Updated Nursing Home Visitation Guidance Issued

For the first time since the beginning of the COVID-19 pandemic, nursing homes must allow residents to have visitors when they want under the Centers for Medicare and Medicaid Services’ (CMS) revised visitation guidance issued last month. This is a welcome change that comes just in time for the winter holidays and new year. 

COVID-19 has had a devastating impact on nursing home. In Pennsylvania, nursing home residents make up approximately 30% of those who have died from COVID-19 since the start of the pandemic. To curb the spread of COVID-19 in these facilities, early in the pandemic CMS issued guidance restricting all visitation in nursing homes, with very few exceptions.  Unfortunately, this lockdown of nursing homes had the secondary effect of nursing home residents becoming isolated from their loved ones, adding an emotional toll to the impact of COVID-19 on those living in facilities. Once vaccines became widely available, CMS partially loosened its nursing home visitation restrictions and on November 12, 2021, CMS lifted all restrictions, citing the physical and emotional impact of keeping residents from their families, high vaccination rates among nursing home residents, and the effectiveness of other measures to prevent the spread of COVID-19. 

Under CMS' new guidance, nursing home residents must be allowed visitors at all times, without the need for advance scheduling. Visits may take place indoors, and nursing homes may no longer limit the frequency or length of visits or the number of visitors. This return to the pre-pandemic level of visitation is not completely unfettered -- the right to visits may be limited if a visit imposes “on the rights of another resident, such as a clinical or safety restriction.” However, the CMS guidance indicates that generalized concerns about visitors spreading COVID-19 no longer qualify as “clinical or safety” concerns that can justify restricting residents’ right to choose who visits them and when.  Instead, the guidance notes visitation planning must be person-centered and emphasizes that adhering to “core principles of COVID-19 infection prevention” such as COVID screening and masking, as well as controlling crowding and limiting movement within the facility should be used to mitigate COVID risks.  For example, nursing homes may bar visitors who test positive for or have symptoms of COVID-19, meet criteria for quarantine due to COVID exposure, or who refuse to abide by reasonable mitigation precautions, but blanket policies restricting visitation are not permitted. 

CMS’ guidance stresses the importance of making residents and their guests aware of the potential risks of visitation in certain situations such as when there is a high community transmission and an unvaccinated resident wishes to receive visitors. 

Prior COVID-19-related visitation guidance allowed service providers to visit residents.  The updated guidance from November clarifies that this includes people who provide education on and assistance with nursing home transition. This is an important clarification. In Pennsylvania, we have heard that nursing home transition coordinators have had challenges accessing residents during the pandemic. 

The guidance also reminds nursing homes that they “must permit residents to leave the facility as they choose” while also emphasizing the importance of educating residents who do leave on how to prevent infection while out in the community.  Upon return to the facility from a short leave (less than a day), residents should be screened for COVID signs, symptoms, and exposure and, depending on the findings from the screenings, tested for COVID-19, quarantined if unvaccinated, or placed on Transmission-Based Precautions (a type of quarantine for confirmed or suspected cases of COVID-19). For absences from the nursing home of 24 hours or more, the guidance suggests testing all residents and treating the returning resident as a new admission for purposes of COVID-19 infection prevention, which includes quarantining those who are unvaccinated and have not had COVID-19 in the last 90 days.

Although not covered by the guidance, it is important for nursing home residents to understand for how long they can leave a facility, whether to visit family for the holidays or to attend to other matters. Residents whose nursing home stay is being paid for by Medicaid are allowed up to 30 days per year of “therapeutic leave” and the facility will hold the bed for the resident during their absence. Residents wishing to take therapeutic leave should discuss their plans with their doctor, as Pennsylvania regulations require the leave to be ordered by the attending physician. Participants whose nursing home stay is being paid for by Medicare (which only covers short-term nursing facility stays) do not have as much flexibility. According to the Center for Medicare Advocacy, these individuals may leave the nursing home for “short periods, such as a day or two … without losing Medicare coverage,” but the nursing home can bill the resident to ensure the bed is available when they return if the residents is informed of this charge beforehand and agrees to it. 

Nursing home residents who feel their rights to receive visitors or leave the nursing home have been violated should contact the Long-Term Care Ombudsman for their area. If they do not know how to contact the Ombudsman directly, they can obtain that information from the Commonwealth’s Ombudsman program office at 717-783-8975 or LTC-ombudsman@pa.gov.