The March 9, 2020, nursing facility QSO memo focuses on several practices to limit the transmission of COVID-19 in nursing facility settings, including screening, restricting, limiting and discouraging visitors and other non-staff, non-resident personnel from non-essential visits to nursing facilities. The memo also provides instructions for when a facility should transfer or accept a resident with suspected or confirmed COVID-19 infection.

Screening and Restricting Visitation

CMS encourages nursing facilities to screen visitors and restrict visitation rights if a visitor meets any of the following criteria:

• Shows signs or symptoms of a respiratory infection, such as fever, cough, shortness of breath or sore throat
• Had contact in the last 14 days with someone with a confirmed diagnosis of COVID-19, or someone who is under investigation for COVID-19 or ill with a respiratory infection
• Traveled within the last 14 days to countries with sustained community transmission
• Resides in a community where community-based spread of COVID-19 is occurring.

If a visitor does not meet any of these criteria, facilities can permit visitation, but facilities may require the use of personal protective equipment (PPE), such as face masks.

Limiting Visitation

For facilities that are in counties or adjacent to counties where a COVID-19 case has occurred, CMS recommends prohibiting visitors, except in limited circumstances, such as end-of-life situations or when a visitor is essential for the resident’s emotional well-being and care.

Discouraging Visitation

For facilities not in counties or adjacent to counties where a COVID-19 case has occurred, CMS recommends discouraging visitation. To discourage visitation, a facility should advise visitors to defer visitation until further notice. Methods of discouraging or limiting visitors include signage at facilities recommending that visitors defer their visit for another time or only visit for certain specific situations (e.g., end of life situations, or when a visitor is essential to a resident’s emotional well-being or care)

In lieu of visits, facilities can consider:

• Offering alternative means of communication for people who would otherwise visit, such as virtual communication
• Sending listserv communication to families, including advice not to visit
• Conducting regular outbound calls to keep families up to date
• Offering a phone line with a voice recording on the facility’s general operating status, including whether it is safe to resume visits.

Visitation Guidelines

When visitation is necessary or allowable, facilities should make an effort to allow for safe visitation for all parties involved. Such measures might include:

• Suggesting limiting physical contact by the practice of social distancing
• Creating dedicated visiting areas (e.g., “clean rooms”) near the facility entrance where residents can meet in a sanitized environment to be disinfected after each resident-visitor meeting
• Advising visitors to report to the facility any signs or symptoms of COVID-19 or acute illness within 14 days of visiting the facility
• Providing instruction on appropriate hand hygiene, encouraging the use of PPE, and increasing availability of alcohol based hand sanitizer (ABHS)
• Taking action to prevent potential transmission from non-visitor third parties such as vendors, volunteers and other practitioners, by requesting that they leave supplies at the loading dock or don PPE before entering the facility, for example.

Medicare Conditions of Participation (42 CFR § 483.10(f)(4)) require long-term care facilities, including nursing facilities, to permit visitors of the resident’s choosing except as the facility’s policies and procedures restrict those visitation rights for clinically necessary or reasonable purposes. Failure to permit access to visitors or to follow the facility’s policies and procedures may result in a citation by a CMS contractor, which could prohibit the facility from participating in Medicare.

Transferring and Accepting Residents

If a resident is suspected of having a COVID-19 infection, nursing facilities should contact the local health department. If the infection is not serious, facilities should follow Centers for Disease Control and Prevention (CDC) infection prevention and control recommendations. Transferring residents to a hospital is not necessary unless the resident requires a higher level of care. In such an instance, the recipient hospital and emergency medical services should be alerted and instructed to wear proper PPE during the transfer.

Nursing facilities may accept a resident diagnosed with a transmissible COVID-19 infection only as long as the facility can follow CDC guidance for transmission-based precautions. Absent this ability, nursing facilities should not admit the resident until the resident has recovered in accordance with CDC guidelines for discontinuation of transmission-based precautions.

If an incoming resident does not have a transmissible COVID-19 infection, nursing facilities should accept the resident in accordance with their standard practice. If the resident is transferred from a hospital where COVID-19 cases were present, CMS encourages nursing facilities to dedicate a unit or wing where residents can transition into short-stay rehab or long-stay residence after demonstrating 14 days with no symptoms.

Key Takeaways: Nursing facilities should prepare policies and procedures for resident visitation to ensure that the facility can restrict visitors who present with COVID-19-related symptoms. Facilities also may want to consider limiting or discouraging in-person visits and offering alternative means of communication. CMS expects nursing facilities to adhere to infection prevention and control recommendations when providing care and when allowing visitors to interact with residents.

Hospices (Inpatient Units, Nursing Facilities, Assisted Living, Hospitals and Home Settings)

The March 9, 2020, hospice QSO memo focuses on several practices to limit the transmission of COVID-19 in hospice and home care settings, including screening and restricting visitors and treating and transferring patients to higher-level care when appropriate.

Identifying Risk of COVID-19 in Volunteers, Visitors and Patients

As described previously in the context of nursing facilities, hospices should identify volunteers, visitors and patients at risk for having COVID-19 by asking if they meet any of the four screening criteria.

Restriction of Visitors to Hospice Inpatient Units

Medicare regulations require a hospice to focus on preventing and controlling infections. Inpatient hospice facilities may have policies regarding patients’ visitation rights and may wish to set clinical restrictions on visitation subject to patients’ rights. If the inpatient hospice services are not provided by the hospice facility itself (such as hospital-based hospice care), the third-party provider may have additional visitation restrictions to address COVID-19 transmission concerns. For more information, see McDermott’s On the Subject “This is Not a Drill: Hospital and Health System Preparedness for COVID-19.” However, if hospice services are provided in a nursing facility, hospice workers should be permitted entry upon donning appropriate PPE and following CDC guidelines for Transmission-Based Precautions.

Caring for Hospice Patients with COVID-19 Symptoms

If a patient demonstrates respiratory symptoms, hospice caregivers should notify local and state public health authorities and implement respiratory hygiene practices, including placing a face mask over the patient’s mouth and nose when coughing, and isolating the patient in a private room with the door closed. If a private room is not available, the patient should be moved to a well-ventilated space, separated from other patients by at least six feet of space. Hospice agencies should continue to adhere to Medicare PPE requirements, including provision of ABHS, tissues, no-touch trash receptacles and face masks at facility entrances.

If a patient in a hospice setting presents with COVID-19-related symptoms, hospice facilities should consult with the patient, the patient’s representative, and state and local public health authorities before deciding whether to administer a diagnostic test versus presuming a positive COVID-19 diagnosis. Patients in home hospice settings should be hospitalized or transferred to an inpatient hospice unit only if their symptoms are exacerbated by a COVID-19 infection that cannot be managed in the home setting.

Key Takeaways: Hospice facilities and providers should consider a patient’s unique healthcare needs and the severity of COVID-19-related symptoms when considering whether to allow visitors to inpatient hospice settings and whether to transfer hospice patients in home settings to an inpatient facility.

Home Health Agencies

The March 10, 2020, home health agency QSO memo focuses on several practices to limit the transmission of COVID-19 in home care settings, including educating family members and treating and transferring patients to higher-level care when appropriate.

Identifying Risk of COVID-19 in Patients

As described above in the context of nursing facilities, home health agencies should identify patients at risk for COVID-19 before or immediately upon arrival at the home by asking patients if they meet any of the four screening criteria.

Caring for Home Health Agency Patients with COVID-19 Symptoms

If a patient demonstrates respiratory symptoms, healthcare professionals should notify the home health agency clinical manager and local and state public health authorities and implement respiratory hygiene practices when caring for the patient. Home health agencies should advise the patient to stay home except to get medical care and to limit contact with other people and animals as much as possible. Home health agencies should advise family members on best practices for preventing the spread of COVID-19 in the home (e.g., hand-washing, monitoring symptoms, regularly cleaning high-touch surfaces, not sharing personal items), including prevention and control recommendations.

Home care staff and other individuals in the home should continue to adhere to Medicare PPE requirements, including the use of ABHS, gowns and face masks. Healthcare professionals and home care staff should be limited to essential personnel only; should don PPE outside of the home prior to entry or, at a minimum, put on face protection prior to entering the home; and should discard used PPE in an external trash receptacle prior to departing the home health service location. Healthcare professionals are encouraged to perform hand hygiene using ABHS prior to removing face protection and again after disposing of PPE.

If home health agencies anticipate providing care to patients confirmed or presumed to have COVID-19 along with respiratory or gastrointestinal symptoms, those agencies should refer to the Interim Guidance for Public Health Personnel Evaluating Persons under Investigation (PUIs) and Asymptomatic Close Contacts of Confirmed Cases at Their Home or Non-Home Residential Settings.

Transfer of Patients

Although COVID-19 patients with mild symptoms may be managed at home, the decision to remain in the home should take into account the patient’s ability to adhere to isolation recommendations along with the potential risk of secondary transmission to household members with immunocompromising conditions. Hospitalization is not required if CDC home care monitoring guidelines can be followed and the patient does not require a higher level of care. If a hospital transfer becomes necessary, the recipient hospital and emergency medical services should be given all necessary medical information and instructed to wear proper PPE during the transfer.

Key Takeaways: Home health providers should wear a face mask prior to entering the home of a patient with COVID-19 symptoms, practice respiratory precautions when providing care, and remove the face mask only after exiting the home. Patients with COVID-19 generally should remain at home until symptoms abate unless a higher level of care is needed. In such case, personnel transporting or receiving the patient should be notified about the importance of wearing appropriate PPE.

Dialysis Facilities

The March 10, 2020, dialysis facility QSO memo focuses on several practices to limit the transmission of COVID-19 in dialysis facility settings through screening patients and staff, isolating patients with suspected or confirmed COVID-19 infections, and transferring patients to alternative dialysis locations.

Identifying Risk of COVID-19 in Patients and Staff

Dialysis facilities are encouraged to screen patients, staff and visitors for COVID-19 symptoms using the four criteria listed previously. Patients who present with signs and symptoms of respiratory infections should be identified prior to entering the dialysis treatment area and should be required to wear a face mask at check-in and until they leave the facility. Dialysis facilities are also encouraged to post signage at the facility entrance instructing patients to notify staff if they have a fever or respiratory infection symptoms so that appropriate precautions may be exercised. Staff who demonstrate signs and symptoms of respiratory infection should not report to work, or if symptoms arise at work, they should immediately stop working, don a face mask, self-quarantine at home, and inform the dialysis facility administrator of any patients or staff with whom they came into contact.

Caring for Patients with COVID-19 Symptoms

CMS recognizes that patients will continue to need dialysis treatment during the symptomatic stage of a COVID-19 infection, so dialysis facilities are encouraged to provide masks to symptomatic patients and to have space in waiting areas to segregate ill patients from other patients by at least six feet. If possible, dialysis treatment of symptomatic patients should occur in a separate room with the door closed or otherwise away from the main flow of traffic, and at least six feet from other patient stations. Facilities should continue to follow infection control requirements, including hand hygiene, PPE, isolation, routine cleaning and disinfection procedures.

For patients who receive at-home dialysis treatments, CMS emphasizes that monthly monitoring in onsite locations should continue in accordance with these precautions.

Transferring Patients to Alternative Sites

Dialysis facilities should consider transferring patients to another treatment site if the facility cannot fully implement the recommended precautions or if the patient requires care that the facility is unable to provide. Transport personnel and the receiving facility should be notified in advance of the patient’s healthcare needs, and the patient should wear a face mask and remain separated from other patients while awaiting transfer.

Key Takeaways: Dialysis services remain necessary for patients infected with COVID-19 or demonstrating signs and symptoms of respiratory infections. Dialysis facilities should provide masks and segregate symptomatic patients by at least six feet if a private room or separate wing is not available.

Conclusion

CMS has provided helpful advice to healthcare providers in non-hospital settings regarding COVID-19-related infection control practices. Limiting, restricting and discouraging visitors in accordance with facilities’ policies and procedures will go a long way toward reducing otherwise avoidable transmissions while allowing caregivers to focus on patients’ individualized needs.

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