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Executive Office of Health and Human Services

Department of Public Health
Bureau of Health Care Safety and Quality

67 Forest Street, Marlborough, MA 01752

 

 

CHARLES D. BAKER

Governor

KARYN E. POLITO

Lieutenant Governor

 

 

 

MARYLOU SUDDERS

Secretary

MONICA BHAREL, MD, MPH Commissioner

 

Tel: 617-624-6000

www.mass.gov/dph

 

Text Box: MARYLOU SUDDERS
Secretary
MONICA BHAREL, MD, MPH Commissioner
Tel: 617-624-6000
www.mass.gov/dph

 

 

 

 

 

 

Memorandum

 

TO:                 Nursing Home and Rest Home Administrators

 

FROM:          Elizabeth D. 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 during the COVID-19 Outbreak

 

DATE:           December 7, 2020

 

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 November 4, 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. 

 

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 

 

 

Planned Resident Leave of Absences:  Holidays 2020

Because of ongoing community transmission of COVID-19 within the Commonwealth of Massachusetts and concerns for the health and safety of residents, the Department recommends that residents do not participate in planned leaves of absence at this time. If, however, a long-term care facility resident wants to schedule a planned leave of absence from the facility, the facility clinical leadership should work with the resident and their loved ones to create a plan for a safer leave. This plan must include education for the resident and loved ones about:

  • wearing cloth face coverings;
  • practicing physical distancing;
  • limiting interaction to the fewest number of people possible while the resident is on their planned leave. 
  • Loved ones also limiting their interaction to the fewest number of people possible for two weeks before the resident’s planned leave/visit.
  • assessment about the possible exposure risks while the resident is on their planned leave and instructions about how to mitigate them. 
  • The need for the resident to quarantine for fourteen days upon return from leave

 

If the facility does not have a room available for quarantine for a resident who is returning from a planned leave of absence, then loved ones may be required to keep and care for the resident until a room is available. The facility must communicate this to the resident and their loved ones prior to the resident leaving the facility. 

 

Long-term care facilities should test any resident returning from a planned leave of absence, however, a negative test result does not remove the requirement to quarantine for the 14 day period. 

 

Executive Office of Health and Human Services Department of Public Health
Bureau of Health Care Safety and Quality 67 Forest Street, Marlborough, MA 01752

 

CHARLES D. BAKER
Governor
KARYN E. POLITO
Lieutenant Governor

 

MARYLOU SUDDERS
Secretary
MONICA BHAREL, MD, MPH
Commissioner

Tel: 617-624-6000
www.mass.gov/dph


Memorandum TO:                Nursing Home and Rest Home Administrators
FROM:          Elizabeth D. Kelley, MPH, MBA, Director Bureau of Health Care Safety and Quality

SUBJECT:    Limitations on Visitors in Long-Term Care Facilities during the COVID-19 Outbreak1

DATE:           June 1, 2020

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 March 16, 2020 and is effective as of June 3, 
2020.

Limitations on Long-Term Care Visitors:

Long-term care facilities may allow visits with residents to occur, provided that the physical 
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 communication 
between residents and visitors, such as Skype, FaceTime, WhatsApp or Google Duo.

Designated Outdoor Visitation Space:

 

!. This guidance applies to all Long-Term Care Facilities other than those that are operated by the 
state.

 

A long-term care facility may allow in-person visitation in a designated outdoor visitation space, 
provided that the long-term care facility implements all of the following safety, care, and 
infection control measures:
•    A resident who is suspected or confirmed to be infected with COVID-19 cannot be visited. A 
resident who has recovered from COVID-19 may be visited.
•    Prior to transporting a resident to the designated outdoor visitation space, the long-term 
care facility must screen the visitor for fever or respiratory symptoms. 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 outdoor 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.
•    A long-term care facility staff member trained in such patient safety and infection control 
measures must remain with the resident at all times during the visit.
•     Visitors must be limited to no more than two individuals. A visitor must remain at least 6 
feet from the resident and attending staff member(s) at all times during the visit.
•    Staff and residents must wear a surgical face mask and visitors must wear a face covering or 
mask for the duration of the visit.

Visits with a resident in a designated outdoor space must be scheduled in advance and are dependent 
on permissible weather conditions, availability of outdoor space, and sufficient staffing at the 
facility to meet resident care needs, and the health and well-being of the resident.

A long-term care facility may limit the length of any visit, the days on which visits will be 
permitted, the hours during a day when visits will be permitted, and the number of times during a 
day or week a resident may be visited.

Compassionate Care Visitation:

 

For compassionate care situations, including but not limited to an end-of-life situation, 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. Decisions about visitation during an end 
of life 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. 
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.

For those who are in end-of-life situations, visitors should be allowed a time limited visit and be 
given a face mask if they do not have a face covering or mask.  For those visitors who are 
permitted to visit in compassionate care situations, the visitors must be restricted to the 
resident’s room or other location designated by the facility.  They must also be reminded to 
frequently perform 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 within 2 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.

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, such as hospice 
workers, dialysis technicians, nursing students or Emergency Medical Service (EMS) personnel in 
non-emergency situations that provide care to residents. They should be 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.

Dining and Group Activities:

All long-term care facilities should continue to suspend communal dining, as well as internal and 
external group activities.

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).

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/healthcare-  facilities/index.html

 

 

 

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

 

 

 

To Families, the link below will provide you access to the MASS.GOV dashboard.  This site updates information on Covid 19. In particular, as you scroll down, you will see Nursing Home Data.  Its important to note the data for Nursing Homes is cumulative and is both for patients and staff.  In addidion, the amount of testing varies widely at different facilities.  Alden Court has tested all residents and staff.

https://www.mass.gov/info-details/covid-19-updates-and-information

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop C2-21-16
Baltimore, Maryland 21244-1850
Center for Clinical Standards and Quality/Quality, Safety & Oversight Group
Ref: QSO-20-25-NH
DATE: April 13, 2020
TO: State Survey Agency Directors
FROM: Director
Quality, Safety & Oversight Group
SUBJECT: 2019 Novel Coronavirus (COVID-19) Long-Term Care Facility Transfer Scenarios
Background
CMS has issued unprecedented flexibility to the long-term care (LTC) facilities (skilled nursing facilities (SNFs) and/or nursing facilities (NFs)) in order to protect residents during the COVID-19 pandemic. On April 2, 2020, CMS and CDC released the “COVID-19 Long-Term Care Facility Guidance,” which alerted facilities to actions they should take to prevent transmission of COVID-19. These actions include separating residents based on COVID-19 status (i.e., positive, negative, unknown/under observation). This may mean facilities will need to transfer residents within the facility, to another long-term care facility, or to other non-certified locations designated by the State. In order to coordinate appropriate relocation of residents between facilities or another location, facilities should work with State and local community leaders to identify and designate facilities dedicated to residents diagnosed with COVID-19 and those with suspected COVID-19.
To facilitate cohorting of residents based on COVID-19 status, CMS issued blanket waivers for certain CMS requirements of participation for LTC facilities. These include a physical environment waiver to temporarily allow rooms not normally used as a resident’s room in a certified LTC facility to be used to accommodate beds and resident care. These also include certain transfer and discharge requirements that are waived solely for the purposes of cohorting. Please view all these waivers, and their exceptions, through the blanket waivers link above.
LTC Facility Transfer Scenarios
In response to the recent questions related to cohorting, CMS is providing supplemental information for transferring or discharging residents between facilities. In general, if two or more certified LTC facilities want to transfer or discharge residents between themselves for the
Memorandum Summary
• CMS is providing supplemental information for transferring or discharging residents between facilities for the purpose of cohorting residents based on COVID-19 status (i.e., positive, negative, unknown/under observation).
purposes of cohorting, they do not need any additional approval to do so. However, if a certified LTC facility would like to transfer or discharge residents to a non-certified location for the purposes of cohorting, they need approval from the State Agency. Please see the attachment, “LTC Facility Transfer Scenarios” for a depiction and explanation of these scenarios.
Contact: For questions or concerns regarding this memo, please contact DNH_TriageTeam@cms.hhs.gov.
Effective Date: Immediately. This policy should be communicated with all survey and certification staff, their managers and the State/Branch training coordinators within 30 days of this memorandum.
/s/
David R. Wright
Attachment: LTC Facility Transfer Scenarios
cc: Survey & Operations Group (SOG) Management
Two or more certifiedlong term care (LTC) facilities (SNFs and/or NFs) transfer patients between facilities to create a COVID-19 and non-COVID-19 facility. Allowed under Blanket Transfer Waiver without additional approval. Each certified facility bills Medicare for the residents in their facility.
Non-COVID-19
COVID-19
CMS is waiving requirements in 42 CFR 483.10(c)(5); 483.15(c)(3), (c)(4)(ii), (c)(5)(i) and (iv), (c)(9), and (d); and §483.21(a)(1)(i), (a)(2)(i), and (b) (2)(i) (with some exceptions) to allow a long term care (LTC) facility to transfer or discharge residents to another LTCfacility solely for the following cohortingpurposes:
•Transferring residents with symptoms of a respiratory infection or confirmed diagnosis of COVID-19 to another facility that agrees to accept each specific resident, and is dedicated to the care of such residents;
•Transferring residents without symptoms of a respiratory infection or confirmed to not have COVID-19 to another facility that agrees to accept each specific resident, and is dedicated to the care of such residents to prevent them from acquiring COVID-19; or
•Transferring residents without symptoms of a respiratory infection to another facility that agrees to accept each specific resident to observe for any signs or symptoms of a respiratory infection over 14 days.
Transfer residents from one or more certified LTC facilities to a non-certified location that is state approved and where residents must be cared for by LTC facility staff. Medicare reimbursement remains with the LTC facility caring for patients in the new location. This location could be utilized by multiple LTC facilities, providing care with their own staff.
State Approved non-LTC Location staffed and operated by Certified LTC facility
CMS is waiving requirements related at 42 CFR 483.90, specifically the following: Provided that the state has approved the location as one that sufficiently addresses safety and comfort for patients and staff, CMS is waiving requirements under §483.90 to allow for a non-certified LTC building to be temporarily certified and available for use by a LTC facility in the event there are needs for isolation for COVID-19 positive residents, which may not be feasible in the existing LTC facility structure to ensure care and services during treatment for COVID-19 are available while protecting other vulnerable adults.
These requirements are also waived when transferring residents to another facility, such as a COVID-19 isolation and treatment location, with the provision of services “under arrangements,” as long as it is not inconsistent with a state’s emergency preparedness or pandemic plan, or as directed by the local or state health department. In these cases, the transferring LTC facility need not issue a formal discharge, as it is still considered the provider and should bill Medicare normally for each day of care. The transferring LTC facility is then responsible for reimbursing the other provider that accepted its resident(s) during the emergency period.
Transfer of COVID-19 residents to Federal/State run facility staffed with Federal or State personnel: Transfers by Order of Governmental Authority (e.g., FEMA) and no reimbursement to the LTC facility.
No waiver necessary as long as transfer is not inconsistent with a state’s emergency preparedness or pandemic plan, or as directed by the local or state health department


COVID-19 Long-Term Care Facility Guidance
April 2, 2020 

 The Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) are issuing new recommendations to State and local governments and long-term care facilities (also known as nursing homes) to help mitigate the spread of the 2019 Novel Coronavirus (COVID-19). Long-term care facilities are a critical component of America’s healthcare system. They are unique, as they serve as both healthcare providers and as full-time homes for some of the most vulnerable Americans. 
 

In recent weeks, CMS and CDC, at President Trump’s direction, have worked together to swiftly issue unprecedented targeted direction to the long-term care facility industry, including a general prohibition of visitors implemented on March 13, 2020, as well as strict infection control and other screening recommendations. However, recent observations made by CDC and CMS experts onsite in facilities have emphasized that even more must be done to universally implement this key guidance. 
 

To provide critical, needed leadership for the Nation’s long-term care facilities to prevent further spread of COVID-19, CMS and CDC are now recommending the following immediate actions to keep patients and residents safe: 
 

1. Nursing Homes should immediately ensure that they are complying with all CMS and CDC guidance related to infection control.

  • In particular, facilities should focus on adherence to appropriate hand hygiene as set forth by CDC. 
  • CMS has also recently issued extensive infection control guidance, including a self-assessment checklist that long-term care facilities can use to determine their compliance with these crucial infection control actions. 
  • Facilities should also refer to CDC’s guidance to long-term care facilities on COVID-19 and also use guidance on conservation of personal protective equipment (PPE) when unable to follow the long-term care facility guidance. 

 

2. As long-term care facilities are a critical part of the healthcare system, and because of the ease of spread in long-term care facilities and the severity of illness that occurs in residents with COVID-19, CMS urges State and local leaders to consider the needs of long-term care facilities with respect to supplies of PPE and COVID-19 tests.
 

  • State and local health departments should work together with long-term care facilities in their communities to determine and help address long-term care facility needs for PPE and/or COVID-19 tests. 
  • Medicare is now covering COVID-19 testing when furnished to eligible beneficiaries by certified laboratories. These laboratories may also choose to enter facilities to conduct COVID-19 testing. 

 

3. Long-term care facilities should immediately implement symptom screening for all. 

  • In accordance with previous CMS guidance, every individual regardless of reason entering a long-term care facility (including residents, staff, visitors, outside healthcare workers, vendors, etc.) should be asked about COVID-19 symptoms and they must also have their temperature checked. An exception to this is Emergency Medical Service (EMS) workers responding to an urgent medical need. They do not have to be screened, as they are typically screened separately. 
  • Facilities should limit access points and ensure that all accessible entrances have a screening station. 
  • In accordance with previous CDC guidance, every resident should be assessed for symptoms and have their temperature checked every day. 
  • Patients and residents who enter facilities should be screened for COVID-19 through testing, if available. 
     

4. Long-term care facilities should ensure all staff are using appropriate PPE when they are interacting with patients and residents, to the extent PPE is available and per CDC guidance on conservation of PPE.

  • For the duration of the state of emergency in their State, all long-term care facility personnel should wear a facemask while they are in the facility. 
  • Full PPE should be worn per CDC guidelines for the care of any resident with known or suspected COVID-19 per CDC guidance on conservation of PPE. 
  • If COVID-19 transmission occurs in the facility, healthcare personnel should wear full PPE for the care of all residents irrespective of COVID-19 diagnosis or symptoms. 
  • Patients and residents who must regularly leave the facility for care (e.g., hemodialysis patients) should wear facemasks when outside of their rooms. 
  • When possible, all long-term care facility residents, whether they have COVID-19 symptoms or not, should cover their noses and mouths when staff are in their room. Residents can use tissues for this. They could also use cloth, non-medical masks when those are available. Residents should not use medical facemasks unless they are COVID-19-positive or assumed to be COVID-19-positive. 
     

5. To avoid transmission within long-term care facilities, facilities should use separate staffing teams for COVID-19-positive residents to the best of their ability, and work with State and local leaders to designate separate facilities or units within a facility to separate COVID-19 negative residents from COVID-19 positive residents and individuals with unknown COVID-19 status.

  • Long-term care facilities should exercise as best as possible consistent assignment (meaning the assignment of staff to certain patients and residents) for all patients and residents regardless of symptoms or COVID-19 status. This practice can enhance staff’s familiarity with their assigned patients and residents, helping them detect emerging condition changes that unfamiliar staff may not notice. The goal is to decrease the number of different staff interacting with each patient and resident as well as the number of times those staff interact with the patient and resident. Also, staff as much as possible should not work across units or floors.
    • i. Long-term care facilities should redeploy existing training related to consistent assignment, and ensure staff are familiar with the signs and symptoms of COVID-19. 
       
  • Long-term care facilities should separate patients and residents who have COVID-19 from patients and residents who do not, or have an unknown status.
    • i. To this end, long-term care facilities should work with State and local community leaders to identify and designate facilities dedicated to patients and residents with known COVID-19-positive and those with suspected COVID-19, ensuring they are separate from patients and residents who are COVID-19-negative; 
    • ii. COVID-19-positive units and facilities must be capable of maintaining strict infection control practices and testing protocols, as required by regulation; 1. When possible, facilities should exercise consistent assignment, or have separate staffing teams for COVID-19-positive and COVID-19-negative patients. 
    • iii. There may be a need for some of these COVID-19-positive long-term care facilities to have the capacity, staffing, and infrastructure to manage higher intensity patients, including ventilator management; 
    • iv. State agencies including health departments, hospitals, and nursing home associations will have to ensure coordination among facilities to determine which facilities will have a designation and to provide adequate staff supplies and PPE; and, if possible, isolate all admitted residents (including readmissions) in their room in the COVID-19-positive facility for 14 days if their COVID-19 status is unknown; and 
    • v. Long-term care facilities should, to the fullest extent possible, inform residents and their families of limitations of their access to and ability to leave and re-enter the facility, as well as any requirements and procedures for placement in alternative facilities for COVID-19-positive or unknown status. 

 

 

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