The Georgia Department of Public Health re-issued guidance for long-term care facilities with respect to phased reopening and expansion of in-person visitation. This guidance was issued through an Administrative Order on September 21, 2020 and replaces a more stringent order issued several days prior. The revised guidance is more closely aligned with the September 17, 2020 Federal nursing home visitation guidance issued by the Centers for Medicare and Medicaid Services.
The guidance applies to intermediate care facilities, personal care homes, skilled nursing facilities, inpatient hospice, and assisted living communities. In the newly reissued guidance, DPH revises the Phase Identification thresholds used to trigger changes in facility operations as facilities transition through each of the three phases. Specifically, for all phases, the guidance eliminates all references to the 14-day county case rate so that facilities now must refer only to the 14-day county positivity rate for all transition determinations. For facilities to transition to Phase II, facilities must have conducted baseline testing of residents and direct care staff; there must be no new onset of COVID-19 cases in the last 14 days (down from 28 days in the original DPH guidance); and the 14-day county positivity rate must be between 5% and 10%. The requirements are the same for Phase III, except that the 14-day county positivity rate must be below 5%.
In keeping with statements by CMS that facilities need not necessarily use CMS county positivity data, which many providers say lags behind data maintained by other sources, the reissued DPH guidance includes a link to the DPH COVID-19 Status Report website which include the 14-day PCR positivity rate by county. The data on the website is updated every Monday. CMS has provided that facilities should consult the same source consistently for their positivity rate data.
Regarding visitation, the reissued guidance organizes the information by type of visitation:
- Window Visits – Window visits are permissible in all three phases of reopening, subject to certain restrictions. Window visits in a resident’s room may be feasible even in an outbreak situation. If a resident does not have a room on the ground floor and would need to be transported elsewhere in the building, window visits are restricted to non-symptomatic and non COVID-19 positive residents unless the facility is weathering an outbreak, in which event such visits outside a resident’s room cannot be conducted.
- Outdoor Visits – Like window visits, outdoor visitation is also permissible in all three phases of reopening, subject to restrictions. This is a change from DPH’s original September 15 guidance, which restricted outdoor visitation to Phases II and III. In an outbreak situation, outside visits are restricted to non-symptomatic and non-COVID positive residents and only if the facility determines that it has sufficient staffing to assist with transportation of residents, conduct observation of the visit (while still allowing for privacy), and assist with cleaning and disinfecting the visitation area. The CMS memorandum includes a seemingly broader requirement, which states, in pertinent part, “Aside from . . . a facility’s outbreak status, outdoor visitation should be facilitated routinely.”
- Limited Indoor Visits – Indoor visitation is prohibited during Phase I of reopening but is permitted in Phases II and III. In both phases II and III, the facility must have completed baseline testing of residents and direct care staff, and be without any new “facility onset” cases of COVID-19 for 14 days. Use of the term “facility onset” in this case creates some ambiguity. It is unclear whether the term is limited to residents only or includes staff, which would be consistent with the CMS definition of an outbreak. Further, the CMS memorandum includes an additional requirement that the facility must not be in the midst of conducting outbreak testing. The DPH guidance omits this requirement. The DPH guidance provides that facilities will need to assess their ability to manage indoor visitation in terms of staffing, sufficiency of needed supplies, and other considerations. They will also need to develop a visitation policy to address such considerations as scheduling logistics, the number of visitors and visits, infection control protocols, personal protective equipment use, screening, testing of visitors (if feasible and especially for those who visit more than once per week, and visitor movement within the facility.
- End of Life and Compassionate Care Visitation – In keeping with the CMS guidance, the reissued DPH guidance expands the notion of compassionate care visitation beyond end of life situations. The guidance provides that compassionate care situations include recently admitted residents who are struggling with the new environment, those experiencing grief from the loss of a loved one, and those having other forms of physical or emotional distress. The guidance also includes a host of protocols that must be followed by facility staff during end of life and compassionate care visits to reduce the possibility for transmission of the virus.
Though the bulk of the DPH guidance seems to have been written with nursing homes in mind, it is nevertheless applicable to several types of long-term care facilities. As a result, these other facilities will need to review the guidance closely and adapt it to their specific needs.
The reissued guidance became effective on September 21 and will remain in effect until the conclusion of the State’s Public Health State of Emergency or until further revisions are issued.