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Guidance for Outdoor Visitation and  Activities Relative to the 2019-Novel Coronavirus (COVID-19) in Long-Term Care  Facilities

Pursuant to Health Officer Order No. C19-02, as amended, this Guidance is Mandatory for Long-term Care Facilities

Published:  November 23, 2020

One strategic approach protecting nursing home and long-term care residents from COVID-19 has focused on limiting non-essential visitation. Sonoma County Public Health Division (SCPHD) recognizes that physical separation from family and other loved ones increases the risk for medical, social and emotional complications. Isolation can lead to depression, anxiety, and other signs of distress. SCPHD offers the following guidance promoting safer visitation and activities to improve the quality-of-life for seniors in long-term-care settings.

Core Principles of Infection Prevention for COVID-19
The following core principles inform this guidance and are effective measures for reducing the risk of COVID-19 transmission.

  • Physical Distancing: A minimum of 6 feet between individuals
  • Universal Screening: Screening individuals for signs and symptoms consistent with COVID-19, recent close contact with a confirmed COVID-19 case, and pending COVID-19 test results
  • Face Coverings: Use of recommended face covering or face mask that covers the nose and mouth
  • Hand Hygiene: Use of alcohol-based hand sanitizer or use of soap and warm water for 20 seconds
  • Cleaning: Frequent disinfection of high touch surfaces and common areas
  • Testing: Early identification of cases through COVID-19 testing
  • Taking Care of Yourself: Stay home when you do not feel well, and follow local isolation and quarantine instructions when directed

Visitation can be conducted through different means based on a facility’s environment and residents’ wants. Facilities will need to determine whether outdoor spaces, indoor visitation areas, or resident rooms are most appropriate based on Sonoma County’s risk level, the facility’s circumstances, as well as the individual’s needs and capacity. Long-term-care facilities should also enable visits to be conducted with an adequate degree of privacy. Regardless of where visits are conducted, adherence to the Core Principles, the Minimum Requirements and Basic Guidelines listed below will reduce the risk of COVID-19 transmission. The Minimum Requirements and Basic Guidelines must be followed for visitation and activities to occur.

Minimum Requirements to Prevent COVID-19 Infection in Long Term Care
To reduce the risk of COVID-19 transmission, all of the following must be in place prior to a facility re-opening non-essential visitation.

  • Adequate staffing: The facility must not be experiencing staff shortages.
  • Personal Protective Equipment (PPE): The facility must have adequate supplies (14 days in-stock) of PPE for staff.  All staff must wear a minimum of a surgical mask and eye protection when they are interacting with residents in the Yellow and Red Zones. For recommended PPE see California Department of Public Health, Healthcare Associated Infections Program library for appropriate PPE chart. PDF is attached to AFL 20-74, https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/AFL-20-74.aspx
  • N95 mask: Staff must wear an N95 respirator, when they are interacting with residents who have a COVID-19 infection, when they are caring for patients in isolation or quarantine (within 6 feet) for suspected COVID-19, and during all aerosol generating procedures. Staff must wear the correct size mask that has been properly fit-tested for them.
  • Access to adequate testing: The facility must maintain access to COVID-19 testing for all residents and staff at a clinical laboratory with acceptable turn-around times.
  • Universal screening: All individuals who enter the facility must be screened for the following: signs and symptoms of COVID-19 (e.g., temperature checks, questions or observations about signs or symptoms); close contact with a confirmed or suspected COVID positive individual within the past 14 days; pending or unknown COVID test results. Those who screen positive for any of the above must be denied entry to the facility.
  • Hand hygiene: Alcohol-based hand sanitizer dispensers must be easily accessible throughout the facility.
  • Face covering: A cloth face mask must be worn by all individuals who enter the facility (covering mouth and nose).
  • Physical distancing: A distance of at least 6 feet must be maintained whenever possible.
  • Cleaning and disinfection: Facilities must have adequate stock of essential cleaning
    and disinfection supplies and understand the kill-times required for products to be used
    effectively against COVID-19. All high-frequency/ high touch surfaces in the facility must be frequently cleaned with an EPA approved product. Refer to N list here: https://www.epa.gov/pesticide-registration/list-n-disinfectants-coronavirus-covid-19

Basic Guidelines for Outdoor and Indoor Visits

  • Residents who test negative for COVID-19 and have no symptoms consistent with COVID-19 and are not in quarantine, or those who are fully recovered from COVID-19, may have one visitor indoors and two visitors outdoors.
  • Visitation should be scheduled ahead of time with a designated person who is able to manage a schedule for the facility. Facility may utilize an on-line event planning tool to facilitate a well-planned schedule.
  • The facility should provide visitors with anticipatory guidance and written instructions on the Basic Guidelines prior to the date of the visit.
  • Cloth face coverings must be worn by both residents (if safe and tolerated) and their visitor.  There must be a minimum distance of 6 feet between the resident and the visitor, regardless of the location of the visit.
  • Signs or posters must be placed throughout the facility in easily visible locations, providing visitor education on COVID-19. Signage should be English-Spanish bilingual, and other languages commonly used by patients and visitors, and address the following: the importance of hand hygiene, the use of face masks, and symptoms associated with COVID-19.
  • All visitors (non-essential and essential) must be screened immediately before the visit occurs, and sign a roster, with name, address and phone number. This documentation will help with contact tracing should a resident later test positive for COVID-19. Any visitor whose screening reveals signs or symptoms consistent with COVID-19, or close contact with a confirmed COVID-19 positive individual within the past 14 days, must leave immediately without the visit occurring.
  • Facility staff will need to monitor the visit to ensure all safety measures are adhered to. Staff will need to monitor physical distancing and prevent handshaking and hugging. Children will need supervision to ensure compliance.
  • The facility must determine the duration and number of visitors allowed on the premises based on their capacity to manage these events safely. Facilities must also consider the needs of all residents and limit the duration, to help ensure all residents are able to receive visitors. The schedule manager should consider arranging shorter indoor visits and longer outdoor visits. Facilities may need to stagger visits to avoid overcrowding in the appropriate visiting areas.
  • Residents and visitors must perform hand hygiene before and after the visit.
  • Surfaces will need to be sanitized after each visit.
  • Visits shall last no longer than 45 minutes indoors and 60 minutes outdoors.
  • The facility must ensure all baseline requirements, listed above, are met.

Outdoor Visitation
Ideally, visits should be held outdoors whenever feasible. Outdoor visits pose a lower risk of transmission due to increased space and airflow. Facilities should create accessible and safe outdoor spaces for visitation, such as courtyards, patios, reconfigured parking lots, screened windows or plexiglass dividers across the opening of a patio door, or via a vehicle with an open-window (provided the visitor remains inside the vehicle) or tents, if available.
If not practical due to inclement weather such as excessive heat or cold, rain, hail, or poor air-quality, visits should occur in an appropriate indoor space.

Indoor Visitation
Indoor visits should occur in large communal indoor spaces such as a lobby, cafeteria, activity room, physical therapy room ‑‑ where 6 foot distancing is possible. Facilities should accommodate and support indoor visitation, including visits for reasons beyond compassionate care situations. Facilities must control movement in the building. For example, visitors should not walk around different halls of the facility. Visitors should go directly to the visiting areas. Chairs should be pre-spaced 6 feet apart. If possible, use spaces close to facility entrance so there is not excessive traffic in the building. The risk of transmission can be further reduced by the use of physical barriers, for example, clear plexiglass dividers. The facility must only allow the number of visitors that it can monitor confidently at one time.

Advise visitors, and any individuals who enter the facility to monitor for signs and symptoms of respiratory infection for at least 14 days after exiting the facility. If symptoms occur, advise them to self-isolate at home and contact their health care provider. Any visitor or other individual who tests positive for COVID-19 within 14 days of their visit must immediately notify the facility of the date they were in the facility, the individuals they were in contact with, and the locations within the facility they visited. Facilities should immediately screen the individuals of reported contact and work with SCPHD to take all necessary actions based on findings.

Facilities that meet the following conditions shall allow indoor visitation:

  • Facilities with substantial or lower levels of community transmission (Red Tier or less restrictive) with an on-going COVID-19 outbreak may allow “green” zone residents indoor in-room visitation even if they have not yet achieved two sequential negative rounds of response testing over 14 days. This visitation is permitted for residents in the “green” (unexposed or recovered) areas (wings or buildings) with staffing that do not overlap the “red or “yellow” status areas.
  • In-room visits may occur if there are no other alternatives and absence of any new COVID-19 cases in the facility for 14 days, among either residents or staff. Visits for residents who share a room should preferably be conducted in a separate indoor space or with the roommate not present in the room (if possible).
  • Facilities must publicly post the ways in which a visitor is expected to move in the facility. Routes of entry and exit should be clearly identified. The purpose of this signage is to keep visitors within areas designated for visiting.

Alternatives to In-Person Visits and Other Ways to Communicate
When in-person visitation is not possible, other visitation options include, but are not limited to:

  • Virtual communications (phone, video-communication). Using screen-based technology to include residents in family social activities, such as mealtimes, can offer an opportunity for consistent contact. Such experiences have the benefit of decreased isolation and eliminate the risk of COVID-19 transmission.
  • Assigning staff as primary contact to families for inbound calls and conduct regular outbound calls to keep families up to date and relay required communication.
  • Offering virtual family town hall meetings for staff and families, such meetings have been shown to improve morale and reduce stress.

Compassionate Care Visitation
Compassionate care visits should take place outdoors if possible. Visits should comply with the requirements for outdoor visitation listed above; however, if the facility and visitor are able to identify a way to allow for personal contact during compassionate care visitation, visitors must be screened for COVID-19 symptoms, be routinely tested for COVID-19 at least weekly, wear a surgical facemask while in the building, restrict their visit to the resident’s room or other location designated by the facility, and be reminded to frequently perform hand hygiene. This visitor must follow all Basic Guidelines with the brief exception of physical distancing. When these conditions are met, the visitor and resident may have agreed upon contact. Compassionate care visitation includes, but is not limited to:

  • End-of-life situations
  • A resident, who was living with their family before recently being admitted to a nursing home, is struggling with the change in environment and lack of physical family support
  • A resident who is grieving after a friend or family member recently passed away
  • A resident who needs cueing and encouragement with eating or drinking, previously provided by family and/or caregiver(s), is experiencing weight loss or dehydration
  • A resident, who used to talk and interact with others, is experiencing emotional distress, seldom speaking, or crying more frequently (when the resident had rarely cried in the past)

Visitor Testing

While not required, SCPHD encourages facilities to test visitors, if feasible, when the county is at a widespread risk level (Purple Tier). If choosing to test visitors, facilities should prioritize those that visit regularly (e.g., weekly), although any visitor can be tested. 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 PCR test results and date of test.

Entry of Health Care Workers and Other Providers of Services
Health care workers who are not employees of the facility but provide direct care to the facility’s residents, such as hospice workers, Emergency Medical Services (EMS) personnel, dialysis technicians, laboratory technicians, radiology technicians, social workers, clergy, etc., must be permitted to come into the facility as long as they are not subject to a work exclusion due to a COVID-19 infection or exposure, or show signs or symptoms of COVID-19 after being screened. Please note that EMS personnel responding to an emergency should be masked but do not need to be screened so they can attend to an emergency without delay. SCPHD reminds facilities that all staff, including individuals providing services under arrangement as well as volunteers, should adhere to the Core Principles of Infection Prevention for COVID-19 and must comply with COVID-19 testing requirements.

Independent Living Residents
Independent Living Residents should continue to shelter in their places of residence to slow the spread of COVID-19 to the maximum extent possible. Residents returning from an outing (e.g., visiting friends, family, a casino, a hair salon, etc.) should not be required to be tested, quarantined, or isolated after the resident’s return, unless the resident was with an individual with COVID-19 infection, a symptomatic and untested person, was at a gathering where social distancing was not maintained, or who spent time talking or socializing with another person or persons not wearing face coverings. If the resident activity includes exposure risk, the licensee should ask them to avoid contact with others in the facility for 14 days, and screen daily for signs and symptoms of COVID-19, including temperature checks.

Skilled Nursing, Assisted Living Residents and Non-Essential Movement
Each Long-Term Care Facility shall discourage non-essential resident movement. Trips off the premises should be considered carefully and limited to essential functions. In all situations when a Long-Term Care Facility resident leaves the premises, the resident is expected to follow the Core Principles listed above, and upon return the facility is required to evaluate the risk of exposure to COVID-19. For residents returning from familial, social, or holiday gatherings in a community with widespread transmission (or gatherings with participants coming from communities with substantial or widespread transmission) must quarantine for 14 days in the yellow-observation area (in a single room, if available), and test at the end of the quarantine period before returning to the general population or green-unexposed area.

For residents who visit locations that have substantial or lower levels of risk the facility is also required to evaluate the risk of exposure to COVID-19. Such residents need not be tested, quarantined, or isolated after their return, unless the resident was with an individual with COVID-19 infection, a symptomatic and untested person, was at a gathering where social distancing was not maintained, or who spent time talking or socializing with another person or persons not wearing face coverings. This list is not exhaustive, if the facility is concerned they may call SCPHD (707-565-4566) for additional guidance. If the resident’s activity includes exposure risk, the licensee should ask them to avoid contact with others in the facility for 14 days quarantine.

Communal Activities
While adhering to the Core Principles of COVID-19 infection prevention, group activities may be facilitated for residents who have fully recovered from COVID-19, and for those not in isolation or quarantine for suspected or confirmed COVID-19. Facilities may be able to offer a variety of activities while also taking necessary precautions. For example, book clubs, stretching and movement classes, crafts, movies, and bingo, are all activities that can be facilitated with alterations and adherence to infection prevention. Facilities offering movement and exercises classes should use a visual marker on the floor so that residents can maintain the required 6-foot radius around them during the exercise class and participants should wear a surgical mask. If the resident is unable to perform the activity with a mask, they should be excluded from that group class.

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