Everyone's mental health has been tested over the past eight months. This includes the staff, the residents, and the visitors in long term care facilities. Daily routines have been disrupted, contact with loved ones has been disjointed and visitations suspended. Decreased interactions with loved ones leads to anxiety and stress for everyone involved.

Prior to the COVID-19 pandemic, mental health disorders represented a public health challenge of overwhelming proportions and a known gateway to more ominous problems. When skilled nursing facilities begin allowing in-person visits with the residents, staff need to be mindful of the emotional and psychological impact this pandemic has had on the residents and also on visitors and staff.  

Many residents have undergone an unfathomable experience with loneliness, confusion, and questions about why the situation is impacting them. Many visitors are faced with unemployment, isolation, and uncertainty about the future. According to the World Health Organization, COVID-19 could lead to upwards of 75,000 deaths from substance abuse and suicide.

Many staff have continued to risk their own lives caring for the country's most vulnerable population while simultaneously experiencing the same challenges as the resident and the visitor.

New Visiting Guidance

While guidance from the Centers for Medicare & Medicaid Services (CMS) has focused on protecting nursing home residents from COVID-19, it recognizes that physical separation from family and other loved ones has taken a physical and emotional toll on them. In light of this, on Sept. 17, 2020, CMS updated the federal visitation guidelines for nursing homes to provide reasonable ways for them to safely facilitate in-person visitation.

CMS says visitation can be conducted in different ways, depending on a facility's structure and its residents' needs, such as in resident rooms, dedicated visitation spaces, or outdoors. Regardless, facilities must follow CMS' nine core principles of COVID-19 infection prevention to remain in compliance with regulations.

1. Screen all individuals who enter the facility for signs and symptoms of COVID-19.
Nursing homes should designate an entrance for visitors to use to access the health care facility. At this location:

• Complete a temperature test.
• While maintaining social distancing, question visitors regarding recent travel, if they have had recent contact with ill people, or if they are experiencing any symptoms themselves.
• Those found to be ill or who may have been exposed should be denied access but may be encouraged to visit another time, or to use alternate means of visiting such as calling or perhaps conducting a visual chat behind clear glass or Plexiglas barriers if the provider can accommodate them.  
  

2. Hand hygiene—the use of an alcohol-based hand rub is preferred.
Instruct visitors on proper hand hygiene, which means washing hands with soap and water for at least 40 seconds and/or applying an alcohol-based hand rub with at least 60 percent ethanol or 70 percent isopropanol for at least 20 seconds.

3. Face covering or mask that covers mouth and nose.
Ensure the availability of personal protective equipment (PPE) for visitors such as facial masks, gloves, and gowns, as it applies to the residents.

• Remind the visitor of the importance of PPE and how it impacts both the visitor and the resident.
• Educate the visitor on the proper use of PPE.

4. Social distancing—keep at least six feet between persons.
When providing opportunities for residents and visitors to visit in place:

• Encourage meetings within a designated area.
• Discourage travel throughout the facility.
• Provide opportunities to maintain social distancing from other family groups.
• Limit visiting hours/length of visits.
• Encourage the use of outdoor areas.
  

5. Post instructional signage throughout the facility, and provide proper visitor education on COVID-19 signs and symptoms, infection control precautions, and other applicable facility practices such as hand hygiene and the use of face coverings or masks and specified entries, exits, and routes to designated areas.
Post reminders to visitors that the facility may decide to limit or temporarily stop visitors or others from the facility should the number of infections increase or become more widespread in the local community.

• Facilities should provide opportunities for visitors to receive education regarding best practices to minimize or limit the transmission of any infectious disease. This may be accomplished with family newsletters, visual aids, or brief instruction on arrival.
• Remind all visitors about respiratory hygiene and cough etiquette (covering mouth and nose with a disposable tissue when coughing or sneezing).
  

6. Clean and disinfect high-frequency touched surfaces in the facility often and designated visitation areas after each visit.

7. Ensure staff use PPE appropriately.

8. Effectively cohort residents (for example, with separate areas dedicated to COVID-19 care).

9. Resident and staff testing should be conducted as required at 42 CFR 483.80(h) (see QSO-20-38-NH).

Indoor Visitation

While taking a person-centered approach and following CMS' core principles of infection prevention, outdoor visitation is preferred due to increased space and air flow. However, with winter approaching, indoor accommodations may become necessary.

Nursing homes should accommodate indoor visitation, including visits for reasons beyond compassionate care situations based on the following guidelines:

• There has been no new onset of COVID-19 cases in the past 14 days, and the facility is not currently conducting outbreak testing;
• Visitors should be able to adhere to the core principles, and staff should provide monitoring for those who may have difficulty adhering to them, 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. Consider scheduling visits for a specified length of time to help ensure all residents are able to receive visitors; and
• Limit hall movement. For example, visitors shouldn't walk around the facility but should go directly to the resident's room or designated meeting space. Visits for residents who share a room should not be conducted in the resident's room.

Community COVID Positivity Rate a Factor

Nursing homes should use their county's COVID-19 positivity rate, found on the COVID-19 Nursing Home Data site as additional information to determine how to facilitate indoor visitation:

• Low (<5%) and Medium (5%-10%) = Visitation should occur according to the core principles of COVID-19 infection prevention and facility policies (beyond compassionate care visits) and
• High (>10%) = Visitation should occur only for compassionate care situations according to the core principles of COVID-19 infection prevention and facility policies.

While not required, CMS encourages nursing homes in medium- or high-positivity counties to test visitors, if feasible. If so, facilities should prioritize visitors that visit regularly (weekly, for example), although any visitor can be tested.

Orchestrating visitation of loved ones with residents in a nursing home is a top priority for health care leaders and staff. Visitors and residents may be unfamiliar with the process and uncomfortable with the guidelines. In order to alleviate the mental health ramifications mentioned earlier, it is important to approach the process with grace, patience, and respect.

Kris Mastrangelo, OTR/L, LNHA, MBA, is chief executive officer and president of Harmony Healthcare International. She can be reached at Kmastrangelo@harmony-healthcare.com.​