and 3-5 days after exposure, regardless of their vaccination status. Individuals who have recovered from COVID-19 within past 90 days do not need to be tested if asymptomatic, even if they had a higher risk exposure or prolonged contact.
- Routine Testing: Health care personnel who are fully vaccinated are not required to be routinely tested based on the county positivity rate. However, health care personnel who are fully vaccinated should still be tested if they are symptomatic, if they experience a higher risk exposure, or if the facility is in outbreak testing. Unvaccinated health care personnel should continue to be routinely tested based on the county positivity rate as required under QSO-20-38. For IHCA/INCAL’s summary on routine testing, please click here