AFL 20-22.5 From the California Department of Public Health
October 23, 2020
TO: Long-Term Care Facilities
SUBJECT: Guidance for Limiting the Transmission of COVID-19 in Long-Term Care Facilities (This AFL supersedes guidance provided in AFL 20-22.4)
All Facilities Letter (AFL) Summary
- This AFL notifies long-term care (LTC) facilities of the Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) guidance for improving their infection control and prevention practices to prevent the transmission of COVID-19, including guidance for visitation.
- This AFL authorizes LTC facilities to temporarily modify their facility’s visitation policies in accordance with CMS and CDC COVID-19 guidance when necessary to protect the health and safety of residents, staff, and the public.
- AFL 20-22.5 updates the California Department of Public Health’s (CDPH’s) visitation guidance to align with CMS QSO-20-39-NH (PDF), including:
- Required visitation; failure to facilitate visitation without adequate reason related to clinical necessity or resident safety may constitute violation of Title 42 Code of Federal Regulations (CFR) section 483.10(f)(4) and subject to citation and enforcement actions
- Updates previously issued indoor and outdoor visitation guidelines
- Allows visitation for residents in the green zone in a facility with an ongoing COVID-19 outbreak that has not yet achieved two sequential negative rounds of response testing over 14 days
- Exceptions to visitation restrictions, which include representatives of protection and advocacy (P&A) programs, individuals authorized by federal disability rights laws, and compassionate care visits
- Use of civil money penalty (CMP) funds to help facilitate visitation
- COVID-19 infection prevention core principles and best practices
On March 11, 2020, CDPH issued AFL 20-22, authorizing LTC facilities to temporarily modify their visitation policies in accordance with CMS and CDC COVID-19 guidance when necessary to protect the health and safety of residents, staff, and the public. On June 26, 2020, CDPH issued AFL 20-22.3, providing guidelines for resuming visitation and exceptions to visitation restrictions. In addition, AFL 20-22.4 revised the visitation exceptions to allow the LTC ombudsman to enter regardless of whether or not there is a COVID-19 outbreak.
On September 17, 2020, CMS issued QSO-20-39-NH (PDF), which supersedes and replaces all previously issued CMS guidance and recommendations regarding nursing home visitation. This AFL updates CDPH’s visitation guidance to align with QSO-20-39-NH (PDF).
General Visitation Guidance
Facilities shall conduct visitation through different means based on the facility’s structure and residents’ needs for circumstances beyond compassionate care situations, such as in resident rooms, dedicated visitation spaces, and outdoors; however, facilities must adhere to the core principles of COVID-19 infection prevention (PDF) at all times. Visitation must be person-centered, consider the residents’ physical, mental, and psychosocial well-being, and support their quality of life. LTC facilities must also enable visits to be conducted with an adequate degree of privacy.
Visitors who are unable to adhere to the core principles of COVID-19 infection prevention should not be permitted to visit or should be asked to leave.
Continuing Outdoor and Communal Space Visitation Requirement
All facilities must continue to allow outdoor and communal space visitation options.
Outdoor visits pose a lower risk of transmission due to increased space and airflow; therefore, outdoor visitation is preferred and should be held whenever practicable. Facilities should allow scheduled visits on the facility premises where there is 6-feet or more physical distancing, and both residents and visitors wear facial coverings with staff monitoring infection control guidelines (e.g., drive-by visits, or visit through a person’s window).
Visitation in Large Communal Indoor Spaces that Allow for Physical Distancing
If outdoor visitation is not possible (e.g., inclement weather, poor air quality, resident inability to be moved outside, etc.), facilities shall accommodate visitation in large communal indoor spaces such as a lobby, cafeteria, activity room, physical therapy rooms, etc. where six-foot distancing is possible. Facilities may need to rearrange these spaces or add barriers to separate the space to accommodate the need for visitation of multiple residents.
Other Visitation Options in Addition to Outdoor and Communal Spaces
In addition, to maximize visitation opportunities and keep residents and families connected, facilities are encouraged to:
- Offer alternative means of communication for people who would otherwise visit, such as virtual communications (phone, video-communication, etc.).
- Assign staff as primary contact to families for inbound calls and conduct regular outbound calls to keep families up to date.
- Offer 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.
- Create/increase listserv communication to update families, such as the status and impact of COVID-19 in the facility.
Indoor In-Room Visitation Requirement for Facilities Meeting Specific Criteria
Facilities that meet the following conditions shall allow residents indoor facility visitation:
- The county is in Tier 2 (Red), 3 (Orange), or 4 (Yellow) under Blueprint for a Safer Economy.
- Case status in the facility: Absence of any new COVID-19 cases in the facility for 14 days, among either residents or staff.
- Facilities that had a COVID-19 outbreak and have achieved two sequential negative rounds of response testing over 14 days among residents should allow indoor in-room visitation, as long as the other conditions are met, while resuming regular screening testing of healthcare personnel (HCP) and targeted response testing of potentially exposed residents as described in AFL 20-53.3 . Visits for residents who share a room should preferably be conducted in a separate indoor space or with the roommate not present in the room (if possible).
- For facilities located in counties with substantial or lower levels of community transmission (“red tier” or less restrictive tier as per CDPH’s Blueprint for a Safer Economy website) with an ongoing COVID-19 outbreak may allow “green” zone residents indoor in-room visitation even if they have not yet achieved two sequential negative rounds of response testing over 14 days. This visitation is permitted for residents in “green” (unexposed or recovered) areas (wings or buildings) with staffing that do not overlap the “red” or “yellow” status areas.
- Adequate staffing: No staffing shortages
- Access to adequate testing: The facility has a testing plan in place in compliance with AFL 20-53.3 and Title 42 CFR 483.80(h).
- An approved COVID-19 Mitigation Plan: The facility must maintain regulatory compliance with CDPH guidance for safety.
Safety Procedures for All Indoor Visitation (Communal Spaces and In-Room Visitation)
Facilities should accommodate indoor visitation in communal spaces or in-room based on the following guidelines:
- Visitors should be able to adhere to the core principles and staff should provide monitoring for those who may have difficulty adhering to core principles, such as children.
- Facilities should limit the number of visitors per resident at one time and limit the total number of visitors in the facility at one time (based on the size of the building and physical space). Facilities should consider scheduling visits for a specified length of time to help ensure all residents are able to receive visitors and should consider encouraging shorter indoor visits and longer outdoor visits.
- Facilities should limit movement in the facility. For example, visitors should not walk around different halls of the facility. Rather, visitors should go directly to and from the resident’s room or designated visitation area. Visits for residents who share a room should preferably be conducted in a separate indoor space or with the roommate not present in the room (if possible).
Any visitor entering the facility must be screened for fever and COVID-19 symptoms, wear appropriate facial covering, and perform hand hygiene when in the facility. If PPE is required for contact with the resident, it must be donned and doffed according to instruction by HCP. If a visitor has COVID-19 symptoms or has been in close contact with a confirmed positive case, they must reschedule their visit.
Per CMS QSO 20-39-NH (PDF), if a facility has had no COVID-19 cases in the last 14 days and its county positivity rate is low or medium, a nursing home must facilitate in-person visitation consistent with the regulations. Except for ongoing use of virtual visits, facilities may still restrict visitation due to the COVID-19 county positivity rate, facility’s COVID-19 status, resident’s COVID-19 status, visitor symptoms, lack of adherence to proper infection control practices, or other relevant factors related to the COVID-19 pandemic; however, facilities may not restrict visitation without a reasonable clinical or safety cause, consistent with resident rights in Title 42 CFR section 483.10(f)(4)(v).
Failure to facilitate visitation, without adequate reason related to clinical necessity or resident safety, would constitute a potential violation of Title 42 CFR 483.10(f)(4), and the facility would be subject to citation and enforcement actions.
Exception to Visitation Restrictions
The following are exceptions to a facility’s visitation restrictions:
- Healthcare workers: Facilities should follow CDC guidelines for limiting access to the facility 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. For purposes of this AFL, health care workers includes employees, consultants, contractors, volunteers, and caregivers who provide care and services to residents on behalf of the facility, and students in the facility’s nurse aide training programs or from affiliated academic institutions.
- Surveyors: CMS constantly evaluates surveyors and CDPH requires testing of their surveyors consistent with same schedule as staff members of the facilities they visit to ensure they do not pose a transmission risk when entering the facility.
- Ombudsman: Facilities must permit ombudsman in the facility. Ombudsman are required to be asymptomatic and CDPH recommends that ombudsman be tested consistent with same schedule as staff members of the facilities they visit to ensure they do not pose a transmission risk when entering the facility.
- 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. Students entering the facility routinely must participate in the facility wide screening testing.
- Compassionate care visitation: For permitted visitors, visits should be conducted using social distancing; however, if the facility and visitor identify a way to allow for personal contact during compassionate care visitation, visitors must be screened for COVID-19 symptoms, be routinely tested for COVID-19 at least weekly, wear a surgical facemask while in the building, restrict their visit to the resident’s room or other location designated by the facility, and be reminded by the facility to frequently perform hand hygiene. Compassionate care visitation includes, but is not limited to:
- End-of-life situations
- A resident, who was living with their family before recently being admitted to a nursing home, is struggling with the change in environment and lack of physical family support
- A resident who is grieving after a friend or family member recently passed away
- A resident who needs cueing and encouragement with eating or drinking, previously provided by family and/or caregiver(s), is experiencing weight loss or dehydration
- A resident, who used to talk and interact with others, is experiencing emotional distress, seldom speaking, or crying more frequently (when the resident had rarely cried in the past)
- Legal matters: Visitors must be permitted for legal matters that cannot be postponed including, but not limited to, voting, estate planning, advance health care directives, Power of Attorney, and transfer of property title if these tasks cannot be accomplished virtually.
- P&A programs: Any representative of a P&A program must be permitted immediate access to a resident, which includes the opportunity to regularly meet and communicate privately with the resident, both formally and informally, by telephone, mail, and in-person.
- Individuals authorized by federal disability rights laws: Facilities must comply with federal disability rights laws such as Section 504 of the Rehabilitation Act and the Americans with Disabilities Act.
- For example, if a resident requires assistance to ensure effective communication (e.g., qualified interpreter or someone to facilitate communication) and the assistance is not available by onsite staff or effective communication cannot be provided without such entry (e.g., video remote interpreting), the facility must allow the individual entry into the facility to interpret or facilitate, with some exceptions.
- This would not preclude facilities from imposing legitimate safety measures that are necessary for safe operations, such as requiring such individuals to adhere to the core principles of COVID-19 infection prevention.
Use of Civil Money Penalty (CMP) Funds
CDPH encourages facilities apply to use CMP funds to help facilitate visitation, such as purchasing communicative devices (e.g., tablets or webcams), to help residents stay connected with their loved ones. CMS will now approve use of CMP funds to purchase tents for outdoor visitation and/or clear dividers (e.g., Plexiglas or similar products) to create a physical barrier to reduce the risk of transmission during-in person visits. Funding for tents and clear dividers is limited to a maximum of $3000 per facility. This grant opportunity is in addition to the communicative technology CMP grant that was made available previously.
Please see AFL-20-77 for additional information on applying for CMP funds.
Infection Prevention Guidance
Facilities should adhere to the core principles and best practices that reduce the risk of COVID-19 transmission. This includes:
1. For all visitations, facilities should make efforts to allow for safe visitation for residents and loved ones.
- Ensure screening of all who enter the facility for fever and COVID-19 symptoms. Facilities should document the name and contact information of any visitors to assist with contract tracing in needed.
- Visitors and residents must have facial coverings (cloth masks or surgical face masks) as mandated by CDPH’s Guidance for the Use of Face Coverings (PDF)
- Staff should monitor to ensure physical distancing of at least 6 feet from any other individual, with no hand-shaking or hugging,
- If possible (i.e. pending design of building), create dedicated visiting areas near the entrance to the facility where residents can meet with visitors in a sanitized, well-ventilated area. Facilities should disinfect rooms after each resident-visitor meeting.
- The risk of transmission can be further reduced through the use of physical barriers (e.g., clear Plexiglas dividers, curtains)
2. Advise visitors, and any individuals who enter 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 and contact their healthcare provider. Any visitor or other individual who tests positive for COVID-19 within 14 days of their visit must 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 work with their local health department to take all necessary actions based on findings.
3. Ensure residents, visitors, and staff perform hand hygiene (use of alcohol-based hand rub is preferred)
4. Place instructional signage throughout the facility and proper visitor education on COVID-19 signs and symptoms, infection control precautions, other applicable facility practices (e.g., use of face covering or mask, specified entries, exits and routes to designated areas, hand hygiene)
5. 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.
6. Clean and disinfect frequently touched surfaces in the facility often, and designated visitation areas after each visit.
7. All staff must wear a minimum of a surgical mask and face shield when they are interacting with residents. Additional PPE should be used according to the COVID-19 status of the resident and to the extent PPE is available and consistent with CDC guidance on optimization of PPE.
8. Conduct resident and staff testing as required by Title 42 CFR 483.80(h); once baseline testing is complete, implement either screening or response driven testing based on the conditions at the facility in accordance with
9. For facilities in counties with minimal to substantial positivity, consider testing visitors if feasible (although not required). If so, facilities should prioritize visitors that visit regularly (e.g., weekly), although any visitor can be tested. Facilities may also encourage visitors to be tested on their own prior to coming to the facility (e.g., within two to three days) with proof of negative test results and date of test. Facilities and visitors must understand that a negative test prior to or at the time of their visit does not negate the requirement to adhere to core infection prevention principles, including face covering and physical distancing, at all times during their visit.
10. 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.
11. Communal activities and dining may occur while adhering to the core principles of COVID-19 infection prevention:
- Residents who are not on isolation precautions or quarantine may eat in the same room with social distancing (e.g., limited number of people at each table and with at least six feet between each person). Facilities should consider additional limitations based on status of COVID-19 infections in the facility. Facilities should consider defining groups of residents that consistently participate in communal dining together to minimize the number of people exposed if one or more of the residents is later identified as positive. Facial coverings should be worn when going to the dining area and whenever not eating or drinking.
- Group activities may also be facilitated (for residents who have fully recovered from COVID-19, and for those not in isolation or quarantine) with social distancing among residents, appropriate hand hygiene, and use of a face covering.
- Encourage as many of these activities to occur outdoors when feasible, especially when eating or drinking and face coverings will not be worn.
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.
Original signed by Heidi W. Steinecker
Heidi W. Steinecker