Nursing Homes Guidelines for COVID-19

The guidelines on infection control and prevention of COVID-19 in nursing homes were released by the Centers for Medicare and Medicaid Services (CMS).

APRIL 2, 2020 -- The guidelines on infection control and prevention of COVID-19 in nursing homes were released by the Centers for Medicare & Medicaid Services (CMS).[1]

Overarching Guidance

Nursing home staff members should regularly monitor the Centers for Disease Control and Prevention (CDC) website for information and resources and should contact their local health department if they have questions or suspect a resident of a nursing home has COVID-19.

Facilities should continue to be vigilant in identifying any possible infected individuals and should consider frequent monitoring for potential symptoms of respiratory infection as needed throughout the day.

Facilities are encouraged to take advantage of resources made available by CDC and CMS for training and preparing staff to improve infection control and prevention practices.

Facilities should maintain a person-centered approach to care, which includes effective communication and an understanding of individual needs and goals of care.

Facilities experiencing an increased number of respiratory illnesses (regardless of suspected etiology) among patients/residents or healthcare personnel should immediately contact their local or state health department.

In addition to the overarching regulations and guidance, CMS provides the following information about some specific areas related to COVID-19.

Guidance for Limiting Transmission of COVID-19 for Nursing Homes

Guidance for all facilities nationwide

Facilities should restrict visitation of all visitors and nonessential healthcare personnel, except for certain compassionate care situations (eg, end of life), and are expected to notify potential visitors to defer visitation until further notice.

Facilities should require individuals who enter in compassionate situations to perform hand hygiene and use personal protective equipment (PPE; eg, face masks).

Visitors with symptoms of a respiratory infection (fever, cough, shortness of breath, or sore throat) should not be allowed entry to the facility at any time, even in end-of-life situations. Visitors who are permitted must wear a face mask in the building and restrict their visit to the resident's room or another designated location; they should also be reminded to perform hand hygiene frequently.

Exceptions to restrictions may be made for the following:

  • Healthcare workers - Facilities should follow CDC guidelines for restricting access to healthcare workers (https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidancerisk-assesment-hcp.html), should contact their local health department for questions, and should frequently review the CDC website (https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html).

  • Surveyors – Surveyors deemed not to pose a transmission risk when entering a facility must be allowed to enter; however, there are circumstances under which surveyors should still not enter (eg, if they have a fever).

Additional guidance

Cancel communal dining and all group activities (both internal and external).

Implement active screening of residents and staff for fever and respiratory symptoms.

Remind residents to practice social distancing and perform frequent hand hygiene.

Screen all staff at the beginning of their shift for fever and respiratory symptoms. If they are ill, have them don a face mask and self-isolate at home.

For individuals allowed in the facility, provide, before entry, instruction on performing hand hygiene, limiting surfaces touched, and using PPE according to current facility policy. Individuals who have fever or other symptoms of COVID-19 or cannot demonstrate proper use of infection control techniques should be restricted from entry.

Identify staff members who work at multiple facilities, and actively screen and restrict them appropriately.

Review and revise facility interactions with vendors and suppliers, agency staff, emergency medical services (EMS) personnel and equipment, transportation providers, and other nonhealthcare providers, and take necessary actions to prevent potential transmission. These visitors may be allowed to enter if necessary, as long as they follow appropriate CDC guidelines for Transmission-Based Precautions.

In lieu of visits, consider the following:

  • Offering alternative means of communication for people who would otherwise visit

  • Creating/increasing listserv communication to update families (eg, advising not to visit)

  • Assigning staff as primary contact to families for inbound calls and conducting regular outbound calls to keep families up to date

  • Offering a phone line with a voice recording updated at set times with the facility's general operating status (eg, when it is safe to resume visits)

When visitation is necessary or allowable, make efforts to allow safe visitation, such as the following:

  • Suggest refraining from physical contact with residents and others while in the facility (social distancing).

  • If possible, create dedicated visiting areas ("clean rooms") near the facility entrance where residents can meet with visitors in a sanitized environment; these areas should be disinfected after each resident-visitor meeting.

  • Residents' access to the ombudsman program should be restricted per the guidance above (except in compassionate care situations); however, facilities may review this on a case-by-case basis. If infection control concerns prevent in-person access, facilities must facilitate resident communication (by phone or other format) with the ombudsman program or any other entity listed in 42 CFR § 483.10(f)(4)(i).

Advise visitors and any other individuals who entered the facility to monitor for signs and symptoms of respiratory infection for at least 14 days after exit. If symptoms occur, advise them to self-isolate at home, contact their healthcare provider, and immediately notify the facility of the date they were in the facility, the individuals they were in contact with, and the locations within the facility they visited. Facilities should immediately screen the individuals of reported contact and take all necessary subsequent actions.

Transfer to or from nursing homes

With regard to transferring a resident with suspected or confirmed COVID-19 infection from a nursing home to a hospital, the following guidance is provided:

  • Symptoms may be mild initially and may not necessitate transfer to a hospital if the facility can follow CDC-recommended infection prevention and control practices.

  • Facilities without an airborne infection isolation room (AIIR) are not required to transfer the resident if he or she does not require a higher level of care and if the facility can adhere to the rest of the infection prevention and control practices recommended for caring for a resident with COVID-19.

  • If the resident develops more severe symptoms and requires transfer to a hospital for higher-level care, EMS and the receiving facility should be alerted to the resident's diagnosis before transfer, and precautions (eg, a face mask on the resident) should be taken during transfer.

  • A resident who does not require hospitalization can be discharged home (in consultation with state or local public health authorities) if appropriate. While awaiting transfer or discharge, the resident should wear a face mask and be isolated in a room with the door closed.

With regard to a nursing home accepting a resident who was diagnosed with COVID-19 from a hospital, the following guidance is provided:

  • A nursing home can accept a resident diagnosed with COVID-19 and still under Transmission-Based Precautions for COVID-19 as long as the facility can follow CDC guidance for such precautions. If a nursing home cannot do this, it must wait until these precautions are discontinued. Decisions to discontinue Transmission-Based Precautions in hospitals will be made on a case-by-case basis in consultation with clinicians, infection prevention and control specialists, and public health officials.

  • Nursing homes should admit any individuals whom they would normally admit, including individuals from hospitals where a case of COVID-19 was or is present.

  • If possible, a unit or wing should be dedicated exclusively for any residents coming or returning from the hospital. This can serve as a stepdown unit where they remain for 14 days with no symptoms.

Other considerations for facilities

Review CDC guidance for Infection Prevention and Control Recommendations for Patients with Confirmed Coronavirus Disease 2019 (https://www.cdc.gov/coronavirus/2019-ncov/infection-control/controlrecommendations.html).

Increase the availability and accessibility of alcohol-based hand rubs (ABHRs), instructions reinforcing strong hand-hygiene practices, tissues, no-touch disposal receptacles, and face masks throughout the facility. Ensure that ABHR is accessible in all resident-care areas, including inside and outside resident rooms.

Increase signage for vigilant infection prevention.

Properly clean, disinfect, and limit sharing of medical equipment between residents and areas of the facility.

Provide additional work supplies to eliminate the need for sharing, and disinfect workplace areas.

State and Federal surveyors should not cite facilities for not having certain supplies if they are having difficulty obtaining these supplies for reasons outside of their control; however, facilities are expected to take actions to mitigate any resource shortages and show that they are taking all appropriate steps to obtain the necessary supplies as soon as possible.

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References
Sources: Guidance for infection control and prevention of coronavirus disease 2019 (COVID-19) in nursing homes. Centers for Medicare & Medicaid Services. Available at: https://www.cms.gov/files/document/qso-20-14-nh-revised.pdf.

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