Issue: Hospice Care in Nursing Homes, Assisted Living Facilities (ALFs) and Similar Facilities (Added 3/19)

Question: Should hospice workers (including volunteers) be allowed access to nursing homes?

Answer: Hospice workers (including volunteers) have experienced some challenges gaining entry to care for nursing home residents on hospice care. Some nursing homes Despite early CMS guidance to nursing homes indicating that “hospice workers can enter a facility when using PPE properly,” and separate CMS guidance issued to hospice providers indicating the following (on page 6): “If hospice care is provided in a nursing home, we have advised nursing homes that hospice workers should be allowed entry provided that hospice staff is following the appropriate CDC guidelines for Transmission-Based Precautions, and using PPE properly,” there were continuing issues with patient access.

Most recently, CMS issued revised guidance to nursing homes (issued March 13, 2020) restricting all visitors to the facility, but specifying that hospice workers are among those excepted from the ban:

For ALL facilities nationwide:

Facilities should restrict visitation of all visitors and non-essential health care personnel, except for certain compassionate care situations, such as an end-of-life situation. In those cases, visitors will be limited to a specific room only. Facilities are expected to notify potential visitors to defer visitation until further notice (through signage, calls, letters, etc.). Note: If a state implements actions that exceed CMS requirements, such as a ban on all visitation through a governor’s executive order, a facility would not be out of compliance with CMS’ requirements. In this case, surveyors would still enter the facility, but not cite for noncompliance with visitation requirements.

For individuals that enter in compassionate situations (e.g., end-of-life care), facilities should require visitors to perform hand hygiene and use Personal Protective Equipment (PPE), such as facemasks. Decisions about visitation during an end of life situation should be made on a case by case basis, which should include careful screening of the visitor (including clergy, bereavement counselors, etc.) for fever or respiratory symptoms. Those with symptoms of a respiratory infection (fever, cough, shortness of breath, or sore throat) should not be permitted to enter the facility at any time (even in end-of-life situations). Those visitors that are permitted, must wear a facemask while in the building and restrict their visit to the resident’s room or other location designated by the facility. They should also be reminded to frequently perform hand hygiene.

Exceptions to restrictions:

  • Health care workers: Facilities should follow CDC guidelines for restricting access to health care workers found here. This also applies to other health care workers, such as hospice workers, EMS personnel, or dialysis technicians, that provide care to residents. They should be permitted to come into the facility as long as they meet the CDC guidelines for health care workers. Facilities should contact their local health department for questions, and frequently review the CDC website dedicated to COVID-19 for health care professionals (https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html).

The guidance further states:

  • When visitation is necessary or allowable (e.g., in end-of-life scenarios), facilities should make efforts to allow for safe visitation for residents and loved ones. For example: a) Suggest refraining from physical contact with residents and others while in the facility. For example, practice social distances with no hand-shaking or hugging, and remaining six feet apart. b) If possible (e.g., pending design of building), creating dedicated visiting areas (e.g., “clean rooms”) near the entrance to the facility where residents can meet with visitors in a sanitized environment. Facilities should disinfect rooms after each resident-visitor meeting.
  • Advise visitors, and any individuals who entered the facility (e.g., hospice staff), 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, contact their healthcare provider, and 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 take all necessary actions based on findings.

This guidance is applicable to all Medicare and Medicaid certified nursing homes. However, it is possible that your state health department may impose more severe restrictions, depending on local circumstances, which could limit hospice worker entry to fulfill certain elements of the plan of care. If that is the case, the hospice interdisciplinary team (IDT) should determine whether certain non-clinical patient care that is included on the plan of care (such as volunteer visits) could be provided through other means – such as phone calls or telehealth methods – and modify the plan of care accordingly. In cases where limitations on PPE create access issues, the hospice may be able to discuss use of facility PPE until the current shortage abates.