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

1. WHERE CAN I FIND THE GUIDANCE?

The Division of Licensing & Protection developed guidance concerning restrictions on visitation and congregate 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 Disabilities, Aging and Independent Living (DAIL) website.

2. 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.

Notes:

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

3. WHAT IS THERE TO KNOW ABOUT THE PHASES OF THE PLAN?

• The Plan operates in Phases. 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.
• Phases of Operation
  • The Phases and their accompanying screening requirements, visitation guidance, congregate activity limits and testing requirements are applied to ALL long-term care residential facilities, which include nursing homes (also known as Skilled Nursing Facilities), residential care homes, assisted living residences, therapeutic community residences, the home for the terminally ill and the intermediate care facility for individuals with intellectual disabilities.
• The Phases now correspond to county positivity rates instead of consecutive days without COVID-19 infections. Facilities should monitor their county positivity rate at least every other week. 
• 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.

4. IN GENERAL, WHAT IS THERE TO KNOW ABOUT 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.

5. WHAT ARE THE PHASES OF THE PLAN?

The Plan has four Phases, starting with Phase 0 and ending with 3. Phase 0 is the baseline, and most restrictive.

Phase 0 is used if there is a new COVID-19 infection in any healthcare personnel (HCP) or any nursing home onset COVID-19 infection in a resident.

Following Phase 0, LTC facilities may progress through Phases 1, 2, and 3.

• PHASE ZERO: Facilities with new COVID-19 infection in any healthcare personnel (HCP) or any nursing home onset COVID-19 infection in a resident.
• PHASE ONE: Facilities in a county with >10% positivity rate.
• PHASE TWO: Facilities in a county with 5%-10% positivity rate.
• PHASE THREE: Facilities in counties with <5% positivity rate.

Note: A “new onset COVID-19 case” refers to COVID-19 cases that originated in the LTC facility. 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.

6. WHAT ARE THE SCREENING REQUIREMENTS, VISITATION GUIDANCE AND CONGREGATE ACTIVITY LIMITS APPLIED DURING EACH PHASE?

PHASE ZERO

[Facilities with new COVID-19 infection in any healthcare personnel (HCP) or any nursing home onset COVID-19 infection in a resident]

1. Symptom screening
   • Screen 100% of all persons entering the facility.
   • Screen 100% of residents at least daily.
   • Increase monitoring of all ill residents to at least three times daily.
2. Visitation
   • Compassionate Care only at first; then refer to "Indoor Visitation During an Outbreak"
3. Non-essential personnel
   • Personnel providing direct care to residents must be permitted entry (unless excluded due to exposure or symptom screening) per the below guidance. Consult with the Vermont Department of Health (VDH) and DAIL to discuss additional situations/details.
4. Trips outside the facility
   • Only medically necessary trips outside the facility at first; and consult with VDH regarding specific situations for non-necessary trips.
5. Communal Dining
   • Consult with VDH and DAIL to review appropriate infection prevention and control measures tailored to your situation.
6. Group activities
   • Consult with VDH and DAIL to review appropriate infection prevention and control measures tailored to your situation.

PHASE ONE

[Facilities in a county with >10% positivity rate]

1. Symptom screening
   • Screen 100% of all persons entering the facility.
   • Screen 100% of residents at least daily.
2. Visitation

   • Only compassionate care visits allowed indoors for unvaccinated residents if less than 70% of residents in the facility are fully vaccinated

   • All other visits allowed, including outdoor visits for unvaccinated residents

3. Non-essential personnel
   • Non-essential healthcare and contractors allowed. Services should be coordinated among residents to reduce repeated visits.
4. Trips outside the facility
   • Non-medically necessary trips permitted, based on risk of activity
5. Communal Dining
   • Communal dining permitted with physical distancing, cohorting encouraged.
6. Group activities
   • Group activities permitted with physical distancing, cohorting encouraged.

PHASE TWO

[Facilities in a county with 5%-10% positivity rate]

1. Symptom screening
   • Screen 100% of all persons entering the facility.
   • Screen 100% of residents at least daily.
2. Visitation
   • Visitation should occur according to the core principles of COVID-19 infection prevention and facility policies (beyond compassionate care visits).
3. Non-essential personnel
   • Non-essential healthcare and contractors allowed. Services should be coordinated among residents to reduce repeated visits.
4. Trips outside the facility
   • Non-medically necessary trips permitted, based on risk of activity.
5. Communal Dining
   • Communal dining permitted with physical distancing, cohorting encouraged.
6. Group activities
   • Group activities permitted, including outings, with physical distancing, cohorting encouraged.

PHASE THREE

[Facilities in counties with <5% positivity rate]

1. Symptom screening
   • Screen 100% of all persons entering the facility.
   • Screen 100% of residents at least daily.
2. Visitation
   • Visitation should occur according to the core principles of COVID-19 infection prevention and facility policies (beyond compassionate care visits).
3. Non-essential personnel
   • Non-essential healthcare and contractors allowed. Services should be coordinated among residents to reduce repeated visits.
4. Trips outside the facility
   • Non-medically necessary trips permitted, based on risk of activity.
5. Communal Dining
   • Communal dining permitted with physical distancing, cohorting encouraged.
6. Group activities
   • Group activities permitted, including outings, with physical distancing, cohorting encouraged.

7. WHAT COVID-19 TESTING STRATEGIES ARE 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 COVID-19 infection in any healthcare personnel (HCP) or any nursing home onset COVID-19 infection in a resident]

1. Testing
   • Any symptomatic residents or staff
   • SNF: Facility-wide testing of all staff and residents with repeat testing of all negatives every 3 – 7 days until no new positives identified for a period of 14 days*
   • Non-SNF: As recommended by VDH

PHASE ONE

[Facilities in a county with >10% positivity rate]

1. Required Testing
   • Any symptomatic residents or staff and outbreak response testing
2. Staff Testing
   • Weekly, ongoing (optional for non-SNF)
3. Facility Wide Testing
   • Following detected positive COVID-19 case in a resident or staff as recommended by VDH; please consult directly with the VDH team.

PHASE TWO

[Facilities in a county with 5%-10% positivity rate]

1. Required Testing
   • Any symptomatic residents or staff
2. Staff Testing
   • Weekly, ongoing (optional for non-SNF)
3. Facility Testing
   • Following detected positive COVID-19 case in a resident or staff as recommended by VDH; please consult directly with the VDH team

PHASE THREE

[Facilities in counties with <5% positivity rate]

1. Required Testing
   • Any symptomatic residents or staff and outbreak response testing
2. Staff Testing
   • Monthly, ongoing (optional for non-SNF)
3. Facility Wide Testing
   • Following detected positive COVID-19 case in a resident or staff as recommended by VDH; please consult directly with the VDH team.

8. WHAT HAPPENS IF A RESIDENT REFUSES A COVID-19 TEST OR IS UNABLE TO MAKE A DECISION ABOUT ALLOWING A COVID-19 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.

9. IF I AM A NEW RESIDENT TO AN LTC FACILITY, WHAT CAN I EXPECT IN TERMS OF VISITATION AND CONGREGATE ACTIVITIES UNDER THE PLAN?

New LTC facility residents/admissions are not eligible for (1) visitation; (2) communal dining; (3) group activities; OR (4) non-medically essential services (like salon services), for at least 14 days due to quarantine requirements.

10. HOW DOES AN LTC FACILITY MOVE BETWEEN PHASES?

Phases are based on county positivity rates and the facility not being in an active outbreak or outbreak recovery situation.

Each facility shall have documentation and policies regarding movement between Phases, which must be readily available per request of DAIL or VDH.

11. WHEN I VISIT AN LTC FACILITY, WILL VISITATION BE OUTDOORS OR INDOORS?

It depends.

Outdoor visitation

• At this point in time, science suggests that outdoor visits have a lower risk of transmission due to increased space and airflow.  Therefore, LTC facilities will most likely hold all visits outdoors whenever practicable.
• Aside from weather considerations (e.g., inclement weather, excessively hot or cold temperatures, poor air quality), an individual resident’s health status (e.g., medical condition(s), COVID-19 status), or a facility’s outbreak status, outdoor visitation should happen at LTC facilities on a regular basis.
• LTC facilities should create accessible and safe outdoor spaces for visitation, such as in courtyards, patios, or parking lots, including the use of tents, if available.

Note: For outdoor visitation, LTC facilities should have a process to limit the number and size of visits happening at any one time to support safe infection prevention actions (e.g., maintaining social distancing).  Reasonable limits on the number of individuals visiting with any one resident at the same time may also be used by LTC facilities. 

• Visits must be arranged in advance and scheduled with the facility
• Visitors are screened for symptoms of COVID-19 immediately prior to any visitation with staff or residents of a facility. Those with symptoms must be excluded from visitation;
• All visitations must be documented and tracked, including maintaining a log of times and dates of all visitors, and their contact information.
• Visitors must have completed quarantine following high risk travel according to ACCD guidance prior to any visits.
• Visitors must be able to adhere to the core principles (including face coverings/masks) and staff should provide monitoring for those who may have difficulty adhering to core principles
• Residents will also be encouraged to wear facemasks or cloth face coverings during visits if they can tolerate them.
• Facilities shall provide visitors with an alcohol-based hand rub/hand sanitizer prior to interaction with any staff members or residents.
• Facilities shall provide staff supervision as needed to ensure social distancing of at least six feet between people, and that other infection prevention measures are always maintained  during the visit.
• Facilities should develop and provide advance notice about facility-specific policies and procedures for safe visitation to scheduled visitors.

• Physical contact between the visitor(s) 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 shall be handled per the facility policy for receiving and sanitizing items.
• Facilities may limit times, dates, and lengths of stays by visitors based on available resources to ensure the proper care and safety of staff and patients.
• Homes may place physical barriers or visual reminders/signage to ensure proper distancing during visits.

Note: “Window visits” may occur, following the below above, if the facility is able to accommodate this type of visit while ensuring core principles are followed.

Indoor visitation

LTC facilities should allow and support indoor visitation based on the following guidelines:

• There has been no new onset of COVID-19 cases in the last 14 days and the facility is not currently conducting outbreak testing;
• Visitors should be able to willing and able follow COVID-19 infection control policies and practices, and staff should provide monitoring for those who may have difficulty following COVID-19 infection control policies and practices, such as children
• Facilities should limit the number of visitors 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 all residents are able to receive visitors; and
• Facilities should limit movement in the facility.  For example, visitors should not walk around different halls of the facility. Rather, they should go directly to the resident’s room or designated visitation area. Visits for residents who share a room should not be conducted in the resident’s room.  

In addition, facilities should use the COVID-19 county positivity rate to determine how to allow for indoor visitation:

Low Positivity Rate (<5%): Visitation (beyond compassionate care visits) should occur at the LTC facilities following COVID-19 infection prevention and facility policies. 

Medium Positivity Rate (5% – 10%): Visitation (beyond compassionate care visits) should occur at the LTC facilities following COVID-19 infection prevention and facility policies. 

High Positivity Rate (>10%): Visitation should only occur for compassionate care situations following COVID-19 infection prevention and facility policies.

Note: Facilities may also monitor other factors to understand the level of COVID-19 risk, such as rates of COVID-19-Like Illness; visits to the emergency department; or the positivity rate of a county adjacent to the county where the LTC facilities is located. Under federal guidance, county positivity rate does not need to be considered for outdoor visitation

Indoor visitation recommendations

Indoor visitation poses increased risk to residents, outdoor visitation remains the preferred method for enabling contact between residents and visitors. The recommendations below are designed to create the safest possible environment to mitigate the enhanced risk posed by indoor visits.

Each facility must have a policy for indoor visitation that incorporates the following:

• A demonstrated mechanism to assess that all visitors can and do comply with core principles throughout the entire visit.
• All visitors must be screened for symptoms of COVID-19 prior to entering the facility. Visitors must have completed quarantine following high risk travel according to ACCD guidance prior to any visits.
• Hand sanitizer must be made available for immediate use prior to the visit; upon entry to the facility and in the visitation area.
• Face coverings or masks must always be worn .
• Use of signage and clear visual reminders of all core principles, best practices and infection prevention and control procedures, which are easily seen and understood by visitors.
• Names and contact information of all visitors must be documented for each visit, to enable any necessary contact tracing. Duration of visits must also be recorded.
• Visits should be scheduled in advance and limited to 2 visitors per visit.
• Visits should be of limited duration to decrease risk; current guidance indicates that anything over 15 minutes constitutes prolonged exposure. Please take this into account when developing policies and scheduling the length of visits, especially when using a small enclosed space with poor ventilation. Compassionate care situations may call for a more flexible approach.
• Physical distancing should always be maintained , and whenever possible, barriers should be used to increase safety.

Physical touch as part of these visits is not consistent with the core principles. For instances in which this is a concern, please contact VDH for individual guidance.

Visits should be conducted in a designated area, as separate from patient care areas as possible (dependent on the physical layout of the facility). Preferably, using entrances and exits that do not require visitors to travel through patient care areas. Compassionate care situations may call for a more flexible approach.

• The designated visitor area must be cleaned and disinfected between each visit.
• The designated area should not have its HVAC system, if one is in place, disabled. Effort should be taken to increase area ventilation to the outdoors and air filtration, as feasible in the space.
• Visitors should be directed to a designated visitor bathroom whenever possible within the facility or encouraged not to use the bathrooms in the facility. If a resident/staff bathroom must be used, ensure it is cleaned and disinfected between use.
• Staff should be prepared to end visits if visitors demonstrate an unwillingness or inability to comply with the core principles.

12. COMMUNAL ACTIVITIES AND DINING

• While adhering to the core principles of COVID-19 infection prevention, communal activities and dining may occur.
  • Residents may eat in the same room with social distancing (e.g., limited number of people at each table and with at least six feet between each person).

• Facilities should consider additional limitations based on status of COVID-19 infections in the facility.
• Additionally, group activities may also be facilitated (for residents who have fully recovered from COVID-19, and for those not in quarantine for observation, or in isolation with suspected or confirmed COVID-19 status) with social distancing among residents, appropriate hand hygiene, and use of a face covering. Facilities may be able to offer a variety of activities while also taking necessary precautions.

13. NEW ADMISSIONS

• Testing of new admissions can be considered along with other infection control interventions such as quarantine but is not required.
• It is not required to have a negative COVID-19 test to be admitted to a long-term care facility.
• Some people who are fully recovered from COVID-19 may test positive for several weeks after the initial positive test.
• New facility admissions should not participate in communal dining, group activities, or nonmedically essential services like salon services for at least 14 days due to recommendations for quarantine.
• New admissions may be able to safely participate in visitation, if visitation can be accommodated while maintaining quarantine (e.g. without coming in close contact with other residents/staff, outdoor visits via an entrance directly to the quarantine area, window visits, or a designated indoor visitation space within the quarantine area).

14. OTHER TESTING CONSIDERATIONS

• In keeping with current CDC recommendations, staff and residents who have recovered from COVID-19 (previously tested positive) and are asymptomatic do not need to be retested for COVID-19 within 3 months (12 weeks) after symptom onset or date of specimen collection for persons remaining asymptomatic.
• Collecting and handling specimens correctly and safely is imperative to ensure the accuracy of test results and prevent any unnecessary exposures. The specimen should be collected and, if necessary, stored in accordance with the manufacturer’s instructions for use for the test and CDC guidelines.
• During specimen collection, facilities must maintain proper infection control and use recommended personal protective equipment (PPE), which includes an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown, when collecting specimens.
• Inquiries to the Vermont Department of Health for supplies, testing and processing assistance, as required by CMS guidance in QSO-20-38-NH, should be made to Shayla Livingston.

On March 30, 2021, the Department of Disabilities, Aging, and Independent Living published guidance for "Senior Centers in Planning for Re-Opening (Effective 3/30/21)."

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).