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COVID-19

Visitation COVID-19

Limitations on Visitors to LTCF During COVID-19

Memorandum

Memorandum

TO: Nursing Home and Rest Home Administrators

FROM: Margret Cooke, JD, Deputy Commissioner

SUBJECT: Updates to Visitation Conditions, Communal Dining, and Congregate Activities in Long-Term Care Facilities during the COVID-19 Outbreak

DATE: February 3, 2021

The Massachusetts Department of Public Health (DPH) continues to work with state, federal and local partners on the outbreak of Coronavirus Disease 2019 (COVID-19), caused by the virus SARS-CoV-2, and we continue to appreciate the essential role you have in responding to this evolving situation.

This memorandum replaces the memorandum issued on December 7, 2020. This updated guidance provides modifications to the conditions for visitation, communal dining and group activities.

The implementation of this guidance is contingent on Massachusetts meeting a range of public health metrics outlined on the Mass.gov website. Ongoing performance related to these measures will inform additional reopening decisions.

In addition to the safety, care, and infection control measures and policies described in detail below for visitation, communal dining, and congregate activities, long-term care facilities must be in compliance with DPH’s surveillance testing program.

Limitations on Long-Term Care Visitation:

Long-term care facilities may allow visits with residents to occur, provided that the social distancing and protection requirements described in detail below are followed. As much as possible, long-term care facilities should continue to use alternative electronic methods for virtual communication between residents and visitors, such as Skype, FaceTime, WhatsApp, or Google Duo.

In-Person Visitation:

A long-term care facility may allow in-person visitation in a designated visitation space, provided that the long-term care facility implements all of the following safety, care, and infection control measures and policies:

A resident who is suspected or confirmed to be infected with COVID-19 cannot participate in a visitation. A resident may be visited if: the resident has recovered from COVID-19; or the resident is currently quarantined after a recent hospital stay and is not suspected or confirmed to be infected with COVID-19, or the resident is not quarantined and has never tested positive for COVID-19.
Prior to transporting a resident to the designated visitation space, the long-term care facility must screen the visitor for COVID-19 symptoms and check their temperature. Any individuals with symptoms of COVID-19 infection (fever equal to or greater than 100.0 F, cough, shortness of breath, sore throat, myalgia, chills, or new onset of loss of taste or smell) will not be permitted to visit with a resident.
Transport of a resident to and from the designated visitation space must be safe and orderly. At a minimum, safe transport means that the resident cannot be transported through any space designated as COVID-19 care space or space where residents suspected or confirmed to be infected with COVID-19 are present. If health care personnel (HCP) expect to provide direct care to residents while transporting the resident or monitoring the visitation, HCP should wear appropriate PPE.
The long-term care facility is not under a contingency staffing plan.
A visitor must remain at least six feet from the resident and attending staff member(s) for the majority of the visit.
Brief physical contact may be allowed if desired by both the resident and visitor. In order to reduce risk of transmission, individuals must:

Use alcohol-based hand sanitizer with at least 60% alcohol before and after contact;
Hug with faces in opposite directions; and
Limit the duration of close physical contact and avoid close face-to-face contact even when face masks are used.

Staff, residents and visitors must wear a face mask for the duration of the visit.
The long-term care facility must implement a schedule for frequent cleaning and disinfection of the designated visitation space, including cleaning high-touch surfaces using an appropriate EPA-registered disinfectant.

Any individual who enters the long-term care facility and develops signs and symptoms of COVID-19 such as fever, cough, shortness of breath, sore throat, myalgia, chills, or new onset loss of smell or taste within two days after exiting the long-term care facility or designated outdoor space must immediately notify the long-term care facility of the date they were in the facility, the individuals they were in contact with, and the locations within the facility they visited. Long-term care facilities should immediately screen the individuals who had contact with the visitor for the level of exposure and follow up with the facility’s medical director or resident’s care provider.

Whether or not a resident has visitors should not impact their access to fresh air and time outdoors. Long-term care facilities are encouraged to offer residents time outdoors provided that the physical distancing and protection requirements described in detail above are followed.

Facilities are encouraged to test visitors if feasible and should prioritize visitors that visit regularly (e.g., weekly), although any visitor may be tested. However, a facility shall not condition a visitation on testing or a negative test result.

Facilities must submit both positive and negative test results to the Department of Public Health’s Bureau of Infectious Diseases and Laboratory Sciences (BIDLS). The spreadsheet attached to this guidance (Addendum A) includes the required data variables. Please send the completed spreadsheet to ISIS-ImmediateDiseaseReporting@mass.gov along with primary contact details and the BIDLS team will follow up with you.

A long-term care facility may limit:

The length of any visit, however, residents must be offered the opportunity to visit for no fewer than 45 minutes;
The days on which visits will be permitted, provided that visits are offered on no fewer than five days of the week and one of the days must be on a weekend day;
The hours during a day when visits will be permitted, provided that at least one day per week visits are offered outside of standard business hours;
The number of times during a day or week a resident may be visited; and
The number of visits occurring at the facility on a given day and may require visits to be scheduled in advance.

Designated Outdoor Visitation Space:

In addition to the in-person visitation conditions described above, the long-term care facility must:

Ensure visits with a resident occur in a designated outdoor space; outdoor visits will be dependent on permissible weather conditions, availability of outdoor space, and the health and well-being of the resident.
A long-term care facility staff member trained in such patient safety and infection control measures must remain immediately available to the resident at all times during the visit.

Designated Indoor Visitation Space:

In addition to the in-person visitation conditions described above, the long-term care facility must:

Identify a designated space for visitation that is as close to the entrance as possible where visits can be socially distanced from other residents and minimize visitor impact in the facility.
Ensure that ventilation systems operate properly, have been serviced in accordance with manufacturer recommendations and increase circulation of outdoor air as much as possible.
Avoid visitation in resident rooms.
A long-term care facility staff member trained in such patient safety and infection control measures must perform frequent safety checks with the resident during the visit.
The unit, floor or care area where the resident lives must not have any confirmed or suspected COVID-19 cases in staff or facility-acquired confirmed or suspected COVID-19 cases in residents on the unit, floor or care area in the past 14 days; however, notwithstanding this condition, if a facility determines that a confirmed or suspected case within the facility presents a risk for all units, the facility in its discretion may suspend indoor visitation.

When indoor visitation is suspended due to a confirmed or suspected COVID-19 case in a resident or staff member, the long-term care facility must notify resident families and/or the resident’s legal representative. The notification must include the reason for suspending indoor visitation and the conditions necessary for resuming indoor visitation. Additionally, long-term care facilities must designate a specific point of contact at the facility for resident families and/or legal representatives to contact with questions.

Please note that if community transmission rates become high, DPH may amend the above visitation conditions.

Compassionate Care Visitation:

Facilities must accommodate compassionate care visits for residents. Compassionate care visits include end-of-life care as well as certain other 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.)

Decisions about compassionate care visits should be made on a case-by-case basis, based on resident care needs. Long-term facilities should work with residents, families, caregivers, resident representatives, and health care personnel to identify the need for compassionate care visits.

For compassionate care situations long-term care facilities must limit visitors in the facility to a specific room: either the resident’s room, if the resident has a private room, or another location designated by the facility. Long-term care facilities must require visitors to perform hand hygiene and give visitors a face mask if they do not have one. Decisions about visitation during a compassionate care situation should be made on a case-by-case basis, which should include careful screening of the visitor (including clergy, bereavement counselors, etc.) for any symptoms of COVID-19 and temperature checks. Individuals with symptoms of a respiratory infection (fever, cough, shortness of breath, sore throat, myalgia, chills or new onset of loss of taste or smell) should not be permitted to enter the long-term care facility at any time.

Out of State Visitors

Long-term care facilities cannot implement policies for out-of-state visitors traveling to Massachusetts to visit long-term care facility residents that are more restrictive than those put in place by Governor Baker’s Travel Order. Information on the requirements for out-of-state visitors can be found here: https://www.mass.gov/info-details/covid-19-travel-order.

Out-of-state visitors are exempt from the requirements to fill out a travel form, self-quarantine or obtain a negative COVID-19 test result if their travel is limited to brief trips for purposes that have been designated as Critical Life Activities. This allowance is limited to short, same-day trips across the state border and back for visiting persons residing in congregate care settings.

Exceptions to Visitor Limitations:

Health care personnel: Long-term care facilities should follow CDC guidelines for the management of health care personnel who may have been exposed to COVID-19 which can be found at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html

The nursing home or rest home must confirm that health care personnel do not have any signs or symptoms of COVID such as a cough, shortness of breath, or sore throat, myalgia, chills, or new onset loss of smell or taste and a fever by taking each healthcare personnel’s temperature upon arrival. The health care worker’s temperature must be below 100.0 oF for him or her to enter the facility and provide care.

Screening and temperature checks also apply to other health care personnel, including, but not limited to, hospice workers, dialysis technicians, nurse aides, nursing or other students in clinical training, dentists, podiatrists, psychiatrists, physical therapists, or Emergency Medical Service (EMS) personnel in non-emergency situations that provide care to residents. All health care personnel are permitted to come into the facility as long as they meet the CDC guidelines for health care personnel.

In emergency situations, EMS personnel should be permitted to go directly to the resident without undergoing screening or temperature checks.

Parents and Guardians: Indoor visitation is permitted for parents and guardians of residents who are 22 years old and younger and outdoor visitation is not appropriate. Parents and guardians of residents must be screened and have their temperature checked upon entry into the facility and must wear a face mask at all times while in the facility.

Family Education: Long-term care facilities may allow family members or caregivers to participate in discharge education and training in order to safely learn how to care for their loved one at home. A family member or caregiver must be screened and have their temperature checked upon entry into the facility and must wear a face mask at all times while in the facility. Discharge education and training should include only necessary participants who must remain at least six feet apart when not engaging in activities such as demonstrating resident transfers.

Dining and Group Activities:

Long-term care facilities may provide outdoor entertainment and activities on the ground of the facility if the facility meets the following conditions:

The long-term care facility has adequate supplies of personal protective equipment and essential cleaning and disinfection supplies to care for residents;
The long-term care facility is not under a contingency staffing plan;
Only residents who have fully recovered from COVID-19, those residents not in isolation for suspected or confirmed COVID-19 status, and those residents not currently quarantined due to exposure or new admission can participate in the outdoor group activities;
Participating residents must remain at least six feet apart.

Long-term care facilities may provide communal dining and provide indoor group entertainment and activities in the facility if the facility meets the following conditions:

The long-term care facility has adequate supplies of personal protective equipment and essential cleaning and disinfection supplies to care for residents;
The long-term care facility has not reported to the Department or CDC’s National Health Surveillance Network that they are experiencing a current shortage of personal protective equipment;
The long-term care facility is not under a contingency staffing plan;
Only residents who have fully recovered from COVID-19, those residents not in isolation for suspected or confirmed COVID-19 status, and those residents not currently quarantined due to exposure or new admission can participate in the indoor group activities;
Participating residents must remain at least six feet apart and residents must wear a face covering, if they are able to do so;
Staff must wear appropriate PPE including a facemask and eye protection;
The space used for activities must enable residents, staff and any other participants to maintain at least six feet of distance and may require a limit on the number of residents who attend;
Staff should perform hand hygiene and observe or assist residents in performing hand hygiene before and after overseeing or engaging in any activity;
Items used in activities should not be shared between or among residents;
The long-term care facility must implement a schedule for frequent cleaning and disinfection of the spaces used for indoor group activities, including cleaning high-touch surfaces using an appropriate EPA-registered disinfectant; and
The long-term care facility must screen any individual entering the facility to provide resident entertainment or activities for COVID-19 symptoms and check their temperature. Any individuals with symptoms of COVID-19 infection (fever equal to or greater than 100.0 F, cough, shortness of breath, sore throat, myalgia, chills or new onset of loss of taste or smell) will not be permitted to enter the facility.

When there is a confirmed COVID-19 positive resident and/or staff member on a unit, floor or care area, the facility should suspend communal dining and group activities for residents on the unit, floor or care area until the unit, floor or care area has gone 14 days without a new COVID-19 positive resident and/or staff member.

Examples of indoor group activities that can be facilitated with appropriate safety, care, and infection control measures include book clubs, crafts, movies, exercise, and bingo.

Examples of indoor group activities that should be avoided at this time include singing or hosting entertainers who might be singing or playing wind instruments.

Long-term care facilities may utilize indoor exercise or gym space for the purposes of physical, occupational or other clinically indicated therapy if the facility meets the following conditions:

The long-term care facility has adequate supplies of personal protective equipment and essential cleaning and disinfection supplies to care for residents;
The long-term care facility is not under a contingency staffing plan;
Residents must be spaced at least six feet apart;
The long-term care facility has implemented procedures for cleaning and disinfecting the space and equipment in between each resident’s use; and
Only residents who have fully recovered from COVID-19, are in quarantine due to being a new admission, and those residents not in isolation for suspected or confirmed COVID-19 status can participate in clinically indicated therapy.

When using indoor exercise space in the long-term care facility, facilities must follow the same safety standards and checklists for fitness centers and health clubs, including but not limited to, maintaining social distancing between residents, hygiene protocols, staffing and operations, and cleaning and disinfection. The guidance may be found here: https://www.mass.gov/info-details/reopening-massachusetts

Nursing Home Family Resource Line

As a reminder, the Executive Office of Health and Human Services has established the Nursing Home Family Resource Line. This phone line provides one central contact for families and community members who have questions about the care their loved one is receiving during the COVID-19 outbreak.

The Nursing Home Family Resource Line is staffed Monday through Friday from 9:00 AM – 5:00 PM. Staff will field questions on a range of topics and coordinate across state agencies to help provide answers.

Contact the Nursing Home Family Resource Line at 617-660-5399.

Ombudsman Program and Legal Representation:

Residents have the right to access the Ombudsman program and to consult with their legal counsel. When in-person access is not available due to infection control concerns, facilities must facilitate resident communication (by phone or another format).

Please note that reports of facilities found to not be adhering to this guidance will be referred to the DPH Complaint Intake Unit.

DPH strongly encourages all long-term care facilities in Massachusetts to monitor the CMS and CDC website for up-to-date information and resources:

Additionally, please visit DPH’s website that provides up-to-date information on COVID-19 in Massachusetts: https://www.mass.gov/2019coronavirus.