Nursing Home Visitation
Frequently Asked Questions (FAQs)
CMS is providing clarification to recent guidance for visitation (see CMS memorandum QSO-20-39- NH REVISED 11/12/2021). While CMS cannot address every aspect of visitation that may occur, we provide additional details about certain scenarios below. However, the bottom line is visitation must be permitted at all times with very limited and rare exceptions, in accordance with residents’ rights. In short, nursing homes should enable visitation following these three key points:
• Adhere to the core principles of infection prevention, especially wearing a mask, performing hand hygiene, and practicing physical distancing;
• Don’t have large gatherings where physical distancing cannot be maintained; and
• Work with your state or local health department when an outbreak occurs.
States may instruct nursing homes to take additional measures to make visitation safer, while ensuring visitation can still occur. This includes requiring that, during visits, residents and visitors wear masks that are well-fitting, and preferably those with better protection, such as surgical masks or KN95. States should work with CMS on specific actions related to additional measures they are considering.
- What is the best way for residents, visitors, and staff to protect themselves from the Omicron variant?
A: The most effective tool to protect anyone from the COVID-19 Omicron variant (or any version of COVID-19) is to be up-to-date with all recommended COVID-19 vaccine doses. Also, we urge all residents, staff, and visitors to follow the guidelines for preventing COVID-19 from spreading, including wearing a well-fitting mask (preferably those with better protection, such as surgical masks or KN95) at all times while in a nursing home, practicing physical distancing, and performing hand hygiene by using an alcohol-based hand rub or soap and water. Residents do not have to wear a mask while eating or drinking, or in their rooms alone or with their roommate.
- How should nursing homes address visitation when they expect a high volume of visitors, such as over the holidays?
A: In general, visitation should be allowed for all residents at all times. However, as stated in CMS memorandum QSO-20-39-NH REVISED 11/12/2021, “facilities should ensure that physical distancing can still be maintained during peak times of visitation,” and “facilities should avoid large gatherings (e.g., parties, events).” This means that facilities, residents, and visitors should refrain from having large gatherings where physical distancing cannot be maintained in the facility. In other words, if physical distancing between other residents cannot be maintained, the facility may restructure the visitation policy, such as asking visitors to schedule their visit at staggered time-slots throughout the day, and/or limiting the number of visitors in the facility or a resident’s room at any time. Note: While these may be strategies used during the holidays or when a high volume of visitors is expected (especially in light of the uncertain impact of the Omicron variant in facilities), we expect these strategies to only be used when physical distancing cannot be maintained. Also, there is no limit on length of visits, in general, as long as physical distancing can be maintained and the visit poses no risk to or infringes upon other residents’ rights. If physical distancing cannot be maintained or infringes on the rights and safety of others, the facility must demonstrate that good faith efforts were made to facilitate visitation.
- Can residents have close contact with their visitor(s) during a visit and visit without a mask?
A: Visitors, regardless of vaccination status, must wear masks and physically distance themselves from other residents and staff when in a communal area in the facility. Separately, while we strongly recommend that visitors wear masks when visiting residents in a private setting, such as a resident’s room when the roommate isn’t present, they may choose not to. Also, while not recommended, if a resident (or responsible party) is aware of the risks of close contact and/or not wearing a mask during a visit, and they choose to not wear a mask and choose to engage in close contact, the facility cannot deny the resident their right to choose, as long as the residents’ choice does not put other residents at risk. This would occur only while not in a communal area. Prior to visiting, visitors should also be made aware of the risks of engaging in close contact with the resident and not wearing a mask during their visit. For additional information see the CDC website Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes.
- Can visits occur in a resident’s room if they have a roommate?
A: Yes. Ideally an in-room visit would be conducted when the roommate is not present, however if that is not an option and as long as physical distancing can be maintained, then a visit may be conducted in the resident’s room with their roommate present. If physical distancing cannot be maintained, the visit should occur in a different area of the facility, or the visit should occur at a time when the roommate is not in the room, or the visitors should be asked to limit the number of visitors that are in the room at one time. Also, visitors and residents should adhere to the principles of infection control, including wearing a mask and performing frequent hand hygiene.
- Can a visitor share a meal with or feed the resident they are visiting?
A: Visitors may eat with a resident if the resident (or representative) and the visitor are aware of the risks and adhere to the core principles of infection prevention. Eating in a separate area is preferred, however if that is not possible, then the meal could occur in a common area as long as the visitor, regardless of their vaccination status, is physically distanced from other residents and wears a mask, except while eating or drinking. If the visitor is unable to physically distance from other residents, they should not share a meal with the resident in a common area. Visitors, regardless of vaccination status, must wear masks and physically distance from other residents and staff when in a communal area in the facility.
- How should nursing homes work with their state or local health department when there is a COVID-19 outbreak?
A: Prior to the COVID-19 Public Health Emergency (PHE), there were occasions when a local or state health department advised a nursing home to pause visitation and new admissions due to a large outbreak of an infectious disease. Consultation with state health departments on how to address outbreaks should still occur. In fact, we remind nursing homes that they are still expected to contact their health department when any of the following occur, per CDC guidelines:
• ≥ 1 residents or staff with suspected or confirmed SARS-CoV-2 infection
• Resident with severe respiratory infection resulting in hospitalization or death, or
• ≥ 3 residents or staff with acute illness compatible with COVID-19 with onset within a 72-hour period.
While residents have the right to receive visitors at all times and make choices about aspects of their life in the facility that are significant to them, there may be times when the scope and severity of an outbreak warrants the health department to intervene with the facility’s operations. We expect these situations to be extremely rare and only occur after the facility has been working with the health department to manage and prevent escalation of the outbreak. We also expect that if the outbreak is severe enough to warrant pausing visitation, it would also warrant a pause on accepting new admissions (as long as there is adequate alternative access to care for hospital discharges). For example, in a nursing homes where, despite collaborating with the health department over several days, there continues to be uncontrolled transmission impacting a large number of residents (e.g., more than 30% of residents became infected*), and the health department advised the facility to pause visitation and new admissions temporarily. In this situation, the nursing home would not be out of compliance with CMS’ requirements.
*CMS does not define a specific threshold for what constitutes a large outbreak and this could vary based on facility size or structure. However, we emphasize that any visitation limits should be rare and applied when there are many cases in multiple areas of the facility.
Nursing facilities should continue to consult with state and local health departments when outbreaks occur to determine when modifications to visitation policy would be appropriate. Facilities should document their discussions with the health department, and the actions they took to attempt to control the transmission of COVID-19.
- Should the facility pause communal activities and dining during an outbreak investigation?
A: If the facility is using a contact tracing approach for an outbreak investigation, those residents who are identified as potentially being a close contact of the individual who tested positive for COVID-19, are considered to have had close contact and should not participate in communal dining or activities. Residents who are not up-to-date with all recommended COVID-19 vaccine doses and have had close contact with someone with COVID-19 infection should be placed in quarantine, even if viral testing is negative. In general, residents who are up-to-date with all recommended COVID-19 vaccine doses and residents who had COVID-19 in the last 90 days do not need to be quarantined or restricted to their room and should wear masks when leaving their room.
When using a broad-based approach for an outbreak investigation, residents who are not up-to-date with all recommended COVID-19 vaccine doses should generally be restricted to their rooms, even if testing is negative, and should not participate in communal dining or group activities until they have met the criteria for discontinuing transmission-based precautions (quarantine). In general, residents who are up-to-date with all recommended COVID-19 vaccine doses and residents who had COVID-19 in the last 90 days do not need to be restricted to their rooms unless they develop symptoms of COVID-19, are diagnosed with COVID-19 infection, or the facility is directed to do so by the jurisdiction’s public health authority.
- Is a resident (not on transmission-based precautions or quarantine) who is unable or unwilling to wear a mask allowed to attend communal dining and activities?
A: A resident who is unable to wear a mask due to a disability or medical condition may attend communal activities, however they should physically distance from others. If possible, facilities should educate the resident on the core principles of infection prevention, such as hand hygiene, physical distancing, cough etiquette, etc. and staff should provide frequent reminders to adhere to infection prevention principles.
A resident who is unable to wear a mask and whom staff cannot prevent having close contact with others should not attend communal activities. To help residents prevent having close contact, such as in the case of a memory care unit, the staff should limit the size of group activities. They should also encourage frequent hand hygiene, assist with maintaining physical distancing as much as possible, and frequently cleaning high-touch surfaces.
If a resident refuses to wear a mask and physically distance from others, the facility should educate the resident on the importance of masking and physical distancing, document the education in the resident’s medical record, and the resident should not participate in communal activities.
- How can a long-term care provider coordinate an onsite clinic to provide COVID-19 vaccine and boosters for staff and residents?
A: Many LTC providers have already identified strategies and partnerships to obtain and administer COVID-19 vaccines for residents and staff, including: working with established LTC partners and retail pharmacy partners or coordinating with state and local health departments. You may request vaccination support from a pharmacy partner enrolled in the Federal Retail Pharmacy Program. See Connecting Long-Term Care Settings with Federal Pharmacy Partners for links and contact information. If you are having difficulties arranging COVID-19 vaccination for your residents and staff, contact your state or local health department’s immunization program for assistance. If the state or jurisdictional immunization program is unable to connect your LTC setting with a vaccine provider, CDC is available as a safety net support (Contact CDC INFO at 800-232-4636 for additional support).
- With COVID-19 cases spiking due to the Omicron variant, should facilities continue to permit visitation?
A: Yes. While CMS is concerned about the rise of COVID-19 cases due to the Omicron variant, we’re also concerned about the effects of isolation and separation of residents from their loved ones. Earlier in the pandemic we issued guidance for certain limits to visitation, but we’ve learned a few key things since then. Isolation and limited visitation can be traumatic for residents, resulting in physical and psychosocial decline. So, we know it can lead to worse outcomes for people in nursing homes. Furthermore, we know visitation can occur in a manner that doesn’t place other residents at increased risk for COVID-19 by adhering to the practices for infection prevention, such as physical distancing, masking, and frequent hand hygiene. There are also a variety of ways that visitation can be structured to reduce the risk of COVID-19 spreading. So, CMS believes it is critical for residents to receive visits from their friends, family, and loved ones in a manner that does not impose on the rights of another resident. Lastly, as indicated above, facilities should consult with their state or local public health officials, and questions about visitation should be addressed on a case by case basis.
- Why can a resident choose to have a visit even when COVID-19 cases are increasing?
A: It is important to note that federal regulations explicitly state that residents have the right to make choices about significant aspects of their life in the facility and the right to receive visitors, as long as it doesn’t infringe on the rights of other residents (42 CFR 483.10(f)(2) and (4), respectively). In this case, as long as a visit doesn’t increase the risk of COVID-19 for other residents (i.e., by using the guidance for conducting safe visits), the resident still has the right to choose to have a visitor. Therefore, if the resident is aware of the risks of the visit, and the visit is conducted in a manner that doesn’t increase the risk of COVID-19 transmission for other residents, the visit must still be permitted in accordance with the requirements.
- Are there any suggestions for how to conduct visits that reduce the risk of COVID-19 transmission? For example, should facilities have different policies for visitors, who are up-to-date with all recommended COVID-19 vaccine doses and those who are not up-to-date with all recommended COVID-19 vaccine doses?
A: While we strongly encourage everyone to be up-to-date with all recommended COVID-19 vaccine doses, the facility must permit visitation regardless of the visitor’s vaccination status (if the visitor(s) has not had a positive viral test, does not report COVID-19 symptoms or meet the criteria for quarantine). There are ways facilities can and should take extra precautions, such as hosting the visit outdoors, if possible; creating dedicated visitation space indoors; permitting in- room visits when the resident’s roommate is not present; and the resident and visitor should wear a well-fitting mask (preferably those with better protection, such as surgical masks or KN95), perform frequent hand-hygiene, and practice physical distancing. Some other recommendations include:
• Offering visitors surgical masks or KN95 masks.
• Restricting the visitor’s movement in the facility to only the location of the visit.
• Not conducting visits in common areas (except those areas dedicated for visitation).
• Increasing air-flow and improving ventilation and air quality.
• Cleaning and sanitizing the visitation area after each visit.
• Providing reminders in common areas (e.g., signage) to maintain physical distancing, perform hand-hygiene, and wear well-fitting masks.
- Are there best practices for improving air quality to reduce risks during visitation?
A: Yes, a facility may consider a number of options related to air quality such as:
• Adding ultraviolet germicidal irradiation (UVGI) to the heating ventilation and air conditioning system (HVAC).
• To avoid having multiple groups of people or multiple visitors for a resident within small rooms or spaces, designate special visitation areas that are outdoors when practical or in designated large-volume spaces with open windows and/or enhanced ventilation.
• Adding portable room air cleaners with high-efficiency particulate air (HEPA, H-13 or -14) filters to communal areas.
• Ensure proper maintenance of HVAC system to ensure maximum outdoor air intake.
For additional information on air cleaning, disinfecting, and UVGI, see CDC’s Ventilation FAQs or the American Society of Heating, Refrigerating and Air-Conditioning Engineers site on Filtration and Disinfection.
- What are ways a facility can improve and or manage air flow during visitation?
A: A facility may consider implementing the following:
• The use of a portable fan placed close to an open window could enable ventilation. A portable fan facing towards the window (i.e. facing outside) serves to pull the room and exhaust air to the outside; a fan facing towards the interior of the room (i.e. facing inside) serves to pull in the outdoor air and push it inside the room. Direct the fan discharge towards an unoccupied corner and wall spaces or up above the occupied zone.
• Activate resident restroom exhaust fans whenever visitors are present.
• Consider opening windows, even slightly, if practical and will not introduce other hazards.
• The use of ceiling fans at low velocity and potentially in the reverse-flow direction (so that air is pulled up toward the ceiling), especially when windows are closed.
• Avoid the use of the high-speed settings for any fan.
For additional information on improving air quality, optimizing air flow and use of barriers, see the Centers for Disease Control and Prevention (CDC) site on Ventilation in Buildings.
- Is there funding available for environmental changes which reduce transmission of COVID-19?
A: Yes, a facility may request the use of Civil Money Penalty (CMP) Reinvestment funds to purchase portable fans and portable room air cleaners with HEPA filters to increase or improve air quality. A maximum use of $3,000 per facility including shipping costs may be requested.
- Can a state require facilities to test visitors as a condition of entering the facility?
A: States can require visitors to be tested prior to entry if the facility is able to provide a rapid antigen test (i.e., the visitor is not responsible for obtaining a test). If the facility cannot provide the rapid antigen test, then the visit must occur without a test being performed if the visitor(s) has not had a positive viral test, does not report COVID-19 symptoms or meet the criteria for quarantine.