COVID-19 Technical Assistance FAQs

What does the updated March 2021 guidance from CMS mean for Ombudsman access in long-term care facilities?

On March 10, 2021 the Centers for Medicare & Medicaid Services (CMS) updated their previous visitation guidance, in light of the introduction and impact of vaccines, expanding visitation in nursing homes in many situations. The updated guidance is effective immediately. Read a full summary of the guidance from Consumer Voice along with their key takeaways.

What This Means for Ombudsman Access:

Long-Term Care Ombudsman programs continue to have immediate access to any resident, but, as before that access does not have to be in-person access. In-person access can be limited due to infection control concerns in the same way access to other visitors is limited (refer to specific scenarios shared in the memo for limiting indoor visitation). However, it cannot be limited without reasonable cause. As with other visitors, Ombudsman programs do not have to be vaccinated to resume in-person visits.

Some additional important changes from the previous guidance include:

Indoor Visitation Should Be Allowed At all Times (with a few exceptions).

While outdoor visitation continues to be preferred, the guidance states “facilities should allow indoor visitation at all times and for all residents (regardless of vaccination status), except for a few circumstances when visitation should be limited due to a high risk of COVID-19 transmission (note: compassionate care visits should be permitted at all times).” Indoor visitation should be limited when:

• A resident is unvaccinated and the nursing home’s county positivity rate is more than 10% and less than 70% of residents are vaccinated.
• Residents have a confirmed COVID-19 infection.
• Residents are in quarantine.

The guidance allows facilities to schedule indoor visits and limit the number of visitors and length of visits based on their ability to maintain the core principles of infection prevention. It also discourages in room visits for residents with roommates.

Physical Contact

While encouraging facilities, residents, and families to adhere to the core principles of COVID-19 infection prevention, the guidance allows fully vaccinated residents to have close contact, including touch, with their visitors while wearing masks and following proper hand hygiene rules. Fully vaccinated residents can now hug their loved ones.

Indoor Visitation During an Outbreak

If an outbreak is limited to one particular area or unit of a facility – which means, if, after a positive case is identified, outbreak testing determines that cases are all within one area or unit, then visitation may resume in other parts of the facility. Compassionate care visitation and visits under federal disability rights law are always permitted.

Visitor Testing and Vaccination

CMS encourages visitors to become vaccinated when they can and acknowledges that facilities may encourage testing, however, they state that visitors should NOT be required to be vaccinated or tested or show proof of such as a condition of visitation.

The rest of the guidance, including Compassionate Care and Required Visitation and Access to Long-Term Care Ombudsman remains unchanged from the September 17th guidance.

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What tips for effective communications and strategies do you have when working with families during challenging situations?

The tips and strategies below are from the resource, Working with Families: Tips for Effective Communication and Strategies for Challenging Situations. Read more on this topic here.

The Coronavirus Disease (COVID-19) is an unprecedented pandemic. In our lifetime, we have never been in the situation of dealing with so many variables impacting us, our families, employers, family caregivers, and residents of long-term care facilities. In addition to the general stress of this pandemic, the way Ombudsman programs operate has been significantly impacted due to the temporary in-person visitation restrictions.

In-person visitation restrictions imposed to reduce the spread of COVID-19 required facilities, families, and Ombudsman programs to adapt quickly. The restrictions may increase family member’s feelings of stress and helplessness since they cannot interact with their loved ones in-person and observe their environment.

Below are resources, tips, and strategies to help Ombudsman representatives improve their skills in working with families during challenging situations.

Tips for Effective Communication

Strong communication skills are the foundation of Ombudsman program work and are vital to successful advocacy. By the time family members contact the Ombudsman program it is likely that they have been dealing with concerns related to their loved one for some time and may be frustrated. Before a representative can begin processing a complaint, they need to give the family member time to tell their story and express their feelings.

Below are some approaches that allow a representative to acknowledge a family member’s feelings before seeking the information necessary to handle a complaint.

• When speaking with family members that are upset, it may be helpful to refer to the resident as Mr.____ or Mrs. _____. As the conversation progresses, switch to “your mother” or “your aunt” depending on the relationship between the resident and the family member. Referring to the resident by the family connection may help the family member feel that you are listening to her experience.
• Discuss the role of the Ombudsman program, especially emphasizing that the program takes direction from the resident.
• Ask family members what they want the outcome to be. This can provide you with important information about the motivation of the person. For instance, if a son’s goal is to get the administrator fired, the case is not about the resident.
• Be clear about what you can and cannot do.  
• Explain that with the resident’s consent, you will investigate and get back to them as quickly as possible.

Most family members have never heard of the Ombudsman program. When they contact the program, it is generally because someone has told them “the Ombudsman can help” with a problem they have run into in the nursing home or assisted living facility. It is critical that representatives give families a clear understanding of their role right from the very beginning.

Self-Advocacy Skills to Empower Family Members

While some family members may not hesitate to advocate on their own when a problem arises, others may be reluctant to speak up on behalf of a loved one. Many families fear retaliation, or they may feel as though they do not have enough knowledge about how the facility operates and may not know the best way to approach problem-solving.

Here are a couple of ways representatives can respond when family members are reluctant to voice their concerns due to fear of retaliation.

• “While we will do what we can to prevent it, I can’t guarantee that there won’t be retaliation. However, I am sure that nothing will change if you don’t speak up, and the program will be here for the resident.”
• “Federal nursing home regulations state the resident or resident’s legal representative has the right to voice grievances without the fear of reprisal and you can file a complaint if you or your loved one experience retaliation.”

Encourage family members to document all aspects regarding their complaint (e.g., examples supporting their complaint, when they addressed the complaint with staff and how staff responded) to have a timeline of events if they need to file a complaint due to retaliation. Helping family members to advocate on their own, and if necessary, to overcome barriers to self-advocacy, is at the heart of Ombudsman program work.

Strategies for Addressing Challenging Situations

There may be times when a representative finds themselves addressing some complicated and challenging situations with family members. Because each situation and each family are different, there are no “one size fits all” solutions. Nevertheless, here are some “tips” from experienced representatives about approaches that may be helpful in certain situations.

Family resistance to working with a particular representative:

• Try to determine the reason for the resistance as that will influence how a representative responds. For example, if a family is resistant because they believe the representative is on the “facility’s side,” see if you can determine what led to that belief. This impression sometimes arises when family members observe the representative speaking with the administrator or staff. Have a conversation to address the concerns of the family.
• Ask another representative to accompany you. For example, representatives that use this approach have found that having the second representative listen and respond to the family can make a difference. The second representative may repeat what the first representative said, but because the words are coming from another person, the family member may hear it differently.

When family wishes conflict with resident wishes:

Since Ombudsman program advocacy is resident directed, representatives are guided by what the resident wishes. If the resident can communicate what she wants and does not want the complaint to be pursued, the representative must honor her request. If someone other than a resident, such as a family member, contacts the Ombudsman program with a complaint the representative will visit the resident to see if the resident has similar concerns and wants to pursue the complaint. If the resident does not want anything to be done, the representative would explain to the original complainant that she needs to follow the resident’s direction. 

It is important to remember that most families care deeply for the resident and are very concerned about their well-being. As a result, simply saying “I can’t work with you” can leave families anxious and worried. Instead, here are some approaches a representative might try:

• Share positive observations about the resident with the family member. For example, after hearing a daughter’s concern that her mother was poorly groomed and learning from the resident that she did not want the representative to do anything, the representative reported the resident’s response back to the daughter. However, the representative also shared with the family member that she had observed that her mother looked neat and well-groomed, and that staff appeared very attentive.
• Tell the family that you will see if you observe the problem yourself or if any other residents are experiencing the same problem.
• Inform the family member that you will check back with the resident again in a few weeks to see if she has changed her mind.
• See if there are other residents with the same issue who are willing to pursue it to resolution. By resolving the issue for others, you might be able to resolve it for the resident who does not want you to proceed on her behalf.
• Inform families about what they can do to take action to achieve the outcome the resident would want (e.g., facilitate a conversation between the resident and family member).
• Encourage families to take their concern to the family council. If there is not an existing family council, encourage them to form one and provide them with resources and information about family councils.

The role of the Ombudsman program when working with family members will vary depending on the resident’s capacity and the situation. When working with families, sometimes the most important role of the representative is to provide them with support and information. Family members need someone outside of the long-term care facility who understands the regulations and knows about good care practices and how facilities operate.

 

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Can long-term care facilities accept food delivered by families or restaurants for residents during COVID-19?

Ombudsman programs have asked us if long-term care facilities can accept food delivered by families or restaurants for residents during the COVID-19 pandemic.

To our knowledge, the Centers for Medicare and Medicaid Services (CMS) has not provided guidance about accepting food for residents from outside of the facility. However, based on the information from the Centers for Disease Control (CDC) provided below there appears to be no reason to ban food provided from outside of the facility.

The Centers for Disease Control (CDC) says the following in response to the frequently asked question about spreading the virus through food.

Can the virus that causes COVID-19 be spread through food, including refrigerated or frozen food?

Coronaviruses are generally thought to be spread from person-to-person through respiratory droplets. Currently there is no evidence to support transmission of COVID-19 associated with food. Before preparing or eating food it is important to always wash your hands with soap and water for 20 seconds for general food safety. Throughout the day wash your hands after blowing your nose, coughing or sneezing, or going to the bathroom.

It may be possible that a person can get COVID-19 by touching a surface or object that has the virus on it and then touching their own mouth, nose, or possibly their eyes, but this is not thought to be the main way the virus spreads.

In general, because of poor survivability of these coronaviruses on surfaces, there is likely very low risk of spread from food products or packaging that are shipped over a period of days or weeks at ambient, refrigerated, or frozen temperatures.

Since restaurants are closed in many states, except for delivery or take-out, there are also some general tips available for receiving food deliveries (e.g., the Today Show had a recent segment that recommends wiping off the containers and washing hands before eating, an article in the Los Angeles Times recommends leaving “the outermost delivery bag on the doorstep (to throw away) if applicable, and carry just the containers inside”).

If you receive complaints about this issue you can share the CDC frequently asked question with facility staff and see if your state survey agency or local public health authority has additional guidance.

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COVID-19: What are the updates on resuming nursing home visitation?

On September 17, 2020, the Centers for Medicare & Medicaid Services (CMS) issued new guidance, which is effective immediately, allowing the resumption of visitation in nursing homes if certain conditions are met.  

Below you will find a summary of the guidance and what it means for residents and Ombudsman programs. 

Visitation Must Be Person-Centered

Each resident’s physical, mental, and psychosocial well-being must inform considerations about visitation. Facilities must ensure that visits are private. 

The guidance identifies “core principles” which must apply to all visits. These principles include screening, hand hygiene, face coverings, and social distancing. The guidance repeatedly emphasizes that visitation must be person-centered. Accordingly, this requirement empowers residents and advocates to seek the most appropriate form of visitation that meets the individual resident's needs.  

Outdoor Visitation Preferred

CMS gives preference to outdoor visitation when possible. Facilities must create accessible and safe outdoor spaces and a process to limit the number of visits and people visiting any one resident. Considerations such as weather and air quality must be considered along with the resident’s health and the status of COVID-19 outbreaks in a facility. 

Here, a focus on person-centered principles will be necessary. Although outdoor visitation is preferred, it will not be feasible for all residents.  In cases where outdoor visitation is not possible, indoor visitation must be considered. Further, as we enter the fall and winter seasons, many residents will be unable to visit outside. Other considerations could be air quality, such as humidity or smoke. 

Indoor Visitation Allowed

According to the guidance, facilities that have had no new cases in the past 14 days and are not in communities with “high” community transmission should accommodate visitors who follow the core principles identified above. Visitors must be limited in movement in the facility and the number of visitors must be limited. Facilities must monitor the infection rate in the county in which the facility is located 

CMS does not distinguish between “essential caregivers,” a category of visitors allowed in some states, from other visitors. CMS again emphasizes a person-centered approach, indicating that residents and their advocates may use the guidance to help facilitate care from loved ones. 

Compassionate Care Visits

This guidance makes clear that compassionate care visits are not limited to end of life situations, but are available to residents for a variety of reasons, including residents struggling are experiencing emotional distress or who are declining and need assistance eating and drinking. Importantly, compassionate care visits are available at any time, regardless of the level of infection in the community.  

Visitation is Mandatory Unless Facilities Have Adequate Reason Related to Clinical Necessity or Resident Safety

Under the new guidance, facilities may restrict visitation due to:

• The COVID-19 county positivity rate.
• The facility’s COVID-19 status.
• A resident’s COVID-19 status.
• Visitor symptoms.
• Lack of adherence to proper infection control practices.
• Other relevant factors related to COVID-19.

However, when restricting visitation, the facility must cite a reasonable cause related to safety or clinical necessity. To illustrate this requirement, CMS states that a facility with no new COVID-19 cases in the past 14 days and with a COVID-19 county infection rate below 10% MUST facilitate indoor visitation. 

CMS makes clear that facilities who do restrict indoor visitation absent a clinical or safety reason will be subject to citation and enforcement.   

Ombudsman Access

The guidance requires facilities to allow Ombudsman program access to residents. Facilities may limit access due to infection control concerns or COVID-19 transmission but cannot limit access without reasonable cause. 

If access is denied, refer facilities to the guidance and inquire about the limitations. If facilities continue to deny access without providing reasonable cause per the guidance, consult with your supervisor and/or State Ombudsman.  

Communal Activities and Dining

The guidance permits communal activities and dining.  Social distancing must be followed along with other infection control procedures.

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