FAQ For Nursing Home Visitation in Tennessee

The Tennessee Department of Health recently released it guidance for Visitation and Activities Guidance for long term care facilities (LTCF). With so much uncertainly, we wanted to share the most Frequently Asked Questions.

Please note that the State’s LTCF Visitation and Activities Guidance documents are not regulations and are not enforced as regulations. The intent is for the guidelines to be flexible enough to inform facility decisions on visitation and activities.

Visit the TN Dept of Health >>

View, download and print the FAQ document here >>

1.   Where can I read a copy of the CMS visitation guidance (QSO 20-39-NH) released on September 17, 2020?
A copy of the CMS visitation guidance is located at:
https://www.cms.gov/files/document/qso-20-39-nh.pdf 

2.   Where can I read a copy of the Tennessee Visitation and Activities Guidance?
A copy of the Tennessee increased visitation and activities guidance is located at:
Visitation
Activities & Dining

3.   When did the TDH visitation guidance go into effect?
They were effective as of October 1, 2020.

4.   How should facilities make plans to operationalize and prepare for visitation?
The facility needs to develop internal policies and procedures for how they will welcome visitors and ensure the safety of residents and staff. Additionally, facilities can choose to have more stringent policies than guidance provided by the Tennessee Department of Health, as CMS allows.

5.   As a CMS certified nursing facility, where can I check my county’s positivity rate?
County positivity data is available here.
The data will be updated once weekly, on Sundays, with data for the prior 7 days (Sunday through Saturday), and will be a 7-day average of the percent of SARS-CoV-2 PCR tests that are positive by county (by test report date).

6.   How often should I check the positivity rate?
TDH strongly recommends that a facility check the website weekly to ensure the most up to date county positivity rate.

7.   What Are the Core Principles of COVID-19 Infection Prevention?
Regardless of how visits are conducted, there are certain core principles and best practices that reduce the risk of COVID-19 transmission:

• Screening of all who enter the facility for signs and symptoms of COVID-19 (e.g., temperature checks, questions or observations about signs or symptoms), and denial of entry of those with signs or symptoms
• Hand hygiene (use of alcohol-based hand rub is preferred)
• Face covering or mask (covering mouth and nose)
• Social distancing at least six feet between persons
• Instructional signage throughout the facility and proper visitor education on COVID-19 signs and symptoms, infection control precautions, other applicable facility practices (e.g., use of face covering or mask, specified entries, exits and routes to designated areas, hand hygiene)
• Cleaning and disinfecting high frequency touched surfaces in the facility often, and designated visitation areas after each visit
• Appropriate staff use of Personal Protective Equipment (PPE)
• Effective cohorting and quarantining of residents (e.g., separate areas
  dedicated COVID-19 care or those possibly exposed)
• [For Nursing Homes] Resident and staff testing conducted as required at 42 CFR 483.80(h) (see QSO-20-38-NH)

8.   What visitation opportunities are always allowed?
Visitation that is always allowed includes: accommodations or support for residents with disabilities; critical assistance; compassionate care/end of life situations; or involvement in a religious exercise.

9. May a Facility adopt a policy allowing ONLY outdoor visitation?
ACLF: Yes. Tennessee’s guidelines allow outdoor visitation if the Facility has had no new cases within the last 14 days and limited indoor visitation if there are no new cases within the last 28 days. However, a Facility may always adopt more stringent policies than are provided for in the guidance.

SNFs: Skilled nursing facilities should follow CMS Guidance that states that “all visits should be held outdoors whenever practicable” because “outdoor visits pose a lower risk of transmission due to increased space and airflow.” A SNF must have “a reasonable clinical or safety cause” for not allowing indoor visitation; however, CMS Guidance includes various factors that the Facility can use to develop such a restriction in its visitation policy.

10. Are children restricted from visiting?
All Facility visitors should be able to adhere to the facility’s policies and core infection control principles. Individuals, such as children, who are likely to have difficulty adhering to those requirements can be limited from visiting from the facility. A facility can consider allowing children when the visit involves compassionate care and/or end life situations. Note, however, that all individuals visiting, regardless of age, should “count” as a visitor under any restrictions on the number of visitors a facility adopts in its policies.

11. What if I have a resident who is bedbound and unable to leave their room. Can indoor visits be conducted in-room?
Yes. For skilled nursing, assisted care living facilities and residential home for the aged, indoor visitation is allowed in a resident’s room when:

• Resident is unable to leave the room; AND
• Visitor has had negative PCR test collected within previous 72 hours; OR
• Visitor has negative onsite point-of-care-test at the facility.

However, to allow any indoor visitation, the facility must have had no new onset of COVID-19 in last 14 days and there must be no outbreak testing continuing within the facility (e.g. from a prior case or outbreak).

12. Should visits be scheduled in advance?

Yes, the facility should develop a system for scheduling visits with family and friends. This applies to both outdoor, indoor visitation, and essential caregiving visits.

13. Is there a limit to the number of visitors a resident can have?
The facility may limit the total number of visitors on a given day/week/etc. based on the ability of the facility to staff and supervise visits. The facility may also limit the number of visitors for each individual resident based on any given day/week/etc. To allow all residents to have visitors, it may also impose limits on the number of visit times allocated to each individual resident.

14. Can a facility prohibit certain individuals from visiting?
Yes. Under both CMS and Tennessee guidance, Visitors who are unable to adhere to the core principles of COVID-19 infection prevention or the facility’s policies should not be permitted to visit or should be asked to leave. The facility can also restrict visitors based on screening for signs and
symptoms of COVID-19, or risks of prior exposure (i.e., close contact with positive or suspected individuals).

15. If a visitor is not visiting the resident in-room, but is just visiting indoors, must a visitor have a negative COVID-19 test?
No, visitors are not required to have a negative COVID-19 test result when visiting with a resident in a designated indoor space. However, visitors should wear a face covering and maintain six (6) feet of social distancing. Additionally, a facility may adopt more restrictive criteria for indoor visitation (for example a requirement to all visitors to provide a negative test.)

16. Can a facility require visitors to provide a negative test?
Yes, a facility can require visitors to be tested. Both CMS and Tennessee visitation guidance encourage visitor testing. In the Tennessee guidance, any visitor who is visiting indoors within a resident’s room must have a negative COVID-19 test result either from a PCR test within the previous 72 hours OR from an onsite point-of-care test at the facility. A facility can require the visitor to obtain their own test prior to visitation or conduct the test for the visitor.

ACLFs and RHAs: If the Facility is going to designate an individual visitor as an “essential caregiver” then in addition to a negative test at the time of the visit, the Tennessee guidance requires regular testing The Facility must test each essential caregiver (or require them to be tested) based on the positivity rate in the county where the facility is located (i.e., twice weekly/once weekly/once monthly). This could be accomplished by having a negative PCR test collected within previous 72 hours OR having a negative onsite point-of-care test at the facility.

SNFs: CMS’s Visitation Guidance does not distinguish between “essential caregivers” or other types of visitors. However, a SNF may incorporate Tennessee guidance on “essential caregivers” into its visitation policy or may adopt a policy applying to all visitors equally using a person-centered approach.

17. Do essential caregivers have to be tested?
Essential caregivers are subject to the regular testing required of the staff (see testing frequency table below as established by CMS Rules listed in the LTCF visitation guidance). A facility can view the state’s data for county positivity rate here.


18. Does Centers for Medicare and Medicaid Services (CMS) recognize Essential Caregivers in skilled nursing facilities?

No. The CMS QSO-20-39-NH memo states the following: “We understand that some states or facilities have designated categories of visitors, such as “essential caregivers,” based on their visit history or resident designation. CMS does not distinguish between these types of visitors and other visitors. Using a person- centered approach when applying this guidance should cover all types of visitors, including those who have been categorized as “essential caregivers.”

19. Can a COVID-19 positive resident or patient have visitors?
Residents who are on transmission-based precautions for COVID-19 should only receive visits that are virtual, through windows, or in-person for compassionate care situations, with adherence to transmission-based precautions. However, this restriction should be lifted once transmission-based precautions are no longer required per CDC guidelines, and other visits may be conducted as described above.

20. If a facility has one or more new cases of COVID-19, should visitation and activities be discontinued?
ACLFs: ACLFs should follow Tennessee visitation and activities guidance. This guidance states that when there is a new case in the facility all visitation should cease, with the exception of compassionate care visits.

SNFs: SNFs should follow CMS 20-39 when deciding when to cease visitation.

21.  If a Facility is in a county with a Red/High Positivity Rate Can/Should It Continue Visitation?
ACLF: Tennessee’s guidelines are based on the incidence of new cases in the facility. The high county positivity rate would not require the facility to cease visitation.

SNFs: CMS’s Visitation Guidance in QSO-20-39-NH states that if a facility is a High/Red County, then indoor visitation should only occur for compassionate care situations according to the core principles of COVID-19 infection prevention and facility policies.

Outdoor visitation may be allowed/continued, because CMS’s guidance states that “county positivity rate does not need to be considered for outdoor visitation.”

22.  Can we use plexiglass or divider curtains for either outdoor or indoor visitation?
Yes. Please see additional guidance about construction of visitation booths and visitation rooms, which can be found here.

Note that if the facility is using an existing room for group indoor visitation, it does not need to seek approval from the Tennessee Department of Health if there is no construction or modification involved. Additionally, the Centers for Medicare & Medicaid Services (CMS) allows use of Civil Money Penalty Reinvestment funds to provide nursing homes with in-person visitation aids. Funding is strictly for in-person visitation, which includes purchase and/or rental of tents or other shelter for outdoor visitation, and/or clear dividers to create a physical barrier to reduce the risk of COVID-19 transmission during in- person visits. The maximum funding request is $3,000 per nursing home, which can include installation, materials and shipping costs. For information or to apply, please contact Shaquallah Shanks at Shaquallah.Shanks@tn.gov or (615) 741-6823.

23. Can a facility use portable heaters for outside visitation?
Yes, but it must adhere to the following standards:
Fired Heaters
1.   Only labeled heating devices shall be used. [NFPA 101-11.11.6.1.1]
2.   Fuel-fired heaters and their installation shall be approved by the authority having jurisdiction. [NFPA 101-11.11.6.1.2]
3.   Containers for liquefied petroleum gases shall be installed not less than 60 inches from any tent and shall be in accordance with the provisions of NFPA 58, Liquefied Petroleum Gas Code.
[NFPA 101-11.11.6.1.3]
4.   Tanks shall be secured in the upright position and protected from vehicular traffic.
[NFPA 101-11.11.6.1.4]

Electric Heaters
1.   Only labeled heaters shall be permitted. [NFPA 101-11.11.6.2.1]
2.   Heaters used inside a tent shall be approved. [NFPA 101-11.11.6.2.2]
3.   Heaters shall be connected to electricity by electric cable that is suitable for outside use and is of sufficient size to handle the electrical load. [NFPA 101-11.11.6.2.3]

For additional questions regarding tents and appropriate heat sources, please contact Nelson Rodriquez, Nelson.Rodriguez@TN.Gov or (615) 306-8424.

24.  When can a facility resume activities and communal dining if it has suspended those activities?
Once a facility has gone 14 days with no new COVID-19 cases, facilities may resume resident activities.

SNFs: Note that CMS QSO-20-39 states that facilities may allow communal dining and activities while adhering to the core infection control principles. Facilities may also consider additional limitations based on status of COVID-19 infections in the facility.

25. Should a resident be quarantined after returning from a routine medical appointment?
There are not currently any requirements for quarantining residents after returning from a routine medical appointment. Facilities should ensure proper steps are taken to protect a resident using face coverings, sanitization of equipment between transports, and screening.

26.  Should a resident be quarantined after hospitalization or an emergency room visit?
A fourteen (14) day observation period is recommended. Per the Centers for Disease Control and Prevention (CDC), “

27.  As we prepare for the upcoming holiday season, what steps should we take if a resident temporarily leaves the facility for a holiday meal or celebration?
If it is for an extended period (multiple days) or for a limited time (i.e. same day or few hours), a fourteen (14) day observation period is recommended for the resident.

28. Are facilities allowed to have interns or students return for clinical rounds?
Yes, note that interns or students are included within the definition of “staff” under the CMS testing rule and therefore must be tested at the same frequency as employees under the CMS testing rule (see 42 C.F.R. §483.80(h)).

29. Are volunteers allowed back into the facility?
Yes, volunteers are included within the definition of “staff” under the CMS testing rule and therefore must be tested at the same frequency as employees under the CMS testing rule (see 42 C.F.R. §483.80(h)).