CMS Revising Thinking on Visitation in Nursing Homes – Post Vaccine

CMS Revising Thinking on Visitation in Nursing Homes – Post Vaccine

Evan Shulman, Director of the CMS Division of Nursing Homes, spoke to LeadingAge members Tuesday, on our first meeting of the Nursing Home Advisory Group.  Evan spoke then answered participants’ questions.  During Evan’s opening presentation he made the following points, selected based on the most commonly asked questions right now:

  • CMS is working with CDC on the conditions under which CMS guidance can be revised to allow more visitation. “It really should happen, we are eager to open,” Evan said.  He pointed out three complicating factors:  (1) it’s a little early, since the vaccine isn’t fully effective until ten days after the second dose; but this concern is diminishing as days go by; (2) while we know vaccines prevent severe illness and even death, we don’t know how effective they are at preventing transmission; (3) there is a lot of churn in nursing homes, so there will always be new people who have not been vaccinated.
  • However, cases are plummeting and it’s time for a change in policy.  In revising the policy, CMS is focused even more on infection control and testing.  “Testing will be very important in changing the visitation policy.”
  • CMS is well aware of the devastating effects of isolation in terms of weight loss, loss of function, and depression.  CMS recognizes now that “the risk of dying from COVID is not as high as the impact of isolation” now that many residents and staff are vaccinated.  
  • Survey teams are focusing on complaint surveys for loss of function, weight loss – as these are a priority.
  • CMS is working to adjust the guidance, “hopefully soon.”
  • In non-visitation issues, Nursing Home Compare has had a facelift and is under Care Compare.  The information is the same, but it is presented in a more user-friendly fashion. The Focused Infection Control survey findings has been added to the health calculation.  These types of surveys will continue in the future.  Nursing homes need to hold all staff accountable to each other and don’t let your guard down outside of clinical nursing units.
  • Care Compare will evolve to include nursing home staff turnover.  CMS continues to worry a lot and work on staff turnover.  “We know that lower turnover leads to better quality.  That’s in the data.  It’s something to think about for the future.”
  • CMS was working on releasing guidance for Phase 3 of RoPs when COVID hit.  They are soon returning to working on that guidance again, as well as some changes in Phase 2.  Evan pointed out that the easiest thing is for providers to work on the things that are clear.  For instance, every nursing home should have a trained infection preventionist on site.  The question of what is “part time” or “sufficient” is yet to be resolved.  He suggested providers start with what’s clear and then work their way down to what might need guidance. The guidance will have a prescribed time for the infection preventionist.

Evan took questions from participants, including:

  • Some primary care physicians refuse to do in person visits with nursing home residents because the providers don’t want to be tested.  Do you have any recommendations? 
    With the advent of vaccines, testing is more important than ever.  Do everything you can to compel them to be tested.  Use the rapid antigen testing machines – there is an advantage to quick tests sometimes — or PCR. advantage to quick tests.  Show the physicians the CMS memo and CDC guidance.  (Participants suggested requiring all health care providers to be tested, not just those in long-term care; and they asked that CMS send primary care doctors’ information about why testing is necessary.
  • Regarding visitation, many family members want to feed their loved ones. 
    This is a very difficult question because all visitors are equal, whether they are there to help the resident with ADLs, help them eat, or just to say hi. Every resident has the same right to a visitor.  Of course, he said, there is nothing to prohibit family members from visiting and helping the resident eat – except to note that this is the job of the nursing home technically.  Visitor programs should not supplant the nursing home.  To complicate matters, if visitors are specifically there to help with feeding, they would have to be designated as volunteers and treated as staff, causing challenges for the provider.  Evan said he is especially concerned about Essential Caregiver programs because “if everyone has one, we have a big infection control concern,” it’s like just opening up with no extra considerations.  “There is not a lot of space for CMS in terms of essential caregivers.  But if you use a person-centered approach, there are ways to enable visits from people who may meet the definition of an essential caregiver.  So, there may be ways to integrate some of the concepts.”
  • Is there any consideration in CMS about adjusting visitation guidance during an outbreak to limit visits only in the affected units? 
    CMS is aggressively working with CDC now on how to adjust the guidance.  This is an important question. CMS is looking at two areas: first, the same thing that caused nursing homes to be the epicenter of COVID is the thing that has let us help nursing homes get ahead of curve of positivity in the entire community.  Visitation guidance that relies on community positivity is not a good barometer anymore.  Second, when you have a good amount of people vaccinated, and outbreak is contained, do you need to shut down the whole facility because you have one case? “We believe there possibly is a way that safe visitation could be enabled even when there’s a new case.  CMS is looking at all of this closely and is trying to get something out very soon.

LeadingAge WA staff were on this call with Evan Shulman. We have alerted RCS to the likely differences between CMS’s visitation guidelines and the ESP program in WA State.  While we believe the CMS plan may be more restrictive than our state guidelines, we will know more once CMS publicly releases the written plan, and we can compare the two.  

We have a meeting scheduled with RCS and CMS on March 5th to begin these discussions. We will provide further guidance to members as more information is available.




Laura Hofmann, MSN, RN – Director of Clinical and Nursing Facility Regulatory Services
c: 425-231-4804