Executive Office of Health and Human Services Department of Public Health
Bureau of Health Care Safety and Quality 67 Forest Street, Marlborough, MA 01752
CHARLES D. BAKER
KARYN E. POLITO
MONICA BHAREL, MD, MPH
Memorandum TO: Nursing Home and Rest Home Administrators
FROM: Elizabeth D. Kelley, MPH, MBA, Director Bureau of Health Care Safety and Quality
SUBJECT: Limitations on Visitors in Long-Term Care Facilities during the COVID-19 Outbreak1
DATE: June 1, 2020
The Massachusetts Department of Public Health (DPH) continues to work with state, federal and local
partners on the outbreak of Coronavirus Disease 2019 (COVID-19), caused by the virus SARS-CoV-2,
and we continue to appreciate the essential role you have in responding to this evolving situation.
This memorandum replaces the memorandum issued on March 16, 2020 and is effective as of June 3,
Limitations on Long-Term Care Visitors:
Long-term care facilities may allow visits with residents to occur, provided that the physical
distancing and protection requirements described in detail below are followed. As much as possible,
long-term care facilities should continue to use alternative electronic methods for communication
between residents and visitors, such as Skype, FaceTime, WhatsApp or Google Duo.
Designated Outdoor Visitation Space:
!. This guidance applies to all Long-Term Care Facilities other than those that are operated by the
A long-term care facility may allow in-person visitation in a designated outdoor visitation space,
provided that the long-term care facility implements all of the following safety, care, and
infection control measures:
• A resident who is suspected or confirmed to be infected with COVID-19 cannot be visited. A
resident who has recovered from COVID-19 may be visited.
• Prior to transporting a resident to the designated outdoor visitation space, the long-term
care facility must screen the visitor for fever or respiratory symptoms. Any individuals with
symptoms of COVID-19 infection (fever equal to or greater than 100.0 F, cough, shortness of breath,
sore throat, myalgia, chills or new onset of loss of taste or smell) will not be permitted to visit
with a resident.
• Transport of a resident to and from the designated outdoor visitation space must be safe and
orderly. At a minimum, safe transport means that the resident cannot be transported through any
space designated as COVID-19 care space or space where residents suspected or confirmed to be
infected with COVID-19 are present.
• A long-term care facility staff member trained in such patient safety and infection control
measures must remain with the resident at all times during the visit.
• Visitors must be limited to no more than two individuals. A visitor must remain at least 6
feet from the resident and attending staff member(s) at all times during the visit.
• Staff and residents must wear a surgical face mask and visitors must wear a face covering or
mask for the duration of the visit.
Visits with a resident in a designated outdoor space must be scheduled in advance and are dependent
on permissible weather conditions, availability of outdoor space, and sufficient staffing at the
facility to meet resident care needs, and the health and well-being of the resident.
A long-term care facility may limit the length of any visit, the days on which visits will be
permitted, the hours during a day when visits will be permitted, and the number of times during a
day or week a resident may be visited.
Compassionate Care Visitation:
For compassionate care situations, including but not limited to an end-of-life situation, long-term
care facilities must limit visitors in the facility to a specific room: either the resident’s room,
if the resident has a private room, or another location designated by the facility. Long-term care
facilities must require visitors to perform hand hygiene. Decisions about visitation during an end
of life situation should be made on a case-by-case basis, which should include careful screening of
the visitor (including clergy, bereavement counselors, etc.) for any symptoms of COVID-19.
Individuals with symptoms of a respiratory infection (fever, cough, shortness of breath, sore
throat, myalgia, chills or new onset of loss of taste or smell) should not be permitted to enter
the long-term care facility at any time.
For those who are in end-of-life situations, visitors should be allowed a time limited visit and be
given a face mask if they do not have a face covering or mask. For those visitors who are
permitted to visit in compassionate care situations, the visitors must be restricted to the
resident’s room or other location designated by the facility. They must also be reminded to
frequently perform hand hygiene.
Any individual who enters the long-term care facility and develops signs and symptoms of COVID-19
such as fever, cough, shortness of breath, sore throat, myalgia, chills, or new onset loss of smell
or taste within 2 days after exiting the long-term care facility or designated outdoor space must
immediately notify the long-term care facility of the date they were in the facility, the
individuals they were in contact with, and the locations within the facility they visited. Long-
term care facilities should immediately screen the individuals who had contact with the visitor for
the level of exposure and follow up with the facility’s medical director or resident’s care
Exceptions to Visitor Limitations:
Health care personnel: Long-term care facilities should follow CDC guidelines for the management
of health care personnel who may have been exposed to COVID-19 which can be found at
https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html The nursing home or
rest home must confirm that health care personnel do not have any signs or symptoms of COVID such
as a cough, shortness of breath, or sore throat, myalgia, chills, or new
onset loss of smell or taste and a fever by taking each healthcare personnel’s temperature upon
arrival. The health care worker’s temperature must be below 100.0 oF for him or her to enter the
facility and provide care.
Screening and temperature checks also apply to other health care personnel, such as hospice
workers, dialysis technicians, nursing students or Emergency Medical Service (EMS) personnel in
non-emergency situations that provide care to residents. They should be permitted to come into the
facility as long as they meet the CDC guidelines for health care personnel.
In emergency situations, EMS personnel should be permitted to go directly to the resident.
Dining and Group Activities:
All long-term care facilities should continue to suspend communal dining, as well as internal and
external group activities.
Ombudsman Program and Legal Representation:
Residents have the right to access the Ombudsman program and to consult with their legal counsel.
When in-person access is not available due to infection control concerns, facilities must
facilitate resident communication (by phone or another format).
DPH strongly encourages all long-term care facilities in Massachusetts to monitor the CMS and CDC
website for up-to-date information and resources:
• CMS website: https://www.cms.gov/About-CMS/Agency-
• CDC website: https://www.cdc.gov/coronavirus/2019-ncov/healthcare- facilities/index.html
Additionally, please visit DPH’s website that provides up-to-date information on COVID-19 in
DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop C2-21-16
Baltimore, Maryland 21244-1850
Center for Clinical Standards and Quality/Quality, Safety & Oversight Group
DATE: April 13, 2020
TO: State Survey Agency Directors
Quality, Safety & Oversight Group
SUBJECT: 2019 Novel Coronavirus (COVID-19) Long-Term Care Facility Transfer Scenarios
CMS has issued unprecedented flexibility to the long-term care (LTC) facilities (skilled nursing facilities (SNFs) and/or nursing facilities (NFs)) in order to protect residents during the COVID-19 pandemic. On April 2, 2020, CMS and CDC released the “COVID-19 Long-Term Care Facility Guidance,” which alerted facilities to actions they should take to prevent transmission of COVID-19. These actions include separating residents based on COVID-19 status (i.e., positive, negative, unknown/under observation). This may mean facilities will need to transfer residents within the facility, to another long-term care facility, or to other non-certified locations designated by the State. In order to coordinate appropriate relocation of residents between facilities or another location, facilities should work with State and local community leaders to identify and designate facilities dedicated to residents diagnosed with COVID-19 and those with suspected COVID-19.
To facilitate cohorting of residents based on COVID-19 status, CMS issued blanket waivers for certain CMS requirements of participation for LTC facilities. These include a physical environment waiver to temporarily allow rooms not normally used as a resident’s room in a certified LTC facility to be used to accommodate beds and resident care. These also include certain transfer and discharge requirements that are waived solely for the purposes of cohorting. Please view all these waivers, and their exceptions, through the blanket waivers link above.
LTC Facility Transfer Scenarios
In response to the recent questions related to cohorting, CMS is providing supplemental information for transferring or discharging residents between facilities. In general, if two or more certified LTC facilities want to transfer or discharge residents between themselves for the
• CMS is providing supplemental information for transferring or discharging residents between facilities for the purpose of cohorting residents based on COVID-19 status (i.e., positive, negative, unknown/under observation).
purposes of cohorting, they do not need any additional approval to do so. However, if a certified LTC facility would like to transfer or discharge residents to a non-certified location for the purposes of cohorting, they need approval from the State Agency. Please see the attachment, “LTC Facility Transfer Scenarios” for a depiction and explanation of these scenarios.
Contact: For questions or concerns regarding this memo, please contact DNH_TriageTeam@cms.hhs.gov.
Effective Date: Immediately. This policy should be communicated with all survey and certification staff, their managers and the State/Branch training coordinators within 30 days of this memorandum.
David R. Wright
Attachment: LTC Facility Transfer Scenarios
cc: Survey & Operations Group (SOG) Management
Two or more certifiedlong term care (LTC) facilities (SNFs and/or NFs) transfer patients between facilities to create a COVID-19 and non-COVID-19 facility. Allowed under Blanket Transfer Waiver without additional approval. Each certified facility bills Medicare for the residents in their facility.
CMS is waiving requirements in 42 CFR 483.10(c)(5); 483.15(c)(3), (c)(4)(ii), (c)(5)(i) and (iv), (c)(9), and (d); and §483.21(a)(1)(i), (a)(2)(i), and (b) (2)(i) (with some exceptions) to allow a long term care (LTC) facility to transfer or discharge residents to another LTCfacility solely for the following cohortingpurposes:
•Transferring residents with symptoms of a respiratory infection or confirmed diagnosis of COVID-19 to another facility that agrees to accept each specific resident, and is dedicated to the care of such residents;
•Transferring residents without symptoms of a respiratory infection or confirmed to not have COVID-19 to another facility that agrees to accept each specific resident, and is dedicated to the care of such residents to prevent them from acquiring COVID-19; or
•Transferring residents without symptoms of a respiratory infection to another facility that agrees to accept each specific resident to observe for any signs or symptoms of a respiratory infection over 14 days.
Transfer residents from one or more certified LTC facilities to a non-certified location that is state approved and where residents must be cared for by LTC facility staff. Medicare reimbursement remains with the LTC facility caring for patients in the new location. This location could be utilized by multiple LTC facilities, providing care with their own staff.
State Approved non-LTC Location staffed and operated by Certified LTC facility
CMS is waiving requirements related at 42 CFR 483.90, specifically the following: Provided that the state has approved the location as one that sufficiently addresses safety and comfort for patients and staff, CMS is waiving requirements under §483.90 to allow for a non-certified LTC building to be temporarily certified and available for use by a LTC facility in the event there are needs for isolation for COVID-19 positive residents, which may not be feasible in the existing LTC facility structure to ensure care and services during treatment for COVID-19 are available while protecting other vulnerable adults.
These requirements are also waived when transferring residents to another facility, such as a COVID-19 isolation and treatment location, with the provision of services “under arrangements,” as long as it is not inconsistent with a state’s emergency preparedness or pandemic plan, or as directed by the local or state health department. In these cases, the transferring LTC facility need not issue a formal discharge, as it is still considered the provider and should bill Medicare normally for each day of care. The transferring LTC facility is then responsible for reimbursing the other provider that accepted its resident(s) during the emergency period.
Transfer of COVID-19 residents to Federal/State run facility staffed with Federal or State personnel: Transfers by Order of Governmental Authority (e.g., FEMA) and no reimbursement to the LTC facility.
No waiver necessary as long as transfer is not inconsistent with a state’s emergency preparedness or pandemic plan, or as directed by the local or state health department
COVID-19 Long-Term Care Facility Guidance
April 2, 2020
The Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) are issuing new recommendations to State and local governments and long-term care facilities (also known as nursing homes) to help mitigate the spread of the 2019 Novel Coronavirus (COVID-19). Long-term care facilities are a critical component of America’s healthcare system. They are unique, as they serve as both healthcare providers and as full-time homes for some of the most vulnerable Americans.
In recent weeks, CMS and CDC, at President Trump’s direction, have worked together to swiftly issue unprecedented targeted direction to the long-term care facility industry, including a general prohibition of visitors implemented on March 13, 2020, as well as strict infection control and other screening recommendations. However, recent observations made by CDC and CMS experts onsite in facilities have emphasized that even more must be done to universally implement this key guidance.
To provide critical, needed leadership for the Nation’s long-term care facilities to prevent further spread of COVID-19, CMS and CDC are now recommending the following immediate actions to keep patients and residents safe:
1. Nursing Homes should immediately ensure that they are complying with all CMS and CDC guidance related to infection control.
2. As long-term care facilities are a critical part of the healthcare system, and because of the ease of spread in long-term care facilities and the severity of illness that occurs in residents with COVID-19, CMS urges State and local leaders to consider the needs of long-term care facilities with respect to supplies of PPE and COVID-19 tests.
3. Long-term care facilities should immediately implement symptom screening for all.
4. Long-term care facilities should ensure all staff are using appropriate PPE when they are interacting with patients and residents, to the extent PPE is available and per CDC guidance on conservation of PPE.
5. To avoid transmission within long-term care facilities, facilities should use separate staffing teams for COVID-19-positive residents to the best of their ability, and work with State and local leaders to designate separate facilities or units within a facility to separate COVID-19 negative residents from COVID-19 positive residents and individuals with unknown COVID-19 status.