​Guidance for Limiting the Transmission of COVID-19 in Long-Term Care Facilities

Please note that this information has been superseded by a more recent item and is only retained here for reference.

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AFL 20-22.1 From the California Department of Public Health

March 11, 2020

TO: All Long-Term Care Facilities

SUBJECT: Guidance for Limiting the Transmission of COVID-19 in Long-Term Care Facilities
(This AFL supersedes guidance provided in AFL 20-22)

All Facilities Letter (AFL) Summary

This AFL notifies long-term care facilities of Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) guidance for improving their infection control and prevention practices to prevent the transmission of COVID-19, including revised guidance for visitation. This AFL is authorizing long-term-care facilities to temporarily modify their facility’s visitation policies in accordance with CMS and CDC COVID-19 guidance when necessary to protect the health and safety of residents, staff, and the public.

This AFL is revised to include updated visitation guidance.

CMS has provided revised guidance to assist facilities improve their infection control and prevention practices which includes guidance on visitation. Specifically, a facility may need to restrict or limit visitation for reasonable clinical and safety reasons. This includes, “restrictions placed to prevent community-associated infection or communicable disease transmission to the resident. A resident’s risk factors for infection (e.g., chronic medical conditions) or current health state (e.g., end-of-life care) should be considered when restricting visitors. The most recent CMS guidance can be found at QSO 20-14 (https://www.cms.gov/files/document/qso-20-14-nh-revised.pdf) (PDF). This guidance is subject to revision by CMS at any time. 

In general, visitors with signs and symptoms of a transmissible infection (e.g., a visitor is exhibiting signs and symptoms of an influenza-like illness) should defer visitation until he or she is no longer potentially infectious.

CMS advises that facilities should actively screen and restrict visitation by those who meet the following criteria:

  1. Signs or symptoms of a respiratory infection, such as fever, cough, shortness of breath, or sore throat.
  2. In the last 14 days, has had contact with someone with a confirmed diagnosis of COVID-19, or under investigation for COVID-19, or are ill with respiratory illness.
  3. International travel within the last 14 days to countries with sustained community transmission. For updated information on affected countries visit Coronavirus Disease 2019 Information for Travel (https://www.cdc.gov/coronavirus/2019-ncov/travelers/index.html)
  4. Residing in a community where community-based spread of COVID-19 is occurring.

For those individuals that do not meet the above criteria, facilities can allow entry but may require visitors to use Personal Protective Equipment (PPE) such as facemasks. 

Limiting visitors and individuals: Expanded recommendations:
CMS is providing the following expanded guidance to prevent the spread of COVID-19.  

  1. Limiting or Discouraging visitation:
  2. Facilities should increase visible signage at entrances/exist, offer temperature checks, increase availability to hand sanitizer, offer PPE for individuals entering the facility (if supply allows). Before visitors enter the facility and residents’ rooms, facilities should provide instruction on hand hygiene, limiting surfaces touched, and use of PPE according to current facility policy while in the resident’s room. Individuals with fevers, other symptoms of COVID-19, or unable to demonstrate proper use of infection control techniques should be restricted from entry. Signage should also include language to discourage visits, such as recommending visitors defer their visit for another time or use an alternative visitation method.
  3. In addition to the screening visitors for the criteria for restricting access (above), facilities should ask visitors if they took any recent trips (within the last 14 days) on cruise ships or participated in other settings where crowds are confined to a common location. If so, facilities should suggest deferring their visit to a later date. If the visitor’s entry is necessary, they should use PPE while onsite. If the facility does not have PPE, the facility should restrict the individual’s visit, and ask them to come back at a later date (e.g., after a 14 days with no symptoms of COVID-19). 
  4. In cases when visitation is allowable, facilities should instruct visitors to limit their movement within the facility to the resident’s room (e.g., reduce walking the halls, avoid going to dining room, etc.) 
  5. Facilities should review and revise how they interact with volunteers, vendors and receiving supplies, agency staff, EMS personnel and equipment, transportation providers, other practitioners, and take necessary actions to prevent any potential transmission. 
  6. In lieu of visits (either through limiting or discouraging), facilities can consider:
    • Offering alternative means of communication for people who would otherwise visit, such as virtual communications (phone, video-communication, etc.).
    • Creating/increasing listserv communication to update families, such as advising to not visit.
    • Assigning staff as primary contact to families for inbound calls and conduct regular outbound calls to keep families up to date.
    • Offering a phone line with a voice recording updated at set times (e.g., daily) with the facility’s general operating status, such as when it is safe to resume visits.
  7. When visitation is necessary or allowable, facilities should make efforts to allow for safe visitation for residents and loved ones. For example:
    • Suggest limiting physical contact with residents and others while in the facility. For example, practice social distances with no hand-shaking or hugging, and remaining six feet apart.
    • If possible (e.g., pending design of building), creating dedicated visiting areas near the entrance to the facility where residents can meet with visitors in a sanitized environment. Facilities should disinfect rooms after each resident-visitor meeting.
    • Residents still have the right to access the Ombudsman program and the right to visitation. If in-person access is allowable, use the guidance mentioned above. If in-person access is not available due to infection control concerns, or guidance provided by local public health officials, facilities need to facilitate resident communication by phone or other format.
  8. Visitor reporting:
    • Advise exposed visitors (e.g., contact with COVID-19 resident prior to admission) to monitor for signs and symptoms of respiratory infection for at least 14 days after last known exposure and if ill to self-isolate at home and contact their healthcare provider.
    • Advise visitors to report to the facility any signs and symptoms of COVID-19 or acute illness within 14 days after visiting the facility.

For purposes of the AFL the following definitions apply:

Restricting means the individual should not be allowed in the facility at all, until they no longer meet the criteria above.

Limiting means the individual should not be allowed to come into the facility, except for certain situations, such as end-of-life situations or when a visitor is essential for the resident’s emotional well-being and care.

Discouraging means that the facility allows normal visitation practices (except for those individuals meeting the restricted criteria), however the facility advises individuals to defer visitation until further notice (through signage, calls, etc.).

Pursuant to the Governor’s declaration of a state of emergency related to COVID-19, the Director of the California Department of Public health may waive any of the licensing requirements of Chapter 2 of Division 2 of the Health and Safety Code and accompanying regulations with respect to any hospital or health facility identified in Health and Safety Code section 1250. CDPH is authorizing LTC facilities to modify their visitation policies in accordance with CMS and CDC guidance when necessary to protect the health and safety of LTC residents, staff, and the public. Facilities seeking to modify their visitation policies shall post a copy of the attached waiver notice in their facility along with a copy of their revised visitation policy.

CDPH understands the importance of maintaining contact with family and friends to LTC residents and encourages facilities to carefully consider the effect of visitation limitations on resident well-being. CDPH is taking this action to protect the health and safety of health compromised residents, staff, and the public. If you have any questions about this AFL, please contact your local district office.


Original signed by Heidi W. Steinecker

Heidi W. Steinecker
Deputy Director

Visitation Waiver in LTC (PDF)