AFL 21-22.7 From the California Department of Public Health
April 16, 2021
TO: 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 20-22.6)
All Facilities Letter (AFL) Summary
- This AFL notifies long-term care (LTC) facilities of the 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 guidance for visitation.
- This AFL authorizes LTC 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 provides the California Department of Public Health’s (CDPH’s) visitation guidance for expanded opportunities for indoor in-room visitation and physical touch and infection control measures for fully vaccinated residents and visitors.
- This revision includes additional visitation guidelines for pediatric residents.
On March 11, 2020, CDPH issued AFL 20-22, authorizing LTC facilities to temporarily modify their 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.
While CMS and CDPH guidance have focused on protecting residents from COVID-19, CDPH acknowledges the adverse impacts of restrictions on visitation, physical contact, and group activities upon residents’ physical, mental, and psychosocial well-being and quality of life during the ongoing COVID-19 pandemic. Residents may feel socially isolated, leading to increased risk for functional decline, depression, anxiety, and other expressions of distress. Due to these factors and the progression of COVID-19 vaccination in California, CDPH is revising the visitation guidance for LTC facilities to expand opportunities for social interaction and improved quality of life.
Given progress with COVID-19 vaccination of skilled nursing facility (SNF) residents and healthcare personnel (HCP), CDPH recommends a cautious and gradual lifting of certain restrictions, while remaining vigilant for breakthrough infections and transmission in SNFs through ongoing surveillance and testing.
SNF residents and HCP are prioritized for COVID-19 vaccination because of the high morbidity and mortality associated with COVID-19 in SNFs. Although currently available COVID-19 vaccines are highly effective in the prevention of severe and symptomatic COVID-19, there is still limited information on how much the vaccines reduce transmission and how long protection lasts. In addition, the efficacy of the vaccines against emerging SARS-CoV-2 variants is not known; therefore, at this time, vaccinated SNF residents and HCP should continue to follow current guidance to protect themselves and others, including wearing a mask, staying at least 6 feet away from others, avoiding crowds and poorly ventilated spaces, covering coughs and sneezes, washing hands often, and following guidance for personal protective equipment use and SARS-CoV-2 testing.
General Visitation Guidance
Facilities shall conduct visitation through different means based on the facility’s structure and residents’ needs for circumstances beyond compassionate care situations, such as in resident rooms, dedicated visitation spaces, and outdoors; however, facilities must adhere to the core principles of COVID-19 infection prevention (PDF) at all times. Visitation must be person-centered, consider the residents’ physical, mental, and psychosocial well-being, and support their quality of life. LTC facilities must also enable visits to be conducted with an adequate degree of privacy and should be scheduled at times convenient to visitors (e.g., outside of regular work hours).
Any visitor entering the facility, regardless of their vaccination status, must adhere to the following:
- Be screened for fever and COVID-19 symptoms, wear appropriate facial covering, and perform hand hygiene when in the facility
- If personal protective equipment (PPE) is required for contact with the resident due to quarantine or COVID positive isolation status (including fully vaccinated visitors), it must be donned and doffed according to instruction by HCP
- If a visitor has COVID-19 symptoms or has been in close contact with a confirmed positive case, they must reschedule their visit
Visitors who are unable to adhere to the core principles of COVID-19 infection prevention should not be permitted to visit or should be asked to leave.
Indoor, In-Room Visitation for Residents and Facilities Meeting Specific Criteria
Facilities shall allow indoor in-room visitation for:
- Fully vaccinated residents (e.g., individual residents who are ≥2 weeks following receipt of the second dose in a 2-dose series, or ≥2 weeks following receipt of one dose of a single-dose vaccine) in “green” (unexposed or recovered) or “yellow” (exposed or observation status ) areas, regardless of the county tier (including Tier 1, Purple) under Blueprint for a Safer Economy
- Unvaccinated or partially vaccinated residents in “green” (unexposed or recovered) or “yellow” (exposed or observation status) areas for facilities in Tier 2 (Red), 3 (Orange), or 4 (Yellow) counties
Indoor visitation shall meet the following conditions:
- Visitors in Tier 1 (Purple) counties for fully vaccinated residents must test negative on a POC antigen or PCR test on a sample taken within the prior two days, regardless of the visitor’s vaccination status. Facilities may offer POC antigen testing. Fully vaccinated visitors of fully vaccinated residents may have brief, limited physical contact with the resident (e.g., a brief hug, holding hands, assisting with feeding or grooming)
- All visitors and residents should wear appropriate facial covering during their visit and should maintain 6-ft physical distancing. Fully vaccinated visitors of fully vaccinated residents may have brief, limited physical contact with the resident (e.g., a brief hug, holding hands, assisting with feeding or grooming).
- Visits for residents who share a room should be conducted in a separate indoor space or with the roommate not present in the room (if possible), regardless of the roommate’s vaccination status.
- Full PPE must be worn for yellow zone visitation.
Continuing Outdoor and Large Indoor Communal Space Visitation Requirements
All facilities must continue to allow outdoor and communal space visitation options for all residents, regardless of vaccination status or the county tier.
Outdoor visits pose a lower risk of transmission due to increased space and airflow; therefore, outdoor visitation is preferred and should be offered unless the resident cannot leave the facility, or outdoor visitation is not possible due to precipitation, outdoor temperatures, or poor air quality. Facilities should facilitate scheduled visits on the facility premises (e.g., visits on lawns, patios, and other outdoor areas, drive-by visits, or visit through a window) with 6-ft or more physical distancing, use of face coverings by both residents and visitors, and staff monitoring of infection control guidelines.
- Outdoor visits should be permitted with appropriate facial covering during the visit and generally maintaining 6-ft physical distancing. Fully vaccinated visitors of fully vaccinated residents may have brief, limited physical contact with the resident with the resident (e.g., a brief hug, holding hands).
Visitation in Large Communal Indoor Spaces that Allow for Physical Distancing
If outdoor visitation is not possible (e.g., inclement weather, poor air quality, resident inability to be moved outside, etc.), facilities shall accommodate visitation in large communal indoor spaces such as a lobby, cafeteria, activity room, physical therapy rooms, etc. where 6-ft distancing is possible. Facilities may need to rearrange these spaces or add barriers to separate the space to accommodate the need for visitation of multiple residents.
Other Visitation Options in Addition to Outdoor and Communal Spaces
In addition, to maximize visitation opportunities and keep residents and families connected, facilities should:
- Offer alternative means of communication for people who would otherwise visit, including virtual communications (phone, video-communication, etc.).
- Assign staff as primary contact to families for inbound calls and conduct regular outbound calls to keep families up to date.
- Offer a phone line with a voice recording updated at set times (i.e. daily) with the facility’s general operating status, such as when it is safe to resume visits.
- Create/increase listserv communication to update families, such as the status and impact of COVID-19 in the facility.
Facilities must continue to follow all other safety procedures and requirements for indoor visitation, including:
- Visitors should be able to adhere to the core principles and staff should provide monitoring for those who may have difficulty adhering to core principles, such as children.
- Facilities should limit the number of visits per resident at one time and limit the total number of visitors in the facility at one time (based on the size of the building and physical space). Facilities should consider scheduling visits for a specified length of time to help ensure as many residents as possible are able to receive visitors. Visits should be scheduled for no less than 30 minutes.
- Facilities should limit visitor movement in the facility. For example, visitors should not walk around different halls of the facility. Rather, visitors should keep six feet distance from others and go directly to and from the resident’s room or designated visitation area.
- Facilities must have adequate staffing.
- Facilities must have a testing plan in place in compliance with AFL 20-53.3 and Title 42 CFR 483.80(h).
- Facilities must maintain regulatory compliance with CDPH guidance for safety and have an approved COVID-19 Mitigation Plan.
Communal dining, group activities, and non-essential personnel/contractor services may resume while adhering to the core principles of COVID-19 infection prevention:
- Residents who are not on isolation precautions or quarantine (e.g. green zone residents) may eat in the same room with physical distancing (e.g., limited number of people at each table and with at least six feet between each person), even for fully vaccinated residents.
- Facilities should consider defining groups of residents that consistently participate in communal dining together to minimize the number of people exposed if one or more of the residents is later identified as COVID-19 positive.
- Facial coverings should be worn when going to the dining area and whenever not eating or drinking, even for fully vaccinated residents.
- Group activities may also be facilitated for all residents (except for those in isolation or quarantine, e.g. green zone residents) with physical distancing among residents, appropriate hand hygiene, and use of a face covering (even for fully vaccinated residents).
- Non-essential personnel/contractors (e.g., barbers, manicurists/pedicurists) who comply with the same screening testing and universal facemask use required of the facility HCP may enter the facility and provide services to residents in appropriate spaces (outdoors, if feasible, or indoors in a well-ventilated area where at least 6-ft distancing can be maintained between residents); non-essential personnel/contractors who enter the facility should be encouraged to seek COVID-19 vaccination through the resources available in their community including the local health department.
- Encourage activities to occur outdoors when feasible, especially when face coverings will not be worn (e.g., when eating and drinking).
Additional Considerations for Pediatric Long-Term Care Facilities
- Visitors are essential for the mental health and developmental needs of pediatric residents. Visitation must be permitted for pediatric residents.
- Involve Child Life workers, parents, legal guardians, or authorized representatives in planning the facility visitation program and the most developmentally appropriate visitation program for each resident, including residents who may not have family who can visit. The visitation program shall provide routine and ongoing visitation to meet each resident’s developmental and medical needs.
- Visitors may include parents, legal guardians, or authorized representatives of the pediatric resident and family, regardless of age. Child visitors must be able to observe the required infection control practices, (e.g., source control, hand hygiene, physical distancing) and should be accompanied by an adult visitor.
- Visitors may also include educational instructors, special education aides, and physical, speech or other therapists and service providers who are referenced in a resident’s Individualized Education Plan, Section 504 Plan, Individualized Program Plan, or Community Placement Plan.
- Extended periods of physical contact may be allowed between the pediatric resident and fully vaccinated visitors.
- Encourage COVID-19 vaccination of staff, visitors, and residents who are 16 years or older for Pfizer-Biotech, 18 years or older for Moderna and Johnson & Johnson’s Janssen vaccine.
All facilities must comply with state and federal resident’s rights requirements pertaining to visitation. Facilities should follow CDPH and local public health department guidance when implementing visitation policies. Failure to facilitate visitation, without adequate reason related to clinical necessity or resident safety, would constitute a violation of resident’s rights and the facility would be subject to citation and enforcement actions.
Exception to Visitation Restrictions
Regardless of the county Tier and vaccination status the following are exempt from a facility’s visitation restrictions and may have access to a resident in any zone:
- Healthcare workers: Facilities should follow CDC guidelines for limiting access to the facility to healthcare workers. Healthcare workers, including those from the local county public health offices, should be permitted to come into the facility if they meet the CDC guidelines for healthcare workers. For purposes of this AFL, health care workers include employees, consultants, contractors, volunteers, and caregivers who provide care and services to residents on behalf of the facility, and students in the facility’s nurse aide training programs or from affiliated academic institutions.
- Surveyors: CMS constantly evaluates surveyors and CDPH requires testing of their surveyors consistent with same schedule as staff members of the facilities they visit to ensure they do not pose a transmission risk when entering the facility.
- Ombudsman: Facilities must permit ombudsman in the facility. Ombudsman are required to be asymptomatic and CDPH recommends that ombudsman be tested consistent with same schedule as staff members of the facilities they visit to ensure they do not pose a transmission risk when entering the facility.
- Nursing students: Students obtaining their clinical experience as part of an approved nurse assistant, vocational nurse or registered nurse training program should be permitted to come into the facility if they meet the CDC guidelines for healthcare workers. Students entering the facility routinely must participate in the facility wide screening testing.
- Compassionate care visitation: For permitted visitors, visits should be conducted using physical distancing; however, if the facility and visitor identify a way to allow for personal contact during compassionate care visitation, visitors must be screened for COVID-19 symptoms, wear a surgical facemask while in the building, restrict their visit to the resident’s room or other location designated by the facility, and be reminded by the facility to frequently perform hand hygiene. For a definition of the type of visits that constitute compassionate care visitation please refer to CMS guidance QSO 20-39-NH (PDF).
- Facilities should consider testing compassionate care visitors who have physical contact with COVID-19 positive residents.
- Legal matters: Visitors must be permitted for legal matters that cannot be postponed including, but not limited to, voting, estate planning, advance health care directives, Power of Attorney, and transfer of property title if these tasks cannot be accomplished virtually.
- P&A programs: Any representative of a P&A program must be permitted immediate access to a resident, which includes the opportunity to regularly meet and communicate privately with the resident, both formally and informally, by telephone, mail, and in-person.
- Individuals authorized by federal disability rights laws: Facilities must comply with federal disability rights laws such as Section 504 of the Rehabilitation Act and the Americans with Disabilities Act.
- For example, if a resident requires assistance to ensure effective communication (e.g., qualified interpreter or someone to facilitate communication) and the assistance is not available by onsite staff or effective communication cannot be provided without such entry (e.g., video remote interpreting), the facility must allow the individual entry into the facility to interpret or facilitate, with some exceptions.
- This would not preclude facilities from imposing legitimate safety measures necessary for safe operations, such as requiring such individuals to adhere to the core principles of COVID-19 infection prevention.
In circumstances where this guidance does not clearly apply, the facility leadership should work with the local health department to develop an individualized plan of action.
All persons exempt from visitor restrictions are still subject toscreening for fever and COVID-19 symptoms, must wear appropriate facial covering, perform hand hygiene when in the facility and comply with core principles of infection control and prevention.
Use of Civil Money Penalty (CMP) Funds
CDPH encourages facilities apply to use CMP funds to help facilitate visitation, such as purchasing communicative devices (e.g., tablets or webcams), to help residents stay connected with their loved ones. CMS will now approve use of CMP funds to purchase tents for outdoor visitation and/or clear dividers (e.g., Plexiglas or similar products) to create a physical barrier to reduce the risk of transmission during-in person visits. Funding for tents and clear dividers is limited to a maximum of $3000 per facility. This grant opportunity is in addition to the communicative technology CMP grant that was made available previously.
Please see AFL-20-77 for additional information on applying for CMP funds.
CDPH will continuously review the scientific literature and CDC guidance for updates on vaccine effectiveness in the SNF resident population, how much the vaccines reduce transmission, how long protection lasts, and efficacy of the vaccines against new SARS-CoV-2 variants. As data emerge to support vaccination coverage levels among SNF residents and HCP that could allow further lifting of restrictions, CDPH will update this AFL.
If you have any questions about this AFL, please contact your local district office.
Original signed by Cassie Dunham
Acting Deputy Director
- CDPH Visitation Fact Sheet – Skilled Nursing Facilities (PDF)
- CMS QSO-20-39-NH (PDF)
- CDPH AFL 20-53.3
- CDPH Guidance for the Use of Face Coverings (PDF)
- CDC Symptoms of COVID-19
- CDC Interim U.S. Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel with Potential Exposure to COVID-19
- CDC Preparing For COVID-19 in Nursing Homes