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IDH Releases Updated Visitation Guidelines, Visitation Signage, and FAQs Document - IHCA

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IDH Releases Updated Visitation Guidelines, Visitation Signage, and FAQs Document

Posted Jun 11, 202113 min Read

Regulatory & Clinical
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Please Note:  On June 11, 2021, this article was updated to include the Indiana Department of Health’s (IDH) FAQ Document on the recently updated Visitation Guidelines.  The Visitation Signage was also updated to clarify that indoor visitation can be limited in certain circumstances and that residents in semi-private rooms are permitted more than one (1) visitor, if social distancing allows.  If the roommate is present, then the curtain should be pulled during the visit.  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.

This article was previously updated on June 4 based on the updated Visitation Guidelines are as follows:

  • 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.
  • 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.
  • Outbreaks:  The guidance regarding outbreaks, as it applies to visitation, now only applies to nursing facilities and not residential care facilities (licensed assisted living).

Further highlights of IDH’s updated 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.
  • Designated Areas:  If simultaneous visits occur in a designated area, residents and visitors in the designated area should all wear masks and physical distancing should be maintained between different visitation groups, regardless of the vaccination status of the residents and/or visitors.  If the resident and visitors are alone in a designated visiting area and all individuals are fully vaccinated (i.e., the residents and visitors), then they may remove their masks.
  • 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. Fully vaccinated residents and visitors may remove their masks and are not required to physically distance if they are alone in the room.
  • Physical Contact:  For those residents who are fully vaccinated, they can choose to have close contact (including touch) with their visitor while wearing a well-fitting face mask and performing hand-hygiene before and after, even if the visitor is not fully vaccinated and regardless of where the visit takes place.  However, visitors should continue to physically distance from other residents and staff in the facility. 
  • 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.

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 5-7 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.
  • Communal Dining / Social Activities / Therapy Services / Excursions:  For communal dining, social activities, therapy services, and/or excursions when all residents participating are fully vaccinated, the residents are not required to wear a mask or physically distance.  If the attending health care personnel and/or another resident involved in the service or activity is unvaccinated, all residents should remain masked, even if vaccinated, and the unvaccinated individual(s) should continue to socially distance.  The vaccinated individuals are therefore not required to socially distance from each if an unvaccinated individual is present but should continue to wear masks.  Residents in outbreak testing and in Yellow and Red Units may not participate in communal activities.
  • Masks for Health Care Personnel:  All health care personnel should continue to wear a mask while indoors at work, as well as a face shield if required (i.e., in a Yellow or Red Zone, if the county positivity rate is above 5%, and/or the facility is in outbreak testing).  However, fully vaccinated health care personnel are not required to wear a mask or physically distance if in a breakroom or private meeting room, so long as no residents or unvaccinated health care personnel are present.  Vaccinated health care personnel may also remove their masks during outdoor activities with residents.

The guidance addresses the following as well: 

  • New Admissions:  Based on the CDC’s updated Healthcare Infection Prevention and Control Recommendations in Response to the COVID-19 Vaccination, new admissions who are fully vaccinated or are COVID-recovered in the past 90 days are not required to be placed in transmission-based precautions for 14 days upon admission.  However, fully vaccinated residents who are new admissions and a close contact of a COVID-positive individual should be placed in transmission-based precautions for 14 days.
  • Excursions: Both vaccinated and unvaccinated residents are not required to be placed in transmission-based precautions for 14 days upon return from an excursion, if the excursion is less than 24 hours of duration and provided that proper precautions with physical distancing, hand hygiene, and mask wearing are taken during the excursion.  Further, fully vaccinated residents may participate in excursions over 24 hours in duration without having to be placed in transmission-based precautions for 14 days upon return if they remain asymptomatic and did not engage in high-risk exposure during the excursion that was over 24 hours in length.  Residents are not required to wear a mask or physically distance during the excursion if all residents present are fully vaccinated, as well as the attending health care personnel.  However, the Visitation Guidelines do make clear excursions should be paused during outbreak testing. 
  • Entertainers and Church Activities:  Facilities can allow church services and entertainers outdoors. When conducting church services or entertainers indoors, shouting or singing should be avoided due to potential aerosol and droplet projection. Residents are not required to wear a mask or physically distance during the service if all persons present (i.e., those hosting the church service, the attending health care personnel, etc.) are fully vaccinated.
  • Aerosol Generating Procedures:  During low community spread (the positivity rate is under 5%) and when the facility is not in outbreak testing, fully vaccinated residents with fully vaccinated roommates may leave the door open during an AGP.  If the roommate is unvaccinated, then the curtain must be closed.  For more information regarding AGPs, please review the Infection Control Guidance Standard Operating Procedure, a summary of which can be found here.

About the Author

Laura Brown, Director of Legislative and Legal Affairs