CMS Updates Nursing Home Visitation Guidance with Eye Toward Indoor Reunions

The federal government on Thursday issued a new set of nursing home visitation guidelines, laying out a roadmap for resuming indoor visits based on community COVID-19 spread and emphasizing the importance of meeting residents’ psychosocial needs.

The Centers for Medicare & Medicaid Services (CMS) unveiled the new recommendations in a memo to directors of State Survey Agencies, the groups responsible for performing routine nursing home inspections.

“CMS understands that nursing home residents derive value from the physical, emotional, and spiritual support they receive through visitation from family and friends,” CMS official David Wright wrote in the memo. “In light of this, CMS is revising the guidance regarding visitation in nursing homes during the COVID-19 PHE [public health emergency]. The information contained in this memorandum supersedes and replaces previously issued guidance and recommendations regarding visitation.”


Under the new framework, operators must conduct all visits based on a set of “core principles of COVID-19 infection prevention,” listed as follows:

  • 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 of residents (e.g., separate areas dedicated COVID-19 care)
  • Resident and staff testing conducted as required at 42 CFR 483.80(h)

Outdoor visits remain preferred under the new rules — with CMS noting that they should be held “whenever practicable” — but the memo provides a blueprint for safe indoor visitation.

Operators should “accommodate and support” indoor visits as long as there have been no new COVID-19 cases in the last 14 days and visitors adhere to those core principles. The total number of visitors should be capped both on a per-resident and overall basis, and operators should restrict visitors’ movement around the facility, generally confining outsiders to residents’ rooms or designated visitation areas.


Similar to a recent testing mandate, indoor visits will depend on the rate of COVID-19 infections in a given community, with CMS recommending they occur only in areas with positivity rates of 10% or lower; in counties with rates above 10%, only compassionate care visits should be conducted indoors.

In order to bolster facilities’ ability to provide safe visitation areas, CMS is expanding the civil monetary penalty (CMP) reinvestment program; operators can now receive up to $3,000 for the purchase of tents and clear dividers, in addition to $3,000 for communication devices used in virtual visits.

CMS ordered the suspension of visits on March 14. The federal government until now has largely left the decision to reopen facilities up to individual states based on a framework released in May, resulting in a patchwork set of rules. CMS’s Thursday memo makes clear that the federal guidance supersedes those state solutions, such as in areas that allowed residents to designate specific caregivers for visitation purposes.

“CMS does not distinguish between these types of visitors and other visitors,” Wright wrote in the memo. “Using a person-centered approach when applying this guidance should cover all types of visitors, including those who have been categorized as ‘essential caregivers.’”

Operators can still deny in-person visits based on a variety of factors, including their county’s infection rates, the presence of COVID-19 cases in a given building, or visitor symptoms. But they will now face citations and enforcement actions for preventing visits without “a reasonable clinical or safety cause”; the memo included a list of specific tags that surveyors should investigate for non-compliance moving forward.

“For example, if a facility has had no COVID-19 cases in the last 14 days and its county positivity rate is low or medium, a nursing home must facilitate in-person visitation consistent with the regulations, which can be done by applying the guidance stated above,” CMS warned.

LeadingAge, a trade group that represents non-profit senior care providers, indicated late Thursday that it supports the new framework, but still called for greater access to vital supplies in order to maintain safe visitations.

“While today’s memorandum helps to clarify the many elements providers must consider to ensure that indoor and outdoor meetings occur safely, it is clear that community positivity rates continue to be a significant consideration in determining the feasibility of in-person visits,” LeadingAge vice president of regulatory affairs Janine Finck-Boyle said in a statement sent to SNN. “Mitigating the virus’s spread is impossible without sufficient access to personal protective equipment, tests and supplies, and staff; without those things, providers face significant challenges.”

The American Health Care Association, which represents primarily for-profit facilities, also welcomed the news.

“Providers are eager to welcome back family and friends to our facilities, but we must remain vigilant in preventing the spread of COVID-19,” the organization said in a statement. “We appreciate CMS looking for ways to safely facilitate more indoor visits for residents, especially as we begin to head into the fall and winter. We also welcome the opportunity to use CMP funds for tents and barriers to help nursing homes adapt their facilities for this new normal.”

This is a developing story. Please check back for updates.

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