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Summary points from September 17, 2020, CMS QSO-20-39-NH

Patti Cullen, CAE
By Patti Cullen, CAE  |  September 25, 2020  |  All members

Below are key highlights from the September 17, 2020, Centers for Medicare & Medicaid Services (CMS) QSO-20-39-NH guidance: “Nursing Home Visitation-COVID-19.” Note that while the memo is directed to nursing facilities, we encourage assisted living to review it as well because there could be portions our state agency adopts for all long-term care settings noted below.

Memorandum summary
  • CMS is committed to continuing to take critical steps to ensure America’s healthcare facilities are prepared to respond to the Coronavirus Disease 2019 (COVID-19) public health emergency (PHE)
  • Visitation guidance: CMS is issuing new guidance for visitation in nursing facilities during the COVID-19 PHE—the guidance below provides reasonable ways a nursing facility can safely facilitate in-person visitation to address the psychosocial needs of residents
  • Use of Civil Money Penalty (CMP) funds: CMS will now approve the use of CMP funds to purchase tents for outdoor visitation and/or clear dividers (e.g., Plexiglas or similar products) to create physical barriers to reduce the risk of transmission during in-person visits

Effective date & applicability
The guidance is effective immediately; however, the states have up to 30-days to communicate with their survey and certification staff, managers, and state/CMS locations. We do not yet know when surveyors will evaluate based upon this memo; our latest communication with the Minnesota Department of Health (MDH) was they needed to review this guidance and reconcile the differences between the CMS guidance and current state visitation policies first. Key policy consideration is how MDH will view the applicability of this CMS guidance to assisted living—the CMS guidance is directed just to nursing facilities but historically MDH has applied much of their state guidance to all long-term care settings.

General guidance/core principles about all types of visits
  • Visitation should be person-centered, consider the resident’s physical, mental, and psychosocial well-being, and support their quality of life
  • Facilities should ensure visits are conducted with privacy
  • Regardless of how visits are conducted, certain core principles apply to all types of visits; among others, these include the following:
    • Screening of all who enter the facility for signs and symptoms of COVID-19 (e.g., temperature checks, questions or observations about signs or symptoms), and denial of entry of those with signs or symptoms
    • Hand hygiene (use of alcohol-based hand rub is preferred)
    • Face covering or mask (covering mouth and nose)
    • Social distancing at least six feet between persons
    • Instructional signage throughout the facility and proper visitor education on COVID-19 signs and symptoms, infection control precautions, other applicable facility practices (e.g., use of face covering or mask, specified entries, exits, and routes to designated areas, hand hygiene)
    • Cleaning and disinfecting high frequency touched surfaces in the facility often, and designated visitation areas after each visit
    • Appropriate staff use of personal protective equipment (PPE)
    • Effective cohorting of residents (e.g., separate areas dedicated COVID-19 care)
    • Resident and staff testing conducted as required at 42 CFR 483.80(h) (see QSO-20-38-NH)
Outdoor visitation
  • Visits should be outdoors whenever practicable; facilities should facilitate outdoor visits routinely except under certain circumstances
  • Facilities should create accessible and safe outdoor spaces and a process to limit the number of visits and people visiting any one resident

Indoor visitation
  • Facilities must facilitate in-person visitation and may only restrict visitation when there is a reasonable clinical or safety cause—these visits must adhere to the following guidelines:
    • If a nursing facility has no COVID-19 cases in the last 14-days; AND, its county positivity rate is low or medium (0-10%), they must support in-person visitation consistent with the regulations by applying guidance within the memo
    • Visitors must follow the core principles
    • Facilities should limit number of visitors per resident at one time; total number of visitors in the facility at one time; and movement in the facility
    • Facilities in medium or high-positivity counties are encouraged to test visitors and notes frequency in the memo
    • Residents who have COVID-19 or are under quarantine should only receive in-person compassionate care visitation, virtual visits, or window visits until they are COVID-19 free or out of quarantine

CMS notes that it does not distinguish between visitors and essential caregivers, but states that such a distinction should not be necessary when a person-centered approach is used.

Note—a significant difference between this CMS directive and current MDH guidance is CMS is requiring facilities who meet certain criteria to open up to visitors, where MDH criteria opens up the option to reopen to visitors.

The other significant difference between this CMS directive and current MDH guidance is the timeline for no COVID-19 exposures...14 days versus 28 days.

Compassionate care visitation
  • Additional examples of compassionate care situations underscore that these visits are not limited to end-of-life situations, but also include instances of resident decline or distress (see memo for specific examples)
  • Visits can be conducted by “any individual that can meet the resident’s needs”—for instance, clergy or lay persons offering religious and spiritual support
  • Generally, visits should adhere to social distancing, however, personal contact can be permitted for a limited amount of time if visitor and facility agree on how that can be done, and appropriate infection prevention guidelines are followed

Entry of healthcare workers (non-employees) & other providers of services
Healthcare workers who provide direct care to facility residents, but are not employees of the facility must be permitted to come into the facility as long as they  have not been exposed to COVID-19 or have symptoms of COVID-19. Examples cited in the memo include the following:
  • Emergency medical services workers (EMS)
  • Dialysis technicians
  • Laboratory technicians
  • Radiology technicians
  • Social workers
  • Clergy

Communal activities & dining
Communal activities and communal dining may occur, while adhering to the principles of COVID-19 infection prevention:
  • Dining:
    • Residents may eat in a common room while social distancing
    • Facilities should consider additional limitations based on COVID-19 infections in the facility
  • Activities:
    • Group activities may occur for residents who have recovered from COVID-19 and for those who are not isolated for observation or do not have suspected or confirmed cases of COVID-19
    • Residents must socially distance, use appropriate hand hygiene, and wear face coverings
    • Examples of activities include book clubs, crafts, movies, exercise, and bingo

Use of CMP funds to aid in visitation
CMS will now approve the use of CMP funds for tents for outdoor visitation and/or clear dividers, like Plexiglass, to reduce the risk of transmission during in-person visits. Facilities can apply for up to $3,000 in CMP funds for this use by contacting the person in charge of CMP funds at their state survey agency. Per our request, MDH Engineering Services is currently working on  guidance regarding what types of tents and heaters would be permitted under the Life Safety Code, and the MN CMP committee is working with CMS on an abbreviated grant form that would align with this new CMP fund allocation. Providers may want to begin investigating their purchase options!

Patti Cullen, CAE  |  President/CEO  |  |  952-851-2487


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