āāāWhy are we changing the requirements for visitors of long-term care facilities (Skilled Nursing Facilities, Intermediate Care Facilities and Adult and Senior Care Residential Facilities) at this time?
Although COVID-19 vaccination remains effective in preventing severe disease, recent data suggest vaccination becomes less effective over time at preventing infection or milder illness with symptoms, especially in people aged 65 years and older. Early data also suggest the increased transmissibility of the Omicron variant is two to four times as infectious as the Delta variant, and there is evidence of immune evasion.
Given the greater transmissibility of the Omicron variant, the risk of outbreaks in long-term care settings is of particular concern given the medical vulnerability of residents in such settings. Furthermore, based on the experience from prior COVID-19 surge periods during which high morbidity and mortality was experienced by residents and staff within such long-term care settings, the impact of such facility outbreaks may be devastating.
Based on the emergence of Omicron, additional statewide facility-directed measures are necessary to ensure we protect the particularly vulnerable populations in long-term care settings
What are the effective dates of the amended Order?
The updated requirements for visitors of long-term care facilities go into effect on January 7th and ends on February 7th, 2022. There has been no change to the previous requirements for visitors in acute care settings.
The CDC recently updated their timeframe for those that received the Pfizer-BioNTech vaccine to 5 months after receiving the second dose, but the Table in the Order still reflects 6 months. Which timeframe should I follow?
The Order was written based on the most current information from the CDC at the time it was issued. Covered facilities should continue to use the timeframe provided in the order. However, CDPH encourages all persons to get boosted as soon as they become eligible.
With this new requirement, will all vaccinated visitors who have not yet received their booster also be required to provide proof of a negative COVID test?
There has been no change to the previous requirements for visitors in acute care settings. Visitors in such settings only need to either (1) provide proof that they are fully vaccinated, or (2) if unvaccinated or incompletely vaccinated, provide documentation of a negative COVID test within 1 day of visitation for antigen tests or within 2 days of visitation for PCR tests.
For visitors of long-term care facilities (during the period January 7th through February 7th):
- Visitors who are vaccinated and booster eligible (per Table A in the Order) must show both proof of vaccination and booster dose
and proof of a negative COVID test for indoor visitation
- Visitors who are vaccinated, but not yet booster eligible (per Table A in the Order), must provide proof that they have received all doses of their primary vaccine series
and proof of a negative COVID test for indoor visitation
- Visitors who are unvaccinated, incompletely vaccinated or are vaccinated and booster-eligible (but have not yet received their booster dose), will be allowed outdoor visitation only upon proof of a negative COVID test within one day of visitation for antigen tests, and within two days of visitation for PCR tests.
Which tests qualify for any visitor in the settings identified in the Order?
Antigen, PCR, or any Nucleic acid amplification (NAAT) test would qualify and must either have Emergency Use Authorization (EUA) by the U.S. Food and Drug Administration (FDA) or be operating per the Laboratory Developed Test requirements by the U.S. Centers for Medicare and Medicaid Services. An FDA approved or EUA authorized over-the-counter test (at-home test) is acceptable but it must be conducted and observed on-site.
How frequently must a visitor test if they are visiting for multiple consecutive days?
In all settings covered under the Order, visitors are required to provide proof of a negative test every third day (meaning testing is only required on day one, day 4 and day 7, and so on).
There appears to be a conflict between CMS guidance related to skilled nursing facility visitation and CDPH guidance. How can facilities meet both state and federal expectations regarding visitation?
The main difference between CMS and CDPH guidance is that California's Public Health Order related to visitation requires vaccination verification and a negative COVID-19 test for indoor visitation to occur. Facilities can comply with both state and federal guidance by ensuring they follow the Public Health Order and ensure that they implement safe infection control practices that allow visitation. CMS memorandum
QSO 20-39-nh-revised 11/12/2021 (PDF), states in general visitation should be allowed for all residents at all times. "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.
How should skilled nursing facilities address visitation when they expect a high volume of visitors?
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 timeslots throughout the day, and/or limiting the number of visitors in the facility or a resident's room at any time.
In addition, facilities should review and implement
measures to improve ventilation in indoor spaces used for visitation, and consider adding Portable Air Cleaners (PACs) in areas where fresh air ventilation cannot be increased. 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.
What if a resident in a long-term care facility is unable to leave their room or meet with visitors outdoors?
The visitation may take place indoors, even for visitors who cannot provide vaccine verification (or proof of booster, if booster eligible) or a negative test; however, these visits cannot take place in common areas, or in the resident's room if the roommate is present, and the visitor must wear a well-fitted mask with good filtration (N95, KF94, KN95, or surgical masks are preferred over cloth face coverings) and the resident must wear a well-fitting face mask at all times and physically distance.
Are fire, police, ambulance, other pre-hospital care workers and county child welfare and adult protective services emergency response (ER) social workers who may need to enter the facility while on duty for their job, covered under this Order?
No, these staff are not deemed visitors if they are entering the facility while on duty for their job, and therefore are not covered by this Order.
Are Long-Term Care Ombudsmen Who Provide Services in Acute Health Care and Long-Term Care facilities considered visitors?
No, Ombudsmen are not considered visitors. Ombudsmen are covered by the
Public Health Officer Order - Health Care Worker Vaccine Requirement dated December 22, 2021 (originally dated August 5, 2021).
Are parents, legal guardians, support persons or those with power of attorney required to comply with the visitor requirements?
Generally, yes, unless one of the following exemptions applies:
- If they are visiting with a patient in any of the covered facilities, and that patient is in critical condition, when death may be imminent.
- If they are parents or legal guardians and their presence is legally necessary to make decisions about care and treatment for a minor child.
- If they are support persons for a patient with physical, intellectual, developmental disability, or cognitive impairment and the facility has determined that allowing their presence, without vaccination or testing, is required as a reasonable accommodation to support the patient with a disability.
- If they have power of attorney and the visit is to address legal matters that cannot be postponed or accomplished virtually, including, but not limited to, voting, estate planning, advance health care directives, Power of Attorney, and transfer of property title.
For the persons listed above when exempt, the requirements of Section III of the Public Health Order, will still apply:
a. wear a well-fitting face mask (a surgical mask or double masking is recommended) upon entry and at all times within the facility;
b. wear any other personal protective equipment (PPE) while in the patient's room that facility personnel deem appropriate to the situation; and
c. physically distance from health care personnel and other patients/residents/visitors that are not part of their group at all times while in the facility.
What if a patient is being seen for urgent or emergent needs (for example, labor and delivery or emergency room services) and is accompanied by another person? How would that accompanying individual need to meet the testing requirement?
Individuals who may be accompanying a person who is seeking urgent or emergent care are exempt from the vaccination and testing requirements of this Order. For such persons the requirements of Section III of the Public Health Order will still apply:
a. wear a well-fitting face mask (a surgical mask or double masking is recommended) upon entry and at all times within the facility;
b. wear any other personal protective equipment (PPE) while in the patient's room that facility personnel deem appropriate to the situation; and
c. physically distance from health care personnel and other patients/residents/visitors that are not part of their group at all times while in the facility.
Does the Order apply to patients who may be visiting the facility for outpatient services?
The Order does not apply to a person who may be visiting the facility for outpatient services. Additionally, a person who accompanies a patient to an outpatient appointment in an acute health care facility is not considered a visitor for purposes of this Order.
Are other NAAT tests (e.g. ID Now) beyond SARS-CoV-2 PCR and antigen acceptable?
Yes, as long as the test has Emergency Use Authorization by the U.S. Food and Drug Administration or is operating per the Laboratory Developed Test requirements by the U.S. Centers for Medicare and Medicaid Services.
Does the Order cover children who are not currently eligible for vaccination?
For long-term care facilities (during the period January 7th through February 7th), indoor visitation is not permitted for children who are not fully vaccinated, including those for whom vaccines are not yet authorized. Outdoor visitation is permitted and visitors between the ages of 2-5 should be tested before such visits. If the resident is unable to leave their room or meet with visitors outdoors, visitation may occur indoors consistent with the exception noted above.
Originally published on August 20, 2021