Over the past year, visiting restrictions in nursing homes have had a dramatic impact on residents, families, staff and administrators of skilled nursing facilities across our country. As the Centers for Medicare & Medicaid Services (CMS) acknowledged in its September 17, 2020 memorandum, nursing homes “have been severely impacted by Covid-19 with outbreaks resulting in high rates of infection, morbidity and mortality”.
In its latest guidance of 10 March 2021, CMS continued to recognize the negative impact of social isolation and stressed the importance of visitation. However, with the resumption of visitation, skilled nursing facilities, their residents and their families face new challenges and risks.
In the guidelines, CMS has issued revised recommendations for visits to skilled nursing facilities, which provide a detailed process for managing visits. While implementation details are beyond the scope of this article, several things are clear from the guidance:
Compliance with the fundamental principles of preventing Covid-19 infection remains a high priority. Outdoor tours are always preferred. The interior visit is possible “at all times” and “for all residents”, subject to specific exceptions.
Risks to consider before authorizing the resumption of visits
Skilled nursing facility staff have done heroic work over the past year. While the resumption of visits is a positive development, there are potential risks to consider.
First, facility staff must consider not only the prevention of Covid-19 infections, but also falls, runaways and other significant risks associated with the many visits occurring both inside the building and outside on the grounds of the establishment.
Second, the determination of the facility’s ability to provide access to the greatest number of potential visitors should be considered and documented. A designated staff member should be responsible for managing the scale and scope of the visitation program.
Third, adherence to the fundamental principles of infection control requires the cooperation of all stakeholders. Staff must be trained in appropriate intervention techniques when a recalcitrant visitor does not comply with infection prevention methods.
As visits resume, the guidelines make it clear that non-compliant visitors should be barred from visits. CMS’s September 17, 2020 memo gave nursing staff the authority to exclude or remove visitors who are “unable to adhere to the fundamentals of preventing Covid-19 infection”. This should be a big relief for front-line staff dealing with non-compliant visitors.
For example, while vaccinated visitors may assume that they are not required to wear face masks, the assumption is against guidelines and facility staff should be equipped to immediately address potential visitor non-compliance. . While families naturally want unrestricted access to loved ones, communities must ensure adherence to infection prevention methods, even for residents and visitors who are fully immunized.
CMS has made it clear that the visits will be dealt with as part of the inquiry process. Access to visits will be reviewed and facilities are required to offer visits unless there is a valid reason to cease visits related to clinical necessity for resident safety. As such, skilled nursing facilities must adhere to current guidelines while facilitating safe visits to avoid negative survey outcomes.
Visitor certificates are suggested
Although there are many challenges to overcome, documentation and planning will undoubtedly make a difference when it comes to potential future claims. We suggest the use of visitor attestations confirming that the visitor complies with the fundamental principles of infection control.
Certifications must be performed by all visitors before entering and upon leaving the facility. The attestations should identify all elements of infection control and commemorate the visitor’s adherence to them prior to the visit.
Visitors must also complete an informed consent form upon entry, which must include an affirmation that the visitor is aware of the risk of contracting Covid-19 due to their visit to the community and, as noted above, agrees to comply with infection control protocols. The frequency and method for which informed consent forms must be completed by visitors varies by state, but having all visitors complete the forms is a priority. Informed consent forms should be discussed with an attorney and retained in accordance with federal and state regulations.
Finally, skilled nursing facilities should prepare for a hiatus in new visiting protocols. Revised guidelines suggest visits can be halted based on a new positive resident or staff member. Facilities should plan for the disruption and proactively communicate with residents and families regarding the consequences of interrupting visits.
Institutions should also preemptively prepare press releases and correspondence to families if an immediate halt to visits is necessary. Although it has been a long year and the isolation has been painful, even a brief hiatus in visits after a successful reopening would be difficult for everyone involved. As such, preparing in advance for potential disruptions would alert families that visitation disruptions are possible and eliminate future surprises.
This column does not necessarily reflect the opinion of the Bureau of National Affairs, Inc. or its owners.
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Drew Grahama partner at Hall Booth Smith PC in New York, founded the firm’s Long-Term Care Practice Group and advises healthcare providers facing the challenges of the complex and highly regulated specialty.
Danielle Walker is associated with Hall Booth Smith, PC in Saddle Brook, NJ. She focuses her practice on advocating for health systems, physicians and other health care providers on medical malpractice lawsuits and applications for long-term care benefits and services for the elderly.