TO:                 Nursing Home and Rest Home Administrators

FROM:          Elizabeth Kelley, MPH, MBA, Director                                                                                                         Bureau of Health Care Safety and Quality    

SUBJECT:     Updates to Visitation Conditions, Communal Dining, and Congregate Activities in Long-Term Care Facilities following the COVID-19 State of Emergency

DATE:           January 6, 2022

The Massachusetts Department of Public Health (DPH) continues to work with state, federal and local partners to address 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 November 22, 2021. As part of ongoing statewide activities to address COVID-19 cases, and in recognition of current and high levels of community transmission, DPH is issuing this updated guidance to ensure that visitation can continue in the safest and most meaningful manner possible and in alignment with the Centers for Medicare and Medicaid Services (CMS).

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.

Long-Term Care Visitation:

DPH understands that long-term care facility residents value the physical, emotional, and spiritual support they receive through visitation from family and loved ones and encourages meaningful visitation. A resident has the right to receive visitors of his or her choosing at the time of his or her choosing, and in a manner that does not impose on the rights of another resident, such as a clinical or safety restriction; in short, long-term care facilities must allow visits with residents to occur.

General Standards for In-Person Visitation:

A long-term care facility must allow in-person visitation, which can occur in designated indoor or outdoor visitation space or the resident’s room, with the following safety, care, and infection control measures and policies in place:

• The long-term care facility must establish a process to ensure everyone arriving at the facility is assessed for symptoms of COVID-19 (cough, shortness of breath, or sore throat, myalgia, chills, or new onset loss of smell or taste and a fever), and exposure to others with suspected or confirmed SARS-CoV-2 infection. Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which, prior to arrival at the facility, people report absence of fever and symptoms of COVID-19, absence of a diagnosis of SARS-CoV-2 infection in the prior 10  days and confirm they have not been exposed to others with SARS-CoV-2 infection during the 5 days prior to a visit[1].
  • Any visitor who has a positive screen with symptoms of COVID-19 infection in the prior 10 days or who has been exposed in the prior 5 days (regardless of the visitor’s vaccination status) will not be permitted to visit with a resident.
  •  Any visitor who had an exposure to SARS-CoV-2 in the prior 10 days must have quarantined for at least 5 days prior to visiting the facility, or have received their booster vaccine or been fully vaccinated within the past five months with Pfizer or Moderna vaccine or two months with Janssen vaccine, be able to wear a facemask at all times, and is strongly encouraged to have received a negative COVID-19 test prior to entering the facility. 

• 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.

• Visitors and residents, as they are able to do so, must wear a face mask for the duration of the visit as described below.

• The long-term care facility must clean and disinfect the designated visitation space, including cleaning high-touch surfaces using an appropriate EPA-registered disinfectant.

• While not recommended, residents who are in isolation or quarantine can still receive visitors. In these cases, visits should occur in the resident’s room and the resident must wear a well-fitting facemask (if tolerated). Before visiting residents who are in isolation or quarantine, visitors should be made aware of the potential risk of visiting and precautions necessary in order to visit the resident. Visitors should adhere to the core principles of infection prevention. It is strongly advised that visitors to COVID-19 positive or quarantined residents should be fully vaccinated and maintain physical distance. Facilities must offer and visitors must wear well-fitting filtering facemasks and monitor visitor compliance with hand hygiene.
   

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 or tests positive for SARS-CoV2 infection 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.

Visitor Testing and Vaccination

Facilities are encouraged to offer and perform rapid point of care testing of visitors using BinaxNOW tests if feasible. However, a facility shall not condition a visit on testing.

Facilities must submit both positive and negative test results to the Department of Public Health’s Bureau of Infectious Diseases and Laboratory Sciences (BIDLS). Please contact ISIS-ImmediateDiseaseReporting@mass.gov to share the primary contact details and the BIDLS team will follow up with you to set up reporting.

Facilities can also ask about vaccination status and strongly encourage visitors to become vaccinated when they have the opportunity. While visitor vaccination can help prevent the spread of COVID-19, a facility cannot require a visitor to be tested or vaccinated (or show proof of such) as a condition of visitation.

Indoor Visitation During Outbreak Investigation:

While it is safer for visitors not to enter the facility during an outbreak investigation, visitors must still be allowed in the facility. Visitors should be made aware of the potential risk of visiting when there have been cases in the last 14 days in the facility and adhere to the core principles of infection prevention. If residents or their representative would like to have a visit during an outbreak investigation, they should wear face coverings or masks during visits, regardless of vaccination status, and visits should ideally occur in the resident’s room.

While residents have the right to receive visitors at all times and make choices about aspects of their life in the facility that are significant to them, there may be times when the scope and severity of an outbreak warrants DPH to advise the facility pause visitation for a brief period of time. In accordance with CMS, DPH expects these situations to be extremely rare and only occur after the facility has worked with DPH to manage and prevent escalation of the outbreak. DPH, in accordance with CMS, also expects that if the outbreak is severe[2] enough to warrant pausing visitation, it would also warrant a pause on the facility accepting new admissions. For example, in a nursing home where, despite collaborating with DPH epidemiologists over several days, there continues to be uncontrolled transmission impacting a large number of residents (e.g., more than 30% of residents are suspected or confirmed to be infected with COVID-19), the facility may pause visitation and new admissions temporarily but for not more than 72 hours. In this situation, the nursing home would not be out of compliance with DPH and CMS requirements. A pause in visitation due to a severe outbreak would not apply to compassionate care visits.

Designated Indoor Visitation Space:
 

In addition to the 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.

Resident Room Visitation Space:
 

In addition to the conditions described above, the long-term care facility should allow:

• Residents who are fully vaccinated to visit with loved ones who are fully vaccinated in their rooms, if they reside in a private room or if their roommate is also fully vaccinated and not immune compromised. 
• Residents who are fully vaccinated may visit with loved ones who are fully vaccinated without maintaining social distancing.

Outdoor Visitation Space:

In addition to the in-person indoor visitation conditions described above, the long-term care facility should continue to offer outdoor visitation and adhere to the following:

• 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.
• Residents who are fully vaccinated may visit with loved ones who are fully vaccinated without maintaining social distancing or wearing masks.

Compassionate Care Visitation:

Compassionate care visits are allowed at all times. Facilities must accommodate compassionate care visits for residents, regardless of vaccination and outbreak status.

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 the resident’s roommate has been fully vaccinated, or another location designated by the facility. Long-term care facilities must require visitors to perform hand hygiene and provide visitors a facemask. Decisions about visitation during a compassionate care situation should be made on a case-by-case basis. 

Long-term care facilities should continue to offer electronic methods for virtual communication between residents and visitors, such as Skype, FaceTime, WhatsApp, or Google Duo to augment in-person visitation.

Exceptions to Visitor Limitations:

Health care personnel: Long-term care facilities should follow DPH guidelines for the management of visitors who are health care personnel and who may have been exposed to COVID-19 which can be found at: https://www.mass.gov/doc/return-to-work-guidance-updated-march-8-2021/download. Health care personnel includes but is not limited to, hospice workers, dialysis technicians, nurse aides, nursing or other students in clinical training, dentists, podiatrists, psychiatrists, physical therapists, clergy 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.

Parents and Guardians: Indoor visitation is permitted for parents and guardians of residents who are 22 years old and younger. Parents and guardians of residents must be screened for symptoms and exposures upon entry into the facility and must wear a mask at all times while in the facility unless the resident and visitor are fully vaccinated.

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 upon entry into the facility and must wear a mask at all times while in the facility.

Non-essential personnel:

Non-essential personnel include, but are not limited to, the following individuals: barbers, hair stylists, volunteers, contractors and vendors performing maintenance or construction work within the facility, surveyors from accrediting organizations, and individuals working in facility gift shops.

If volunteers are permitted in a long-term care facility, the following safety, care, and infection control measures should be implemented in addition to the measures described above:

•           Volunteers must wear a face mask for the duration of their time in the facility, and

•           Volunteers are permitted in common spaces within the facility and may be permitted in resident rooms, if the volunteer and the residents in the room are all fully vaccinated.

Long-term care facilities should perform rapid point of care testing of non-essential personnel who are not part of the facility’s weekly surveillance testing program using BinaxNOW tests.

Dining and Group Activities:

Long-term care facilities may provide outdoor entertainment and activities on the grounds 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.
• All residents except for those residents in isolation for suspected or confirmed COVID-19 or in quarantine due to exposure or new admission status, regardless of vaccination status, can participate in the outdoor group activities.
• Participating residents must wear a mask if any of the participating residents are not fully vaccinated.
• If all participating residents are fully vaccinated, then residents do not need to wear a mask.

Long-term care facilities may provide communal dining and 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.
• 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 wear a mask if any of the participating residents are not fully vaccinated.
  • If all participating residents are fully vaccinated, then residents do not need to socially distance or wear a mask.
• Small groups of residents who are fully vaccinated may dine together at a table without social distancing or wearing masks. 
• Staff must wear appropriate PPE including a facemask and eye protection.
• Staff should perform hand hygiene and observe or assist residents in performing hand hygiene before and after overseeing or engaging in any activity.
• 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.
• Enhancements to ventilation, including open windows, HVAC filtration or use of HEPA filters should be encouraged in areas where groups congregate for activities or dining.

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

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, 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:

• CMS website: https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page
• CDC website: https://www.cdc.gov/coronavirus/2019-ncov/hcp/facility-planning-operations.html

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