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Guidance for Outdoor Visitation and Activities in Long-Term Care Facilities

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Guidance for Outdoor Visitation and Activities Relative to the 2019-Novel Coronavirus (COVID-19) in Long-Term Care Facilities

Pursuant to Health Officer Order No. C19-02, as amended, this Guidance is Mandatory for Long-term Care Facilities

October 16, 2020

Much of the past guidance from state and federal health officials has focused on protecting nursing home and long-term care residents from COVID-19 by limiting non-essential visitation. Sonoma County Public Health Division (SCPHD) recognizes that physical separation from family and other loved ones increases the risk for medical, social and emotional complications. Isolation can lead to depression, anxiety, and other signs of distress. SCPHD offers the following guidance promoting safer visitation and activities to improve the quality-of-life for seniors in long-term-care settings.

At this time, visitation can only take place outdoors pursuant to the requirements set forth in this Guidance. Compassionate Care Visits can take place indoors if outdoors is not possible.

Core Principles of Infection Prevention for COVID-19

The following core principles inform this guidance and are effective measures for reducing the risk of COVID-19 transmission.

  • Physical Distancing: A minimum of 6 feet between individuals
  • Universal Screening: Screening individuals for signs and symptoms consistent with COVID-19, recent close contact with a confirmed COVID-19 case, or pending COVID-19 test results
  • Face Coverings: Use of face covering or face mask that covers the nose and mouth
  • Hand Hygiene: Use of alcohol-based hand sanitizer or use of soap and warm water for 20 seconds
  • Cleaning: Frequent disinfection of high touch surfaces and common areas
  • Testing: Early identification of cases through COVID-19 testing
  • Taking Care of Yourself: Stay home when you do not feel well, and follow local isolation and quarantine instructions when directed

Minimum Requirements to Prevent COVID-19 Infection in Long Term Care

To reduce the risk of COVID-19 transmission, the following must be in place prior to a facility re-opening non-essential visitation regardless of whether it is outdoors or a compassionate care visit indoors:

  • Adequate staffing: The facility must not be experiencing staff shortages.
  • Supply of 14 days of Personal Protective Equipment (PPE) and disinfection supplies: The facility must have adequate supplies of PPE for staff and visitors such that all staff and visitors wear all appropriate PPE when indicated, and have adequate stock of essential cleaning and disinfection supplies.
  • Access to adequate testing: The facility must maintain access to COVID-19 PCR testing by PCR for all residents and staff at a clinical laboratory.
  • Universal screening: All individuals who enter the facility must be screened for the following: signs and symptoms of COVID-19 (e.g., temperature checks, questions and observations about signs or symptoms); recent close contact with a confirmed or suspected COVID positive individual; pending or unknown COVID test results. Those who screen positive for any of the above must be denied entry to the facility.
  • Hand hygiene: Alcohol-based hand sanitizer dispensers must be easily accessible throughout the facility.
  • Face covering: A mask must be worn by all individuals who enter the facility (covering mouth and nose).
  • Physical distancing: A distance of at least 6 feet must be maintained whenever possible.

Cleaning and disinfection: All high-frequency and high touch surfaces in the facility must be frequently cleaned with an EPA approved product (refer to list here https://www.epa.gov/pesticide-registration/list-n-disinfectants-coronavirus-covid-19).

Basic Guidelines for Outdoor Visits

  1. Residents who test negative for COVID-19 and have no symptoms consistent with COVID-19 and are not in quarantine, or those who are fully recovered from COVID-19, may participate in visits with one or two
  2. Visitors should be assessed to determine risks to their health, those who are at increased risk for severe illness from COVID-19 are discouraged from visiting patients.
  3. Face coverings must be worn by both residents and their visitor(s) during visits. There must be a minimum distance of 6 feet between the resident and the visitor, regardless of the location of the visit.
  4. Signs or posters must be placed throughout the facility in easily visible locations, providing visitor education on COVID-19. Signage should be bilingual and address the following: the importance of hand hygiene, the use of face masks, and symptoms associated with COVID-19.
  5. All visitors must be screened immediately before the visit occurs, and sign a roster, which shall be maintained for 45 days. This documentation will help with contact tracing should a resident later test positive for COVID-19. Any visitor whose screening reveals signs or symptoms consistent with COVID-19, or recent close contact with a confirmed COVID-19 case, must leave without the visit occurring.
  6. Every facility must have an identified staff who responds to inquiries and schedules visitation on a timely basis.
  7. The facility should provide visitors with anticipatory guidance and written instructions on the Basic Guidelines prior to the date of the visit.
  8. Facility staff will need to monitor the visit to ensure physical distancing is maintained and all safety measures are adhered to. Staff will need to monitor physical distancing, and prevent hand-shaking and hugging unless the visitor is gloved and gowned. Children will need supervision to ensure compliance.
  9. The facility must determine the duration and number of visits allowed on the premises based on their capacity to manage these events safely. Facilities may need to stagger visits to avoid overcrowding in the appropriate visiting areas.
  10. Residents and visitors must perform hand hygiene before and after the visit.
  11. Surfaces will need to be sanitized after each visit.
  12. Visits shall last no longer than 60 minutes.
  13. The facility is responsible for ensuring all baseline requirements, listed above, are met.

Alternatives to In-Person Visits and Other Ways to Communicate

When in-person visitation is not possible, other visitation options include, but are not limited to:

  • Offering alternative means of communication for people who would otherwise visit, such as virtual communications (phone, video-communication, etc.).
  • Assigning staff as primary contact to families for inbound calls and conduct regular outbound calls to keep families up to date and relay required communication.
  • Offering virtual family town hall meetings for staff and families, such meetings have been shown to improve morale and reduce stress.

Compassionate Care Visitation

Compassionate Care Visits should take place outdoors if possible.  Visits should comply with the requirements for outdoor visitation listed above; however, if the facility and visitor are able to identify a way to allow for brief personal contact, following all Basic Guidelines, and the addition of an N95 face mask while in the building, and restrict their visit to the resident’s room or other location designated by the facility, they may have agreed upon limited contact. Compassionate care visitation includes, but is not limited to:

  • End-of-life situations; in these situations a visit can occur with a resident who is positive for COVID-19 or in quarantine provided the visitor wears full PPE
  • A resident, who was living with their family before recently being admitted to a nursing home, is struggling with the change in environment and lack of physical family support.
  • A resident who is grieving after a friend or family member recently passed away.
  • A resident who needs cueing and encouragement with eating or drinking, previously provided by family and/or caregiver(s), is experiencing weight loss or dehydration.
  • A resident, who used to talk and interact with others, is experiencing emotional distress, seldom speaking, or crying more frequently (when the resident had rarely cried in the past).