On March 10, Centers for Medicare & Medicaid Services (CMS) released updated nursing home visitation guidance. This update is a revision to the guidance released in September 2020 and provides even more flexibility thanks to vaccination of residents and nursing home staff. These changes are effective immediately and are consistent with updated guidance for healthcare settings released concurrently from Centers for Disease Control & Prevention (CDC).

Outdoor Visitation

Outdoor visitation is still the preferred method of visitation, regardless of the vaccination status of residents or visitors. As before, outdoor visitation may generally continue regardless of the nursing home’s outbreak status or county positivity rate. Residents on transmission-based precautions, either due to suspected or confirmed infection or due to quarantine, are still restricted from visitation regardless of vaccination status until transmission-based precautions have been discontinued.

Indoor Visitation

Indoor visitation has been revised significantly. The new guidance has adjusted restrictions related to county positivity rates and outbreak status, as outlined below. As noted above, residents on transmission-based precautions are still restricted from visitation regardless of vaccination status until transmission-based precautions have been discontinued.

Indoor Visitation – County Positivity Rate. Indoor visitation may now take place regardless of the county positivity rate, with one exception: residents who are not fully vaccinated are restricted from indoor visitation if the county positivity rate is greater than 10% and fewer than 70% of the nursing home’s total resident population has been vaccinated. If the county positivity rate is less than 10% or if more than 70% of the nursing home’s total resident population has been vaccinated, unvaccinated residents may enjoy indoor visitation. Fully vaccinated residents may enjoy indoor visitation regardless of county positivity rate and the vaccination rate of the total nursing home resident population.

Indoor Visitation – Outbreak. Indoor visitation may now occur during an outbreak according to the following processes and parameters:

• If one positive case has been identified among staff or one nursing home-onset case among residents (outbreak), indoor visitation is immediately suspended and the nursing home must initiate outbreak testing protocols.
• After one round of outbreak testing of all staff and residents, if the outbreak is found to be contained to a single area, such as a single unit, indoor visitation may resume in the unaffected areas / units. Outbreak testing will continue according to previously-outlined requirements.
• If the first round of testing or any subsequent outbreak testing indicate that the outbreak is not contained to a single area or unit, indoor visitation is restricted for all residents regardless of vaccination status until criteria have been met to discontinue outbreak testing. That is, all residents and staff test negative and 14 days have passed since the last positive test result.

Additional Flexibilities and Considerations

Nursing homes should continue to screen all visitors prior to entry. Visitors who have had close contact with someone with COVID-19 infection in the past 14 days should be restricted regardless of the visitor’s vaccination status. Visitors should also continue to adhere to core principles of COVID-19 infection prevention including wearing a mask throughout the visit and practicing effective hand hygiene. Visitors should be notified of the risk for exposure during visitation, including appropriate signage regarding current outbreaks.

Fully vaccinated residents may choose to have physical contact with their visitors provided they are wearing a well-fitting mask and hand hygiene is performed before and after physical contact. Visitors must continue to maintain social distancing from all other residents and staff during the visit.

CMS permits testing of visitors or inquiries about vaccination status; however, nursing homes may not require proof of testing or vaccination as a condition of visitation. Similarly, CMS does not require vaccination of surveyors and nursing homes must permit entry of the surveyor regardless of vaccination status.

It is essential to note that testing requirements do not change. Nursing homes must continue to test all residents and staff regardless of vaccination status in response to signs or symptoms of COVID-19 and in response to an outbreak. Nursing homes must continue to test all staff routinely based on county positivity rates regardless of vaccination status.

Additionally, we note that the CDC guidance referenced above encourages unvaccinated residents to delay indoor visitation until they have been fully vaccinated. CDC additionally recommends that both residents and visitors are counseled on risks prior to beginning indoor visitation.