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COVID-19 Safe and Limited Re-Opening of Long-Term Care Facilities

by the Agency For Health Care Administration

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On October 22, 2020, at the direction of Governor Ron DeSantis, Florida Division of Emergency Management Director Jared Moskowitz issued Emergency Order 20-011 revising some of the requirements for individuals entering residential and long-term care facilities. The information in this blog is content written and published by the Agency For Health Care Administration.

Key revisions in the Governor’s Order

  • Collapse Essential Caregiver into the Compassionate Caregiver definition
  • Require signage in the facility for infection control reminders
  • Clarify hospice may serve their residents
  • Allow resident visits from their legal counsel when virtual means are not available
  • Eliminate maximum limit on the number of visitors a resident may have listed – the facility must have policies addressing the number of visitors allowed with a resident or in the facility at one time
  • Allow children to visit with appropriate monitoring
  • Allow outdoor visitation regardless of facility COVID-19 cases

Changes in the Order align with federal Centers for Medicare and Medicaid Services (CMS) requirements for nursing facilities. Nursing facilities are expected to follow both state and federal requirements.

Q & A About Access To Senior Facilities During COVID-19

1. Effective Date – When does the Emergency Order (Order) take effect?

Answer: The Order was effective on October 22, 2020. Facilities must comply with requirements in the Order before beginning visitation but are expected to move quickly to have all appropriate measures in place to enable visitors to enter the facility. No additional rules or regulations are needed from the state to proceed.

2. Affected Facilities: Which facilities are subject to the Order?

Answer: The Emergency Order addresses visitors in the following types of facilities under each of the following agencies below: Agency for Persons with Disabilities: Group Home Facilities APD-licensed Foster-Care Facilities Developmental Disability Centers Department of Children and Families: Adult Forensic Facilities Mental Health Commitment Civil Facilities Agency for Health Care Administration: Nursing Homes Homes for Special Services Transitional Living Facilities Intermediate Care Facilities for the Developmentally Disabled Assisted Living Facilities including those offering Memory Care programs Adult Family Care Homes Adult Mental Health and Treatment Facilities

3. Hospitals: Does the Order apply to hospitals or long-term care hospitals?

Answer: No, the Order does not apply to visitation in hospitals including long-term care hospitals. Hospitals are non-residential settings and must have their own procedures for visitor screening. Please note that hospital-based skilled nursing units must comply with federal CMS requirements for visitation.

4. Visitor Screening and Testing: Does a visitor need to be screened or tested to enter the facility?

Answer: Facilities are required to continue visitor screening (i.e., temperature checks and COVID-19 signs, symptoms, and exposure screening questions). Long-term care facilities are strongly encouraged to utilize testing resources to perform COVID-19 testing for visitors and staff and many have received Point of Care tests to use for this purpose. If the facility conducts testing, it must be based on current CDC and FDA guidance and results must be reported to the Department of Health, as required. Facilities may also encourage visitors to be tested on their own prior to coming to the facility (e.g., within 2–3 days) with proof of negative test results and date of test. Regardless of testing, screening must still be conducted.

5. Testing Cost: Can facilities require visitors pay for testing?

Answer: If a facility requires testing of visitors prior to entry, the facility cannot pass the cost of testing on to the visitor.

6. Personal Protective Equipment (PPE) – Is the facility required to provide PPE for visitors?

Answer: The facility must make sure the visitor wears the appropriate PPE including a face mask, but is not required to supply it to the visitor. The facility should allow the visitor to wear their own PPE unless it does not meet the requirements. For example, a Compassionate Care visitor must wear a surgical mask, therefore if the Compassionate Care visitor arrives with a bandana or inappropriate face covering, that would not be allowed. The facility may offer a surgical mask if one is available, but they are not required to provide.

7. Resident contact: Can visitors have physical contact with a resident, such as a hug?

Answer: Only Compassionate Care visitors may have physical contact with the resident during visitation if they wear appropriate PPE and follow infection control guidelines. Those visitors entering for General Visitation may not have physical contact with a resident. Visitor Scheduling

8. Visit Location: Can multiple visitations occur at the same time in a large, common area if each group maintains minimum distance from others?

Answer: This is acceptable as long as residents may have private communications with their visitors, and infection control precautions are followed, including properly wearing face masks.

9. Visit Duration: How does a visitor schedule these visits? And how often can they occur?

Answer: Facilities are required to schedule visitors by appointment and monitor adherence to proper use of masks and social distancing, while allowing for auditory privacy. Facilities must also notify and inform residents, their representatives and recurring visitors of any change in the visitation policy. Compassionate Care Visitors

10. What is the difference between a Compassionate Care Visitor and a General Visitor?

Answer: Compassionate Care Visitors are those who visit to assist with a difficult time or event for the resident, and those who provide assistance and support including emotional support to a resident (similar to what was allowed for Essential Caregivers under the prior rule). Compassionate Care Visitors are generally close family members or friends of the resident. Examples of a General Visitor may be a friend or family member who visits occasionally, young children or grandchildren accompanied by adults, an out-of-town visitor, or clergy (other than for end of life visits or other circumstances which qualify as compassionate care).

11. Required Access: Are facilities required to allow Compassionate Care visitors?

Answer: Facilities must allow entry of Compassionate Care visitors who meet the requirements in the Order. Compassionate Care visitors are not required to be addressed in the resident care plan or service plan.

12. Designation: How does an individual become a recognized Compassionate Care Visitor? Must they register with the Department of Health (DOH) or Agency for Health Care Administration (AHCA)?

Answer: Compassionate Care Visitors should discuss their interest with the facility for visitation during a resident’s difficult situation or to provide support, including emotional support. Compassionate Care Visitors work directly with the facility and do not have to register with DOH or AHCA.

13. Visit Duration: Can the facility limit the length of time of a Compassionate Care Visitor’s visit?

Answer: Facilities must schedule visitor time and be able to manage visitors in a fair manner for all residents. Although the Order does not create a maximum visit length, facilities and Compassionate Care Visitors should work together to establish reasonable visit length to accommodate the services provided, while recognizing the facility’s responsibility to manage visitation. General Visitation

14. Required Access: Are facilities required to allow General Visitation?

Answer: Facilities that are eligible based on the conditions in the Order for General Visitation must permit visitors who meet screening and other requirements in the Order. Visits can occur in outdoor spaces, indoor spaces, or both. The Order also prescribes requirements of facilities related to these individuals. If a facility does not meet criteria for indoor General Visitation, outdoor visitation may occur.

15. Visitation Hours: Can communities determine their specific visitation hours, for example, from 9 to 6 p.m. instead of 9 to 9 p.m.?

Answer: Reasonable visitation hours may be established for general visitation. The facility must develop an agreeable schedule for compassionate care visits that considers the visitor’s availability, including evenings and weekends.

16. Children Visiting: Is a facility required to allow children to visit?

Answer: Children may visit long-term care facilities and a facility may not prohibit children as a rule. The facility should have reasonable policies for visitation which should address the need to monitor visitors. Young children should be accompanied by an adult and monitored for adherence with infection control protections. The facility must revoke visitation for any person unable to comply with the infection control protections after attempts to address concerns.

17. Facility Eligibility COVID Status: How does a facility determine if they meet the requirement for 14 days with no new facility-onset resident cases?

Answer: The date of onset is the day a COVID positive resident began their symptoms or tested positive if they are asymptomatic. A facility can hold General Visitation if 14 days have passed since onset of the most recent resident COVID positive case.

18. Outdoor Visitation: Can a facility allow outdoor general visitation even if there have been new COVID-19 cases in the last 14 days?

Answer: Yes, outdoor general visitation is permitted even if the facility has had recent COVID-19 cases; however, an individual resident may not receive general visitors if they are suspected or confirmed for having COVID-19.

19. Facility Eligibility Information: How will a family member know if a facility meets the requirements for General Visitation?

Answer: The facility should explain their visitor status with respect to criteria in the Order to all residents and their families.

20. Sponsored Services: May a facility allow a person to enter to host church services or entertainment for residents? [specific question: Can we begin allowing entertainers inside / outside? Church services in our building? Are we required to COVID test those individuals? Can we have more than 10 residents attend if socially distanced?]

Answer: Based on current CDC guidance, group activities (such as church services or entertainment activities) may be facilitated (for residents who have fully recovered from COVID-19, and for those not in isolation for observation, or with suspected or confirmed COVID-19 status) with social distancing, appropriate hand hygiene, and use of a face covering. Arrange tables and chairs to allow for social distancing and encourage visitors and residents not to form a line at the door.

21. Barber and Salon Services: If the facility has a large spa area, may they serve more than one resident at a time if socially distanced?

Answer: Yes, as long as all expectations regarding barber and salon services in the Order are followed and residents are socially distanced, more than one resident may receive services at the same time.

22. Tours for Prospective Residents: May a facility allow tours by prospective residents and their families?

Answer: Facilities that meet criteria for General Visitation, may make arrangements for a tour by no more than two individuals as long as the visitors comply with the same requirements for General Visitation and are accompanied by facility staff at all times.

23. Holiday Leave: Can a resident leave the facility for a holiday visit with family and are there restrictions on the length of absence?

Answer: Residents must be permitted to leave the facility if they wish, including holiday visits. There is no restriction on the length of absence and it may include an overnight absence. Residents leaving the facility temporarily must wear a face mask, if tolerated by the resident’s condition. Eye protection should also be encouraged. All residents must be screened upon return to the facility. Families must be informed of necessary precautions to take during the absence, and of the requirement to screen the resident upon return to the facility.

Any time a resident is out in the community, the resident and the resident’s family should encourage adherence to infection prevention and control requirements, including social distancing and especially hand hygiene. In addition to routine screening criteria for temperature and symptoms, screening for returning residents should assess potential exposure such as contact with anyone who was symptomatic, attendance at large gatherings and adherence to social distancing. If upon return, the resident does not pass screening criteria, they should be quarantined or isolated based on their circumstances consistent with CDC guidance. If the resident passes screening criteria, then they do not have to be quarantined or isolated. Please continue to monitor any updates from the CDC or Department of Health.

Many individuals who contract COVID-19 may not display symptoms or test positive for several days after exposure, so it is still critical to diligently follow infection control precautions for residents returning from an absence including wearing a mask, hand washing, and social distancing. Facilities may consider re-testing residents periodically after an extended absence.

Long-term care facilities are strongly encouraged to utilize testing resources to perform COVID-19 testing for residents returning from absences. Many facilities have received Point of Care tests that may be used for this purpose; however, this should not be the only tool to monitor residents. Symptomatic individuals who test negative with a Point of Care test should still be quarantined, and retesting using a PCR test should be considered. If the facility conducts testing, it must be based on current CDC and FDA guidance and results reported to the Department of Health as required.

Agency For Health Care Administration

The content provided by the ACHA in an effort to let people know how to safely resume visits to loved ones in long-term care facilities in Florida. If you have questions about access, you may contact ACHA or The Miller Elder Law Firm who specializes in the laws affecting aging and special needs adults. Connect with us at 352.379.1900 and we will guide you through any access issues you and your family are experiencing.