For hospice agencies and their staff serving nursing home residents receiving hospice care, CMS nursing home visitation guidance has been unevenly applied across the country leading to service disruption and patients not getting care they need. In February 2022, CMS updated the nursing home visitation FAQs based on guidance issued in November 2021. These updates do not change CMS’ initial March 2020 guidance which clearly outlined healthcare workers and other providers of services must be permitted entry into facilities. To help support hospice and nursing home members to serve residents end-of-life and compassionate care needs, this article provides an overview of the most up to date CMS guidance. 

If you are a provider of hospice services and have been experiencing difficulties accessing residents in long-term care settings, please reach out to Katy Barnett, Director, Home Care and Hospice Operations and Policy at kbarnett@leadingage.org.

Hospice Staff Expectations for Nursing Home Entrance

According to CMS guidance, “All healthcare workers must be permitted to come into the facility as long as they are not subject to a ‘work exclusion’ or showing signs or symptoms of COVID-19.” CMS considers everyone providing any type of service, including hospice volunteers, as “staff” subject to following the core principles of COVID-19 infection prevention.

The guidance is also clear that workers who are under “Work exclusion” or restrictions due to COVID-19 infection or COVID-19 exposure may not enter facilities. For this, CMS asks providers to follow the CDC recommendations for work exclusions.

An expectation of entrance to nursing homes for hospice staff is that they continue to comply with infection prevention principles including hand hygiene (use of alcohol-based hand rube is preferred), properly using face covering/masking, physical distancing at least six feet between people, complying with all posted facility instructions, and appropriate use of Personal Protective Equipment.

The updated guidance also references the recently released interim final rule on mandatory vaccinations for facility staff. This vaccination mandate applies to all staff in CMS-certified settings which includes hospice staff. That means any hospice staff entering a facility will need to comply with the mandate on vaccination unless otherwise exempted. Vaccine Mandates: Information, Tools and Resources.

Additional End-of-Life and Compassionate Care Visitation Guidance

End-of-life and the compassionate care that comes along with hospice enrollment also includes support of families. For hospice agencies helping to support and facilitate family member and community visitations, the following is additional guidance updated in November 2021 on nursing home visitation regarding compassionate care and end-of-life.

Throughout the Public Health Emergency, CMS has supported exceptions to visitation restrictions (i.e. those restrictions applying to non-healthcare workers and providers like family and community members) in compassionate care situations, such as an end-of-life situation.

Previously, during the Public Health Emergency, CMS was limiting all residents to visitation only in compassionate care circumstances for clinical or safety reasons. According to the updated CMS guidance, compassionate care visits are now “allowed at all times.” CMS expects scenarios where visitation would be limited to only compassionate care due to a resident being severely immunocompromised to be rare events.

For unvaccinated residents, they may choose to have physical touch based on their preference and needs with visitors participating in certain religious practices, including in end-of-life situations. The unvaccinated resident (or their representative) and their visitor will be advised of the risks of physical contact prior to the visit by the facility. Hospice staff should reiterate these risks to family members of the resident as well and ensure their staff is consistently maintaining infection prevention principles.

State-Based Guidance

Hospice providers should always review their state’s guidance on nursing home visitations as they are supporting families with end-of-life and compassionate care scenarios. Due to each state’s individual infection rates and regulations, state healthcare officials may determine additional visitation restrictions are necessary to protect residents.