AFL 21-14.1 From the California Department of Public Health
August 12, 2021
TO: Intermediate Care Facilities/Developmentally Disabled (ICF/DD)
Intermediate Care Facilities/Developmentally Disabled – Habilitative (ICF/DD-H)
Intermediate Care Facilities/Developmentally Disabled – Nursing (ICF/DD-N)
Intermediate Care Facilities/Developmentally Disabled – Continuous Nursing (ICF/DD-CN)
SUBJECT: Visitation Guidance for ICF/DD-H-N-CN Facilities During the Coronavirus Disease-2019 (COVID-19) Pandemic
(This AFL supersedes AFL 21-14)
All Facilities Letter (AFL) Summary
- This AFL notifies all ICF/DD-H-N-CN 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 all ICF/DD-H-N-CN 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 clients/residents, staff, and the public.
- This AFL provides visitation guidance in accordance with CMS Quality, Safety and Oversight Group (QSO) 21-14 (PDF), including guidance for safely facilitating in-person visitation in indoor and outdoor facility settings.
- This AFL requires ICF/DD-H-N-CN facilities to develop and implement processes for verifying the vaccination status of all visitors, and for obtaining and tracking documentation of SARS-CoV-2 diagnostic test of all visitors who are unvaccinated and incompletely vaccinated to have an indoor visit.
This AFL provides California Department of Public Health’s (CDPH’s) visitation guidance and recommendations for the above-named facilities, to permit in-person visitation while reducing the risk of COVID-19 transmission. These recommendations align with CMS QSO 21-14 (PDF), issued February 10, 2021.
While CMS and CDPH have focused on protecting clients/residents from COVID-19, CDPH acknowledges the adverse impacts of restrictions on visitation, physical contact, and group activities upon clients/residents’ physical, mental, emotional, and psychosocial well-being and quality of life during the ongoing COVID-19 pandemic. Clients/residents living with an intellectual disability and/or a severe mental illness may find visitor restrictions and other ongoing changes related to COVID-19 confusing or upsetting. Additionally, clients/residents may feel socially isolated, leading to increased risk for functional decline, depression, anxiety, and other expressions of distress. CDPH recognizes the importance that visitation and social interaction play in improving resident quality of life.
As transmissible variants of the SARS-CoV-2 virus circulate in California, COVID-19 cases are rising rapidly, and the vast majority of cases are occurring in unvaccinated individuals. Despite the availability of safe and highly effective COVID-19 vaccination, many individuals remain unvaccinated and are at high risk of acquiring COVID-19 and exposing ICF/DD-H-N-CN facilities residents and health care personnel (HCP). In an ongoing effort to ensure resident safety, and to minimize the spread of COVID-19 among vulnerable individuals, CDPH is requiring ICF/DD-H-N-CN facilities to develop and implement processes for verifying the vaccination status of all visitors seeking indoor visitation, and for obtaining and tracking documentation of SARS-CoV-2 diagnostic test of all visitors who are unvaccinated and incompletely vaccinated seeking indoor visitation. Visitors who are unvaccinated or incompletely vaccinated must show documentation of a negative SARS-CoV-2 test that occurred within 72 hours before each indoor visit.
Options for Providing Proof of Vaccination
Per the CDPH Guidance for Vaccine Records Guidelines & Standards, only the following modes may be used as proof of vaccination:
- COVID-19 Vaccination Record Card (issued by the Department of Health and Human Services Centers for Disease Control & Prevention or WHO Yellow Card1) which includes name of person vaccinated, type of vaccine provided, and date last dose administered); OR
- A photo of a Vaccination Record Card as a separate document; OR
- A photo of the client’s Vaccination Record Card stored on a phone or electronic device; OR
- Documentation of COVID-19 vaccination from a healthcare provider; OR
- Digital record that includes a QR code that when scanned by a SMART Health Card reader displays to the reader client name, date of birth, vaccine dates and vaccine type.
Visitors may access their digital vaccination record by using the CDPH Digital COVID-19 Vaccine Record website.
In the absence of knowledge to the contrary, ICF/DD-H-N-CN facilities may accept the documentation presented as valid. Facilities must have a plan in place for tracking verified visitor vaccination status. Documentation of the verification must be kept on file at the facility and made available upon request by CDPH or the local public health department for one year following the end of the public health emergency.
Visitors that are unvaccinated or incompletely vaccinated and are seeking indoor visitation must show documentation of a negative SARS-CoV-2 test where the specimen collection occurred within 72 hours before each visit and for which the test results are available at the time of entry to the facility. Visitors may choose to use antigen or molecular (e.g., PCR) testing to satisfy this requirement. Any molecular or antigen test used must either have Emergency Use Authorization by the U.S. Food and Drug Administration or be operating per the Laboratory Developed Test requirements by the U.S. Centers for Medicare and Medicaid Services. ICF/DD-H-N-CN facilities can offer to conduct onsite testing of visitors if practical per facility testing capacity but are not required to do so.
General Visitation Guidance
Visitation can be conducted through different means based on a facility’s structure and clients/residents’ needs as well as COVID-19 vaccination status. Visitation can be conducted in resident rooms, dedicated visitation spaces, and outdoor areas. Facilities should communicate infection prevention and control (IPC) requirements to visitors.
The following recommendations mitigate the risk of COVID-19 transmission and are consistent with current CDC guidance for congregate settings such as ICF/DD-H-N-CN. These recommendations should be followed except where they prevent a necessary accommodation.
- Screen and triage all visitors, regardless of their vaccination status, upon entry to the facility in accordance with current CDC guidance for signs and symptoms of COVID-19 and/or exposure within the prior 14 days to another person with COVID-19.
- All visitors, regardless of their vaccination status, must wear a well-fitting face mask (medical mask, also called surgical masks or double masking is recommended) upon entry and at all times while in the facility unless eating or drinking and perform hand hygiene.
- Visits should be conducted with an adequate degree of privacy and should be scheduled at times convenient to visitors (e.g., outside of regular work hours).
- All visitors, regardless of their vaccination status, must follow physical distancing guidelines and maintain at least 6 feet distance from other visitors from different households, as well as from facility staff and clients/residents; circumstances when visitors may interact without physically distancing from the client/resident they are visiting are outlined below.
Additionally, for facility/staff:
- Facility staff must, regardless of their vaccination status, wear a face mask for source control and maintain physical distancing from visitors.
- Routinely clean and disinfect frequently touched surfaces in the facility and designated visitation areas after each visit.
- Use physical barriers during visits (e.g., clear Plexiglass/plastic dividers, curtains).
- Post instructional signage throughout the facility on COVID-19 signs and symptoms, IPC precautions, other applicable facility practices (e.g., use of face covering or mask; specified entries, exits, and routes to designated areas; hand hygiene).
When accommodations to meet the specific needs of a resident prevent implementation of a protective measure during visitation, additional levels of protection should be addressed in a person-centered manner such as:
- Touch-based communication may be necessary for clients/residents with combined hearing and vision impairment. Increased use of touch-based communication may necessitate higher levels of hand hygiene, respiratory protection and/or other protections.
- When communicating with individuals who are deaf or hard of hearing, staff and visitors should use a clear mask or cloth mask with a clear panel.
Visitors who are unwilling to adhere to the recommended principles of COVID-19 infection prevention or who have tested positive for COVID-19 should not be permitted to visit in person or should be asked to leave. Under such circumstances, facilities must offer alternatives for remote (skype, etc.) or telephone visitation.
Outdoor visits pose a lower risk of transmission because of increased space and airflow; therefore, outdoor visitation is preferred and should be offered unless the resident cannot leave the facility, or outdoor visitation is not possible due to precipitation, outdoor temperatures, or poor air quality. Facilities should facilitate scheduled visits on the facility premises (e.g., visits on lawns, patios, and other outdoor areas, drive-by visits, or visit through a window) with 6-ft or more physical distancing, use of face coverings by both residents and visitors, and staff monitoring of infection control guidelines.
Outdoor visits between fully vaccinated clients/residents and fully vaccinated visitors may be conducted without face masks and physical distancing and include physical contact (e.g., a brief hug, holding hands); otherwise, visits between residents or visitors that are unvaccinated or incompletely vaccinated should be conducted with appropriate face mask during the visit and should maintain 6-ft physical distancing.
To ensure the protection of visitors and clients/residents, CDPH recommends the following:
- Facilitate routine visitation unless weather considerations (e.g., inclement weather, excessively hot or cold temperatures, poor air quality), an individual’s health status (e.g., medical condition(s) or COVID-19 status) make these options untenable.
- Set the time duration for each visit and have a process to limit the number and size of visits occurring simultaneously to support safe infection prevention practices.
- Consider limiting the number of individuals visiting per resident at the same time based on the size of the outdoor space.
Facilities shall accommodate and support indoor visitation based on the following guidelines:
- Facilities must verify vaccination status or document evidence of a negative test of the visitor within 72 hours of the indoor visit.
- Indoor visits must be conducted with both the resident and visitor wearing a well-fitting face mask. If both the resident and visitor are fully vaccinated, they do not need to physically distance and can include physical contact (e.g., hugs, holding hands) but must wear a well-fitting face mask while in the resident’s room.
- Visitors must be willing to adhere to the recommended principles of infection prevention, including wearing a well-fitting facemask and maintaining physical distancing from other visitors from different households, facility staff and clients/residents, regardless of the visitor’s vaccination status. Staff should provide monitoring for persons who may have difficulty adhering to recommended principles, such as children.
- Facilities should reasonably limit the number of simultaneous visitors per resident and limit the total number of visitors in the facility simultaneously, based on the size of the building and physical space.
- Facilities may consider scheduling visits for a specified length of time to help ensure all clients/residents are able to receive visitors.
- Facilities should limit visitor movement in the facility, regardless of the visitor’s vaccination status; for example, visitors should not walk around the hallways of the facility and should go directly to and from the resident’s room or designated visitation area.
- Visits for residents who share a room should be conducted in a separate indoor space or with the roommate not present in the room (if possible), regardless of the roommate’s vaccination status.
- Where practical based on the size of the facility dedicated bathrooms solely for visitors should be clearly designated and communicated by staff to visitors. Exhaust fans should run continuously.
- When permissible, facilities should “consider ventilation system upgrades or improvements and other steps to increase the delivery of clean air and dilute potential contaminants,” per CDC Guidance on Ventilation.
Visitors who are visiting a client/resident in critical condition, when death may be imminent, are exempt from the vaccination and testing requirements, however, must comply with all infection control and prevention requirements applicable for indoor visits.
NOTE: For situations where there is a roommate and the health status of the resident prevents leaving the room, facilities should attempt to enable in-room visitation while adhering to the recommended principles of COVID-19 infection prevention.
Visitation in 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 communal indoor spaces such dining area, activity room, etc. where 6-ft distancing can be maintained between the visitor and facility staff and other clients/residents they are not visiting. Facilities may need to rearrange these spaces or add barriers to separate the space to accommodate the need for visitation of multiple residents.
During indoor large communal space visits between fully vaccinated residents and fully vaccinated visitors, both the resident and visitor must always wear a well-fitting face mask unless eating or drinking. These visits may be conducted without physical distancing and include physical contact (e.g., hugs, holding hands) while in designated spaces for visitation that maintain 6-ft distancing between the visitor and facility staff and other residents they are not visiting; otherwise, visits between residents or visitors that are unvaccinated or incompletely vaccinated must be conducted with well-fitting face masks during the visit and maintain 6-ft physical distancing.
Other Visitation Options in Addition to Outdoor and Communal Spaces
Clients/residents who are on transmission-based precautions for COVID-19 should only receive visits that are virtual, through windows, or in-person for compassionate care situations, with adherence to transmission-based precautions. However, this restriction should be lifted once transmission-based precautions are no longer required per CDC guidelines.
For clients/residents that are not able to have visitors because of their high-risk medical status, or for clients/residents that test positive for COVID-19 infection, facilities are encouraged to implement one or more of the following options:
- Offering alternative means of communication for people who would otherwise visit, such as virtual communications (phone, video-communication, etc.).
- Creating/increasing listserv communication and website notifications to update families and caregivers, or outside HCPs, such as advising them not to visit when circumstances require.
- Assigning dedicated staff as primary contacts to families and caregivers for inbound calls and conduct regular outbound calls to keep families and caregivers up to date.
- Offering a phone line with a voice recording updated at set times (e.g., daily) with the facility’s general operating status, COVID-19 infection status, and when it will be safe to resume visits.
Communal Activities and Dining
Communal activities and dining may occur in the following manner:
- Fully vaccinated clients/residents who are not in isolation or quarantine may eat in the same room without physical distancing; if any unvaccinated clients/residents are dining in a communal area (e.g., dining room) all clients/residents should use source control when not eating and unvaccinated patients/residents should continue to remain at least 6 feet from others, (e.g., limited number of people at each table and with at least six feet between each person).
- Fully vaccinated clients/residents who are not in isolation or quarantine may participate in group/social activities together without face masks or physical distancing; if any unvaccinated clients/residents are present, then all participants in the group activity should wear face masks for source control and unvaccinated patients/residents should physically distance from others.
When it is not possible to ensure all persons participating in an activity are fully vaccinated (e.g., in break rooms and other common areas where staff or residents may come and go), then all participants should follow all recommended infection prevention and control practices including physical distancing and wearing a face mask for source control. As such, activities where participants do not use source control and physical distancing should be carefully planned in advance and monitored so that vaccination status of all participants can be verified and ensured throughout the activity. Facilities should consider, in consultation with their local health department, reimplementing limitations on communal activities and dining based on the status of COVID-19 infections in the facility, e.g., when one or more cases has been identified in facility staff or clients/residents.
Clients/Residents Who Leave and Return to the Facility
Clients/residents taking social excursions outside the facility should be educated about potential risks of public settings, particularly if they have not been fully vaccinated, and reminded to avoid crowds and poorly ventilated spaces. They should be encouraged and assisted with adherence to all recommended infection prevention and control measures, including source control, physical distancing, and hand hygiene. If they are visiting friends or family in their homes, they should follow the source control and physical distancing recommendations for visiting with others in private settings as described in CDPH and CDC’s Interim Public Health Recommendations for Fully Vaccinated People.
- Clients/residents who have prolonged close contact (within 6 feet for a cumulative total of 15 minutes or more over a 24-hour period) with someone with SARS-CoV-2 infection while outside the facility should quarantine in the yellow-observation area for 14 days and be tested immediately, at 5–7 days after exposure and again prior to return to their usual room in green-unexposed/recovered area, regardless of their vaccination status.
- Fully vaccinated clients/residents who leave for any duration (including hospital admissions) and return to the facility do not routinely need to quarantine and be tested upon return to the facility.
- Unvaccinated and incompletely vaccinated clients/residents who leave the facility for < 24 hours and return to the facility should be tested 5-7 days after their return; unvaccinated and incompletely vaccinated residents who leave the facility for > 24 hours should be quarantined in the yellow-observation area for 14 days and tested prior to return to their usual room in green-unexposed/recovered area.
Compassionate Care Visits
The term “compassionate care situations” does not exclusively refer to end-of-life situations, reference: Nursing Home Visitation-COVID-19 (PDF). Examples of other types of compassionate care situations that are applicable may include, but are not limited to the following:
- A resident, who was living with their family before recently being admitted and is struggling with the change in environment and lack of physical family support.
- A resident who needs cueing and encouragement with daily care needs such as eating, drinking, or hygiene previously provided by family and/or caregiver(s). This may be especially significant for minors.
- A resident, who is used to talking and interacting with others, is experiencing emotional distress, seldom speaking, or crying more frequently.
All facilities must comply with state and federal resident’s rights requirements pertaining to visitation. Facilities should follow CDPH and local public health department guidance when implementing visitation policies. Facilities should promote and may not restrict visitation without a reasonable clinical or safety cause, consistent with Code of Federal Regulations (CFR) requirements at 42 CFR 483.420(a) (PDF) (“Standard: Protection of clients’ rights.”) and 42 CFR 483.420(c) (PDF) (“Standard: Communication with clients, parents, and guardians.”).
Failure to facilitate visitation, without adequate reason related to clinical necessity or resident safety, would constitute a violation of resident’s rights and the facility would be subject to citation and enforcement actions.
Additional Considerations for Pediatric Facilities
- Visitors are essential for the mental health and developmental needs of pediatric residents. Visitation must be permitted for pediatric residents.
- Involve Child Life workers, parents, legal guardians, or authorized representatives in planning the facility visitation program and the most developmentally appropriate visitation program for each resident, including residents who may not have family who can visit. The visitation program shall provide routine and ongoing visitation to meet each resident’s developmental and medical needs.
- Visitors may include parents, legal guardians, or authorized representatives of the pediatric resident and family, regardless of age. Child visitors must be able to observe the required infection control practices, (e.g., source control, hand hygiene, physical distancing) and should be accompanied by an adult visitor.
- Visitors may also include educational instructors, special education aides, and physical, speech or other therapists and service providers who are referenced in a resident’s Individualized Education Plan, Section 504 Plan, Individualized Program Plan, or Community Placement Plan.
- Extended periods of physical contact may be allowed between the pediatric resident and fully vaccinated visitors.
- Encourage COVID-19 vaccination of staff, visitors, and residents who are 16 years or older for Pfizer-Biotech, 18 years or older for Moderna and Johnson & Johnson’s Janssen vaccine.
Exception to Visitation Restrictions
The following are exempt from a facility’s visitation restrictions and may have access to clients/residents.
- 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 include 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 weekly regardless of their vaccination status 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 weekly regardless of their vaccination status 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 physical 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, 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. For a definition of the type of visits that constitute compassionate care visitation please refer to CMS guidance QSO 20-39-NH (PDF).
- Facilities should consider testing compassionate care visitors who have physical contact with COVID-19 positive residents.
- 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 necessary for safe operations, such as requiring such individuals to adhere to the core principles of COVID-19 infection prevention.
- Communication Assistance: If a resident requires assistance to ensure effective communication (e.g., a 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 entry into the facility of a person to interpret or facilitate as stated in Title 42 CFR 483.420(a)(1) and (2) (PDF).
The above-mentioned exemptions from visitation restrictions do not preclude facilities from imposing legitimate safety measures that are necessary for safe operations, such as requiring such individuals to adhere to the recommended principles of COVID-19 prevention. In circumstances where this guidance does not clearly apply, the facility leadership should work with the local health department to develop an individualized plan of action.
CDPH understands the importance of maintaining contact with family and friends to clients/residents. We encourage facilities to monitor the CDC website for information and resources. If you have any questions about this AFL, please contact your local district office.
Original signed by Cassie Dunham
Acting Deputy Director
 People are considered fully vaccinated for COVID-19: two weeks or more after they have received the second dose in a 2-dose series (Pfizer-BioNTech or Moderna or vaccine authorized by the World Health Organization), or two weeks or more after they have received a single-dose vaccine (Johnson and Johnson [J&J]/Janssen ).
 CDC Defines quarantine as separate and restrict the movement of people who were exposed to a contagious disease to see if they become sick. CDC Quarantine and Isolation