COVID-19 Coronavirus and Impact on Nursing Homes, Long-Term Care Facilities and Senior Centers

The Division of Licensing & Protection developed guidance aimed at easing restrictions on visitation and congregate (communal) activities in Vermont’s long-term care (LTC) facilities – nursing homes, residential care homes and assisted living residences. The guidance can be found on the Department of Disabilities, Aging and Independent Living (DAIL) website.

The Vermont Department of Health (VDH) and a working group that included representatives from LTC facilities worked with DAIL on the guidance. The guidance was issued on July 14, 2020.

We summarize the plan here.

What is the purpose of the plan?

The Division of Licensing & Protection’s plan (“guidance”) represents a general framework that LTC facilities in Vermont should use in determining how to allow for safe visitation and congregate activities at their facilities during COVID-19.

• Licensing & Protection notes that each LTC facility is unique. The guidance provides LTC facilities with the flexibility to determine the best implementation strategy for their specific circumstances.   

• A critical part of facilities being able to expand visitation and congregate activities, is the infection phase of the state and the local community surrounding the facility.
• Licensing & Protection cautions that many aspects of COVID-19 remain unknown (indicating that the plan will be “revisited from time to time” as knowledge and circumstances change).

How is the plan organized?

The plan operates in phases that:

• allow for a gradual reduction of restrictions at LTC facilities, and
• enable LTC facilities to fall back to earlier phases if circumstances change.

The phase that an LTC facility is in depends on:

• Infection rates in the state and surrounding community; AND
• Actions being taken within a facility.

Each phase identifies the maximum allowable activities in that phase. Facilities may choose to implement fewer allowable activities in a phase. The phases – and their screening requirements, visitation guidance and congregate activity limits - are applied to all LTC facilities:

• nursing homes (also known as skilled nursing facilities)
• residential care homes
• assisted living residences

Proper use of PPE must be maintained throughout all phases.

No matter the phase, all residents, visitors, staff and non-essential healthcare personnel (and contractors) must practice appropriate infection control measures, including:

• hand hygiene,
• universal masking, and
• physical distancing.

What are the plan’s COVID-19 testing strategies?

• Symptomatic residents and staff:
  • For all LTC facilities, testing of symptomatic residents and staff is REQUIRED.

• Nursing Homes:
  • Adherence to the testing strategy for each phase is REQUIRED to be followed by the nursing home in order to move between the phases.

• Residential Care Homes (including Enhanced Residential Care) and Assisted Living Residences:
  • Adherence to the testing strategy for each phase is OPTIONAL in order to move between the phases.

Note:

• For all facilities, facility-wide testing is recommended following a new onset COVID-19 case in a staff or resident.

• Staff and residents should be tested when experiencing any COVID-19 symptoms.
• All facilities should consider facility-wide testing under the following circumstances:
  • when there is substantial community spread; or
  • when any residents or staff are confirmed by laboratory testing to have COVID-19.

What are the phases of the plan?

The plan has four phases, starting with Phase 0 and ending with Phase 3. 

• PHASE ZERO: Facilities with new onset COVID-19 positive residents or staff within the last 14 days. Phase 0 is the baseline, and most restrictive.
• PHASE ONE: Facilities with no new onset COVID-19 positive residents or staff for at least 14 days.
• PHASE TWO: Facilities with no new onset COVID-19 positive residents or staff for at least 28 days, and no substantial local community spread.
• PHASE THREE: Facilities with no new onset COVID-19 positive residents or staff for at least 42 days, and no substantial local community spread.

Note: A “new onset COVID-19 case” refers to COVID-19 cases that originated in the LTC facility. A new onset cases do not include:

• admitted individuals with a known COVID-19 positive status, or
• those individuals who tested COVID-19 positive during their admission or a re-admission quarantine.

What rules and limits are applied for each phase?

PHASE ZERO [facilities with new onset COVID-19 positive residents or staff within the last 14 days]

• Symptom screening
  • Screen 100% of all persons entering the facility.
  • Screen 100% of residents at least daily.
• Visitation
  • Compassionate Care only
• Non-essential personnel
  • No non-essential personnel
• Trips outside the facility
  • Only medically necessary trips outside the facility
• Communal dining
  • No communal dining
• Group activities
  • No group activities

PHASE ONE [facilities with no new onset COVID-19 positive residents or staff for at least 14 days]

• Symptom screening
  • Screen 100% of all persons entering the facility
  • Screen 100% of residents at least daily
• Visitation
  • Compassionate Care only
  • Outdoor visitation with up to two visitors following VDH guidance
• Non-essential personnel
  • No non-essential personnel
• Trips outside the facility
  • Only medically necessary trips outside the facility.
• Communal dining
  • No communal dining
• Group activities
  • No group activities

PHASE TWO [facilities with no new onset COVID-19 positive residents or staff for at least 28 days, and no substantial local community spread]

• Symptom screening
  • Screen 100% of all persons entering the facility
  • Screen 100% of residents at least daily
• Visitation
  • Compassionate Care only
  • Outdoor visitation with up to 4 visitors following VDH guidance
• Non-essential personnel
  • Non-essential healthcare and contractors allowed as determined necessary by the facility
  • Services should be coordinated among residents to reduce repeated visits
• Trips outside the facility
  • Some non-medically necessary trips permitted, based on risk of activity
• Communal dining
  • Communal dining permitted with physical distancing, cohorting required
• Group activities
  • Group activities permitted with physical distancing, up to 10 residents, cohorting encouraged
  • Outside activities are preferred over indoor activities

PHASE THREE [facilities with no new onset COVID-19 positive residents or staff for at least 42 days, and no substantial local community spread]

• Symptom screening
  • Screen 100% of all persons entering the facility
  • Screen 100% of residents at least daily
• Visitation
  • Visitors allowed with social distancing and masks (as tolerated)
• Non-essential personnel
  • Non-essential healthcare and contractors allowed as determined necessary by the facility
  • Services should be coordinated among residents to reduce repeated visits
• Trips outside the facility
  • Some non-medically necessary trips permitted, based on risk of activity
• Communal Dining
  • Communal dining permitted with physical distancing, cohorting required
• Group activities
  • Group activities permitted, including outings, with physical distancing, cohorting encouraged

What testing is applied during each phase?

In reviewing the testing strategies for each phase, note that:

• Nursing Homes:
  • Adherence to the testing strategy for each phase outlined below is REQUIRED to be followed by the nursing home in order to move between the phases.
• Residential Care Homes (including Enhanced Residential Care) and Assisted Living Residences:
  • Adherence to the testing strategy for each phase outlined below is OPTIONAL in order to move between the phases.

PHASE ZERO [facilities with new onset COVID-19 positive residents or staff within the last 14 days]

• Required Testing
  • new admissions - upon admission, and
  • symptomatic residents or staff - consider even mild symptoms
• Facility-Wide Testing
• immediately following detected positive COVID-19 case in a resident or staff

PHASE ONE [facilities with no new onset COVID-19 positive residents or staff for at least 14 days]

• Required Testing
  • new admissions - upon admission, and
  • symptomatic residents or staff - consider even mild symptoms, and
  • direct health care personnel – weekly tests
• Facility-Wide Testing
  • immediately following detected positive COVID-19 case in a resident or staff, but not required to enter Phase One

PHASE TWO [facilities with no new onset COVID-19 positive residents or staff for at least 28 days, and no substantial local community spread]

• Required Testing
  • new admissions - upon admission, and
  • symptomatic residents or staff - consider even mild symptoms, and
  • direct health care personnel – ongoing, bi-weekly tests (every other week)
• Facility-Wide Testing
  • baseline testing of all staff and all residents in the facility is required prior to entering Phase Two for the first time
  • facility-wide, baseline testing includes all residents and all staff of a facility

PHASE THREE [facilities with no new onset COVID-19 positive residents or staff for at least 42 days, and no substantial local community spread]

• Required Testing
  • new admissions - upon admission
  • symptomatic residents or staff - consider even mild symptoms
• Optional Testing
  • direct health care personnel – ongoing, bi-weekly tests (every other week)
• Facility Wide Testing
  • immediately following detected positive COVID-19 case in a resident or staff

What happens if a resident refuses a COVID-19 test or can’t make a decision about allowing a test?

Facilities should develop a procedure for residents or staff that refuse or are unable to be tested.

If a resident or staff member refuses to be tested, the facility should:

• educate the refusing individual on the importance of testing in providing protection to other facility residents and facility staff
• answer any questions posed by the refusing individual
• address any concerns about testing raised by the refusing individual
• have a plan in place for how to handle staff who refuse to be tested.

When is facility-wide COVID-19 testing expected to take place?

Long-term care facility-wide testing is expected to take place July - September of 2020 for facilities entering Phase 2 for the first time.

Facility-wide testing aims at early detection and isolating new cases to prevent COVID-19 from entering and spreading in an LTC facility. In addition, the guidance states that:

• molecular testing (e.g., PCR) is preferred
• the test used should be able to detect SARS-CoV-2 virus with greater than 95% sensitivity, greater than 90% specificity, with results obtained in a timely manner
• facilities need to determine a process that captures which residents and staff were tested or were unable to be tested and the results from each test
• serology (antibody) testing should not be used to inform diagnosis or patient care or cohorting decisions.

If I am a new resident to a LTC facility, what can I expect?

For at least 14 days due to quarantine requirements, new LTC facility residents/admissions are not eligible for:

• visitation
• communal dining
• group activities, or
• non-medically essential services (like salon services).

How does a facility move between phases?

Self-Certification: A facility shall notify the Division of Licensing & Protection as it enters each phase.

• Notifications of phase movement should be made to surveyandcertification@vermont.gov.
• Each facility shall have documentation and policies regarding movement between phases, which must be readily available at the request of DAIL or VDH.

1. Do the current prohibitions on indoor visits to long-term care (LTC) facilities — which took effect with the governor’s executive order on March 21, 2020 — remain in effect? 

Yes. The prohibitions on indoor visits to LTC facilities (nursing homes, residential care homes and assisted living) remain in effect. 

See our section about indoor visitation(including exceptions to the prohibition) below. Read the governor’s executive order concerning indoor visitation. 

2. What should I know about how visitation at LTC facilities has changed with Governor Scott’s announcement on June 17, 2020?  

LTC facilities (nursing homes, residential care homes and assisted living) can now offer outdoor visitation.  

3. Does a LTC facility have to offer outdoor visitation? 

No. Each LTC facility can decide whether or not to allow outdoor visitation.  

4. If a LTC facility decides to offer outdoor visitation, what must it do to help protect residents and visitors from COVID-19 (as well as to help prevent further spread of the virus)?  

Every LTC facility that chooses to allow for outdoor visitation must: 

• Develop facility specific polices about outdoor visitation.  

• Ensure that outdoor visitation polices are followed.  

• Include minimum guidelines for outdoor visitation.

• Note: A facility’s policies for outdoor visitation may be stricter than the minimum guidelines. 

• Suspend visits if a visitor is unable or unwilling to follow a facility’s policies for outdoor visitation.  

5. What are Vermont’s minimum guidelines for outdoor visitation for LTC facilities? 

A facility’s outdoor visitation policy must ensure that each of the following procedures are taken:  

• Schedule, in advance with the facility, each visit with a resident. 

• Screen every visitor for symptoms of COVID-19 immediately prior to any visitation with staff or residents of a facility.

• Note: Those with symptoms must be excluded from visitation.  

• Limit each visit to no more than two persons. 

• Allow each resident to receive scheduled visitors only once per day. 

• Document all visits (including maintaining a log of times and dates of all visitors, along with the visitor’s contact information).  

In addition to the above procedures, facilities must: 

• Adopt policies to ensure compliance with the governor’s current executive orders about out-of-state visitors to Vermont who intend to visit a resident.  

• Require that all visitors (with the exception of children 2 years old or younger) wear facemasks or cloth face coverings at all times during the visit.

• Note: The guidelines state that facilities will require that visitors provide their own facemasks to use during the visit.  

• Residents will also be encouraged to wear facemasks or cloth face coverings during visits if they can tolerate them.  

• Provide visitors with an alcohol-based hand rub/hand sanitizer prior to interaction with any staff members or residents.  

• Provide staff supervision, as needed, to ensure social distancing of at least six feet between people. Staff supervision may also be provided to ensure other infection prevention measures are maintained at all times during the visit.  

Note: Facilities will develop and provide advance notice about their facility-specific policies and procedures for safe visitation to scheduled visitors.  

6. What else should I know about a LTC facility’s policies about outdoor visitation?  

• Physical contact between visitors and residents, including the passing of items directly to the resident and vice versa, is prohibited.  

• Any gifts or items to be delivered to the resident must be handled according to a facility’s policy for receiving and sanitizing items.  

• Facilities may limit the times, dates, and lengths of stays by visitors 

• These limitations are to be based on available resources to ensure the proper care and safety of staff and residents.  

• Homes may place physical barriers or visual reminders/signage to ensure proper distancing during visits.  

• Residents under quarantine (due to being a new admission, recovering from a hospital stay, or for any other reason) should not be scheduled for visits until the quarantine period is successfully completed. 

7. Can residents visit with each other? 

• Yes. A LTC facility may develop an outdoor visitation policy specific for residents.  

• When a facility chooses to do so, up to three residents at a time may visit with each other outdoors.

• Note: A facility’s outdoor visitation policy specific to residents must follow the same minimum guidelines as for visitors.  

Read DAIL’s guidelines to LTC facilities for outdoor visitation, dated June 19, 2020. 

Note: Within the state’s guidelines on outdoor visitation is encouragement that LTC facilities (nursing homes, residential care homes, and assisted living residences) continue to explore and use creative strategies to encourage connection with families during this time of COVID-19. This includes telephone visits, video visits and calls. The goal is to combat isolation among residents and address families’ desire for communication and contact with loved ones. 

1. Nursing homes

Indoor visitor access is prohibited.

Exemptions to the prohibition are:

• Medically Necessary Personnel
• Visitors for residents receiving end-of-life care

2. Residential Care Homes & Assisted Living Residences

Indoor visitor access is prohibited.

Exemptions to the prohibition are:

• Two designated visitors for each resident
• Medically Necessary Personnel
• Visitors for residents receiving end-of-life care

Note: Any visitor to a nursing home, residential care home or assisted living residence will be screened using the recommendations issued by the Vermont Department of Health.

Do not go to a facility if you are sick or may have been in contact with someone with the virus. Consider using the phone or the internet to visit with a loved one.

On June 17, 2020, the State of Vermont announced that Senior Centers may begin to reopen. Senior Centers serve Vermonters over the age of 50 who are independent and can physically distance and follow infection control guidance. 

The announcement does not mean Adult Day programs can resume.  

In order to reopen, Senior Centers must follow the technical guidance provided by Vermont Department of Health and Department of Disabilities Aging and Independent Living. 

Even if they are closed, the providers may offer and provide alternative services by phone or essential in-person services to adult day participants in their own homes. You can contact the Adult Day Center in your area to ask if services are being offered. 

If they are closed, home delivered meals are an option for those who need them. Contact the local Area Agency on Aging for more information about nutrition services at 1-800-642-5119. 

What is being done about COVID-19 in long-term care (LTC) facilities?

The Vermont Health Department (VHD) is contacting all long-term care facilities proactively to review strategies to prevent COVID-19 infection and develop plans to respond immediately if an infection is identified.

VDH also provides COVID-19 testing at admission, discharge, and for certain residents who require regular care outside of the long-term care facility.

Survey and Certification, the state agency regulating long-term facilities, is examining long-term care facilities to determine if requirements related to implementing proper infection control practices to prevent the development and transmission of COVID-19 are being followed properly.

What steps can LTC facilities take to prevent and control COVID-19?

Staff should:

• Wear personal protective equipment, such as facemasks and gloves.
• Wash their hands or use hand sanitizer before and after contact with each resident, after using medical equipment, and after taking off masks, gowns, and/or gloves.
• Place alcohol-based hand sanitizer in all resident-care areas, including both inside and outside resident rooms.
• Practice cough etiquette/hygiene.
• Stay home when sick.
• Clean residents’ hands after toileting or eating.
• Clean and disinfect medical equipment between residents and areas of the facility.

 What should the administrations of LTC facilities be doing in response to COVID-19?

• Complete a self-assessment designed to determine if the LTC facility’s infection control plan and protections are adequate to address COVID-19.
• Communicate frequently with the Vermont Department of Health and Survey and Certification to share facility conditions, obtain the most up-to-date information and resources, and ask for help as needed.
• Put a plan in place for frequent communication with residents and families about facility conditions and individual resident updates.

What can you do if you have concerns about the facility’s infection control practices or other issues?

• Talk to the director of nursing or administrator about your concerns and ask what they will do to address them.
• Contact the Vermont Long-Term Care Ombudsman program for assistance. Ombudsmen advocate for residents and can help resolve your concerns.
• File a complaint with Survey and Certification.
  • Survey and Certification is currently focusing only on complaints classified as “Immediate Jeopardy.” This means that the problem/concern has caused or could cause serious harm, injury, impairment or death. If you believe your concern rises to that level, make sure to indicate that in your complaint.
  • File a complaint even if you don’t think it is Immediate Jeopardy. The complaint will still be entered into the system. The federal government will be issuing guidance about how these complaints will be handled.

What happens if a resident or staff person at a long-term care facility tests positive for COVID-19?

• If a case of COVID-19 is identified within a long-term care facility, VHD contacts the facility to provide recommendations and infection control support. VHD also begins contact tracing to try and determine the source of the infection and how the infection may be spreading.
• When a resident or staff member tests positive for COVID-19 at a long-term care facility, testing is offered to all staff and residents at the facility. In addition to the initial test, residents and staff are re-tested at 3 days, 7 days, 10 days and 14 days after the initial test. Staff and residents may decline testing, and facilities may decline universal testing. When it comes to any symptomatic or exposed residents or staff who refuse testing, they should be treated as presumptive positive (treated as if they have the virus).