Updated Elder Care Visitation Guidance

Fennemore Client Alert

Updated Elder Care Visitation Guidance

On July 28, 2020, Arizona Governor Doug Ducey announced the formation of the Task Force on Long Term Care (the “Task Force”). The Task Force, made up of various facility operators, family members, elder-care advocates and government officials, met weekly to come up with recommendations as to how and under what circumstances in-person visitation could resume.

Using the information gleaned by the Task Force, the Arizona Department of Health Services (AZDHS) released, “COVID-19 Guidance for Visitation at Congregate Settings for Vulnerable Adults and Children” (the “Guidance”). The Guidance has an effective date of October 1, 2020 but was revised on October 9, 2020. A copy of the Guidance is available here.

Per the Guidance, facilities should immediately allow compassionate care visitation and should begin to allow increased in-person visitation based on the level of COVID-19 spread in each county. Spread is defined based on certain benchmarks:

  • Minimal Spread: <10 cases/100,000, <5% positivity, and <5% of COVID-like illnesses present in the county
  • Moderate: 10-100 cases/100,000; 5-10% positivity, and 5-10% of COVID-like illnesses present in the county
  • Substantial: >100 cases/100,000; 10% of greater positivity, and >10% of COVID-like illnesses present in the county

This data is available at the ADHS website at azhealth.gov/businessCOVID19 and is updated each Thursday.

The level of visitation, and whether those visits make take place in- or outdoors, is based on the level of spread in the county in which the facility operates. This chart explains more:

AHS Chart

Facilities should note, however, that the chart is not completely consistent with the guidance. You should review the written guidance as a whole before making any decisions.

Indoor visitation may resume during any level of spread if all of the following are met:

  • The visitor presents the facility a negative COVID test (either PCR or antigen) that is less than 48 hours old.
  • The visitor signs an attestation that they have isolated in the time between the sample was taken and the visit and is free from symptoms.
  • The facility limits contact as much as possible, including a dedicated visitation space.
  • The facility requires mask-wearing by residents (when safe), visitors, and staff.
  • The facility requires hand sanitizing before the visit.
  • The facility maintains a visitor log for contact tracing purposes.
  • The facility institutes enhanced cleaning and sanitation of the facility where the visits occur.
     

In addition, residents may choose 1-2 “Designated Essential Visitors” who will be allowed to visit at any time during normal (i.e., pre-COVID) visiting hours if all of the following requirements are met:

  • The [Designated] Essential Visitor presents the facility documentation of a negative COVID test (either PCR or antigen) on the same testing interval required by CMS for the facility staff:
    • Minimal (Percent Positivity <5%): Once a month
    • Moderate (5% – 10%): Once a week
    • Substantial (>10%): Twice a week
  • The Designated Essential Visitor must have their first test and results before the first visit takes place.
  • The Designated Essential Visitor signs an initial attestation that they will avoid attending largegatherings in between testing and visitation;
  • The Designated Essential Visitor attests on each visit that they are free from symptoms;
  • The Designated Essential Visitor must be at least 18 years of age;
  • The facility requires mask-wearing by residents (when safe), visitors, Designated Essential Visitor, and staff.
  • The facility requires hand sanitizing before the visit.
  • The facility maintains a visitor log for contact tracing purposes.
     

Residents may change their Designated Essential Visitor. They may also have physical contact with their Designated Essential Visitor, which is an important distinction afforded to those so designated. The Designated Essential Visitor must be allowed to enter the resident’s living quarters, though certain concessions must be made if the resident has a roommate.

In addition, certain categories of visitors may be allowed even without a COVID test. Health care workers who are not employees of the facility, but provide direct care to the facility’s residents, social workers, and members of the clergy, must be permitted to come into the facility as long as they are not subject to a work exclusion due to an exposure to COVID-19 or show signs or symptoms of COVID-19 after being screened. Therapy dogs should be permitted, however, the handler must adhere to the visitation policy. Regulatory and investigative personnel who are not employees of the facility but ensure the health and safety of the residents, such as law enforcement, AZDHS/CMS licensing surveyors, Adult Protective Services Investigators, and health plan quality assurance investigators, etc., must be permitted to come into the facility as long as they are not subject to a work exclusion due to an exposure to COVID-19 or show signs or symptoms of COVID-19 after being screened.

While facilities need to resume some level of visitation immediately, they may still limit the number of visitors present at any one time and should develop plans and policies that are communicated to residents, their families and personal representatives so that visitation expectations and requirements are clear. Facilities also need to ensure that they continue to take other steps to limit the spread of COVID-19 such as requiring the use of masks or face-coverings, enforcing social distancing policies, etc. 
 
Expanded Definition of “Close Contact” with a COVID-positive individual

As facilities work through these issues, they should also be mindful that on October 21, 2020, the CDC expanded its definition of “close contact” with an individual with COVID-19. Originally, “close contact was defined as 15-minutes of consecutive contact within 6 feet of an infected person. It has been redefined to allow for cumulative contact:

Someone who was within 6 feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period* starting from 2 days before illness onset (or, for asymptomatic patients, 2 days prior to test specimen collection) until the time the patient is isolated.

*Individual exposures added together over a 24-hour period (e.g., three 5-minute exposures for a total of 15 minutes). Data are limited, making it difficult to precisely define “close contact;” however, 15 cumulative minutes of exposure at a distance of 6 feet or less can be used as an operational definition for contact investigation. Factors to consider when defining close contact include proximity (closer distance likely increases exposure risk), the duration of exposure (longer exposure time likely increases exposure risk), whether the infected individual has symptoms (the period around onset of symptoms is associated with the highest levels of viral shedding), if the infected person was likely to generate respiratory aerosols (e.g., was coughing, singing, shouting), and other environmental factors (crowding, adequacy of ventilation, whether exposure was indoors or outdoors). Because the general public has not received training on proper selection and use of respiratory PPE, such as an N95, the determination of close contact should generally be made irrespective of whether the contact was wearing respiratory PPE. At this time, differential determination of close contact for those using fabric face coverings is not recommended.

https://www.cdc.gov/coronavirus/2019-ncov/php/contact-tracing/contact-tracing-plan/appendix.html

This expanded definition should trigger more testing for exposed staff and residents and more  thorough contact tracing. It should also be taken into consideration when visitation policies are drafted and in screening visitors.

For best practices to ensure compliance with AzDHS and other guidance, as well as how to ensure senior living visitation is appropriately tailored to avoid risk to residents and staff, consider contacting a Fennemore attorney.