On June 26, the California Department of Public Health released a new policy regarding visitation that, for the first time since March, REQUIRES senior living communities to permit visitors for outdoor and indoor visits. Facilities with no current COVID-19 outbreak must permit outdoor visitation. Indoor visits must be permitted if a facility meets six criteria: 1. no current COVID-19 outbreak, 2. a decline in cases in the community, 3. no new COVID-19 cases in the facility for the past 14 days, 4. no staffing shortages and not using a COVID-19 staffing waiver, 5) an adequate testing plan per AFL 20-53, and 6) an approved COVID-19 Mitigation Plan. For indoor visits, only one designated visitor allowed per resident (per visit – more than one visitor may visit, just not at the same time). All visits (indoor or outdoor) must be scheduled in advance with visitors screened for fever or COVID-19 symptoms. All visitors must comply with social distancing (6 feet or more physical distancing), wear facial coverings, and permit staff monitoring to ensure compliance with infection control guidelines.

Exception to Visitation Restrictions

The following are exceptions to a skilled nursing facility visitation restrictions:

• Healthcare workers: Facilities should follow CDC guidelines for restricting access to healthcare workers. Healthcare workers, including those from the local county public health offices, should be permitted to come into the facility if they meet the CDC guidelines for healthcare workers.
• Surveyors: CMS and CDPH are constantly evaluating their surveyors to ensure they do not pose a transmission risk when entering the facility. Any surveyor entering the facility are subject to screening for fever and COVID-19 symptoms and must wear appropriate PPE.
• Ombudsman: Facilities not experiencing an outbreak (i.e., one or more confirmed positive cases) should permit ombudsman representatives in the facility. Any ombudsman representative entering the facility is subject to screening for fever and COVID-19 symptoms and must wear appropriate PPE.
• Nursing students: Students obtaining their clinical experience as part of an approved nurse assistant, vocational nurse or registered nurse training program should be permitted to come into the facility if they meet the CDC guidelines for healthcare workers.
• End of life visitation: For permitted visitors for end of life situations, those individuals:
  • Must be screened for COVID-19 symptoms
  • Must wear a surgical facemask while in the building
  • Restrict their visit to the resident’s room or other location designated by the facility
  • Should be reminded by the facility to frequently perform hand hygiene

Resuming Other Visitation

To resume visitation, facilities should refer to the “Recommended Nursing Homes Phased Reopening for States” attachment in QSO 20-30 (PDF) and work with their local health department in determining the general community’s current reopening phase. Due to the elevated risk COVID-19 poses to SNF residents, CMS recommends that facility reopening should lag behind the general community by 14 days. Facilities experiencing an outbreak (i.e. one or more confirmed positive cases) should not resume visitation.

Facilities that meet the following conditions shall allow residents to designate one visitor per resident for inside facility visitation:

• Case conditions in the community – There is a decline in the number of new cases, hospitalizations or deaths in the community.
• Case status in the facility – Absence of any new COVID-19 cases in the facility for 14 days, either residents or staff.
• Adequate staffing – No staffing shortages and the facility is not using a COVID-19 staffing waiver.
• Access to adequate testing – The facility has a testing plan in place in compliance with AFL-20-53.
• An approved COVID-19 Mitigation Plan- The facility must maintain good regulatory compliance for safety.

Facilities unable to meet the conditions specified above may not resume in room facility visitation, but they shall provide outdoor and other visitation options, including but not limited to:

• Allow scheduled visits on the facility premises where there is 6-feet or more physical distancing, and both residents and visitors where facial coverings with staff monitoring infection control guidelines. (i.e. large communal spaces, outdoor visits, drive-by visits or visit through a person’s window).
• Offering alternative means of communication for people who would otherwise visit, such as virtual communications (phone, video-communication, etc.).
• Creating/increasing listserv communication to update families, such as advising not to visit.
• Assigning staff as primary contact to families for inbound calls and conduct regular outbound calls to keep families up to date.
• Offering a phone line with a voice recording updated at set times (i.e. daily) with the facility’s general operating status, such as when it is safe to resume visits.

Visitation Guidance

1. For all visitations, facilities should make efforts to allow for safe visitation for residents and loved ones.
   • Ensure visitor screening for fever and COVID-19 symptoms
   • Visitors and residents should have facial coverings (cloth masks or surgical face masks)
   • Staff should monitor to physical distancing is practiced with no hand-shaking, hugging, and remaining six feet apart.
   • If possible (i.e. pending design of building), creating dedicated visiting areas near the entrance to the facility where residents can meet with visitors in a sanitized environment. Facilities should disinfect rooms after each resident-visitor meeting.
2. Advise visitors, and any individuals who entered the facility (e.g., hospice staff), to monitor for signs and symptoms of respiratory infection for at least 14 days after exiting the facility. If symptoms occur, advise them to self-isolate at home, contact their healthcare provider, and immediately notify the facility of the date they were in the facility, the individuals they were in contact with, and the locations within the facility they visited. Facilities should immediately screen the individuals of reported contact, and take all necessary actions based on findings.
3. For medically necessary trips away from the facility, the resident must wear a cloth face covering or a surgical facemask and the facility must share the resident’s COVID-19 status with the transportation service and entity with whom the resident has the appointment.
4. All staff must wear appropriate PPE when they are interacting with residents, to the extent PPE is available and consistent with CDC guidance on optimization of PPE. Staff should wear cloth face covering if surgical facemask is not indicated.
5. Once baseline testing is complete implement either surveillance or response driven testing based on the conditions at the facility in accordance with AFL-20-53.
6. Have dedicated space in the facility for cohorting and managing care for residents with COVID-19; plan to manage new/readmission with an unknown COVID-19 status and residents who develop symptoms.

Additional Guidance

The following are additional CMS guidance to prevent the spread of COVID-19. This guidance is subject to revision by CMS at any time.

1. Cancel communal dining and all group activities, such as internal and external group activities. For COVID-19 negative or asymptomatic residents, communal dining should be limited, but residents may eat in the same room with social distancing (limited number of people at tables and spaced by at least 6 feet).
2. Remind residents to practice social distancing and perform frequent hand hygiene. Residents must wear cloth face covering or facemasks as mandated in CDPH’s Guidance for the Use of Face Coverings (PDF).
3. Facilities should identify staff that work at multiple facilities (e.g., agency staff, regional or corporate staff, etc.) and actively screen and restrict them appropriately to ensure they do not place individuals in the facility at risk for COVID-19.
4. Facilities should review and revise how they interact with vendors and receiving supplies, agency staff, EMS personnel and equipment, transportation providers, and other non-health care providers (e.g., food delivery, etc.), and take necessary actions to prevent any potential transmission.

CDPH understands the importance of maintaining contact with family and friends to LTC residents. If you have any questions about this AFL, please contact your local district office.

Sincerely,

Original signed by Heidi W. Steinecker

Heidi W. Steinecker
Deputy Director