TABLE OF CONTENTS:



In response to the increasing number of COVID cases across Washington State, Governor Inslee issued Proclamation 20-25.8 on November 15, 2020. This proclamation supersedes the visitation requirements of Safe Start for Long-Term Care Plans through January 4, 2021. In general, Proclamation 20-25.8 temporarily prohibits indoor visitation, with exceptions for “essential support persons” and “end-of-life circumstances”.All other criteria of the Safe Start for Long-Term Care Plan remain in effect.TABLE OF CONTENTS:HYPERLINK \l "_Essential_support_person,"Essential support person, compassionate care, and essential medical visits HYPERLINK \l "_Communal_dining_and" Communal dining and group activities HYPERLINK \l "_Visits_outside_the" Visits outside the community and new admissions HYPERLINK \l "_Visits_–_outdoor," Visits – outdoor, indoor, window HYPERLINK \l "_Travel_advisory" Travel advisory HYPERLINK \l "_Phases" Phases HYPERLINK \l "_Miscellaneous" MiscellaneousWHAT IS ALLOWED(click on the graphic to enlarge it)PHASES OF THE PLAN(click on the graphic to enlarge it)Essential support person, compassionate care, and essential medical visitsWhat is the definition of an essential support person?** Essential Support Person Requirements** Recognizing the critical role family members and other close, outside caregivers have in the care and support of residents, and recognizing how they advocate for the resident, it is strongly recommended LTC facilities develop a process to designate an essential support person (ESP) where appropriate. An ESP could be an individual who was previously actively engaged with the resident or is committed to providing companionship and/or assistance with activities of daily living. Who approves an essential support person?The resident must be consulted about their wishes to determine whom to designate as the ESP. Consider persons such as a family member, outside caregiver, friend, or volunteer who provided regular care and support to the resident prior to the pandemic.What is the definition of psycho-social needs?While end-of-life situations have been used as examples of compassionate care situations, the term “compassionate care visits” does not exclusively refer to end-of-life situations. Examples of other types of compassionate care visits include, but are not limited to: A resident, who was living with their family before recently being admitted to a facility and is struggling with the change in environment and lack of physical family support. A resident who is grieving the recent loss of a friend or family member. 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). Are visits allowed for psycho-social reasons? Yes, visits are allowed for psycho-social reasons. WA DSHS is using the definition and examples of compassionate care to describe psycho-social needs. Indoor visits for psycho-social reasons are permitted only if the person is unable to participate in outdoor, window or remote visits.What is the difference between an essential support person and one who is visiting for psycho-social needs? Under the current Governor’s Proclamation, the essential support person is the person allowed for compassionate care reasons (psycho-social needs) and indoor visits only if the person is unable to participate in outdoor, window or remote visits. What is the definition of end of life? End of life is defined as a dramatic decline in condition.Can anyone have an essential support person or only for end of life? Any resident can have a visit from an essential support person for a compassionate care visit, however the indoor visit is allowed only if the person is unable to participate in outdoor, window or remote visits. Any resident can have indoor visitors for end of life. All visitors must pass the health screening and use any required level of PPE. How many visitors are permitted for end of life visits? There is no limit established in the Governor’s Proclamation for number of visitors for end-of-life purposes. The number must be established taking into consideration the ability to provide PPE for multiple visitors, social distancing in the room where the resident lives or other space available for visitation. Do home health, hospice workers, behavioral health providers, physical therapy and occupational therapy constitute essential medical visitors and in which phases are essential medical visitors permitted? Yes, and essential medical and essential health care providers are allowed in all phases. In fact, they cannot be denied access to the resident unless they do not pass the health screening at the facility or do not have PPE. Should the essential support person be tested for COVID prior to entering the facility? This is not a requirement and cannot be denied access if they do not have evidence of a recent COVID test result. The essential support person must pass the health screening of the facility and use PPE, social distancing and hand washing. Are POA permitted to engage in indoor visitation? Only if the purpose of the visitation is to complete a required function of a POA. For example, to determine whether a resident should consent to a medical procedure or to determine the resident consent for a financial or banking transaction and this function cannot be completed remotely or otherwise. Is a chaplain allowed to visit indoors with a resident on hospice, but not actively dying? If the chaplain is an employed by the hospice agency and part of the resident’s hospice care plan then they can visit with a resident munal dining and group activitiesWhat do we do if a newly admitted resident/client does not adhere to quarantine guidance? The facility should discuss quarantine requirements with the resident prior to admission. If a resident is not able to or chooses not to follow quarantine requirements, they facility must continue to communicate the requirements and consult with the LHJ for other action that can be taken by the local health authority. Accommodations must be considered and utilized whenever possible without endangering other residents or caregivers. What are the restrictions on communal dining and group activities for each phase?Refer to the LTC Safe Start documents on the ALTSA website linked here: are crisis staffing strategies (for group activity and communal dining guidance)?Group activities and communal activities are not permitted in Phase 1. Facilities should not allow communal dining or group activities, regardless of LTCF phase, if the facility is functioning under crisis staffing capacity. Crisis staffing capacity strategies include:Allowing asymptomatic staff who have an unprotected exposure to?COVID but are not known to be infected to continue to work.Allowing staff with suspected or confirmed COVID-19 who are well enough and willing to work but have not met all Return to Work Criteria to work with work restrictions. Visits outside the community and new admissionsCan residents leave facility for family or other community visits?Yes, residents may leave the facility. Facilities should assess the risk of potential exposure to the resident using the Risk Assessment Template. However, the Governor’s proclamation encourages Washingtonians to limit social gatherings and prohibits indoor social gatherings with people outside of the household unless they quarantine prior. Can facilities decline to accept someone back if they leave the facility?No. This would require extensive review and consideration of all resident rights, why the facility was declining to take someone back and make sure that all regulatory discharge requirements have been met. Any LTC facility considering this action should consult with their RCS Field Manager. Do we use the risk assessment for staff who have appointments in the community?The Risk Assessment Template is intended for residents only. Staff should be encouraged to practice COVID mitigation measures consistent with Safe Start guidance, Governor’s proclamations, and state and local guidance.For residents returning from visits outside the community, can residents quarantine in their room or do they need to be placed on the quarantine unit?Ideally, residents on quarantine would be placed in single occupancy rooms and cohorted in a dedicated unit or area. If a dedicated unit or area is not available, facilities may have the resident stay in their room. If a single occupancy room is not available, the facility may place the resident with a roommate, but should consider the likelihood of actual exposure and vulnerability of the roommate. If a new resident is admitted and has a negative COVID test prior to admission, how long does the resident need to be in quarantine?For newly admitted or readmitted residents whose COVID-19 status is unknown or previously tested negative prior to quarantine for 14 days.Test for SARS-CoV-2 if symptoms develop during the 14-day quarantine period, or if there is a new exposure.Wear all recommended COVID-19 PPE during care of residents under observation, which includes use facemask (NIOSH-approved and fit-tested N95 or higher if aerosol generating procedures), gown, gloves, eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face).New residents could be transferred out of the observation area or from a single to a multi-resident room if they remain afebrile and without symptoms for 14 days after their last exposure (e.g., date of admission). Testing at the end of this period could be considered to increase certainty. Is there a time limit for outdoor visits? There is no specified time limit in the Governor Proclamation or the LTC Safe Start plans, however time limits may need to be in place to allow as many residents as possible to have visitors. Outdoor visitors are limited to two each day in Phase 1 and five visitors in Phase 2 through Phase 4. The outdoor visitors must also wear masks and maintain six feet of physical distancing. Also refer to the Outdoor Visitation Guidance: Interim Supplemental Guidance for Group Activities and Communal Dining in LTCF (PDF)Outdoor Visitation for LTCF?(PDF)Do residents who have recovered from COVID and are newly admitted have to be placed in quarantine for 14 days?Newly admitted and readmitted residents with COVID-19 who have met criteria for discontinuation of Transmission-Based Precautions can go to a regular unit.If Transmission-Based Precautions have been discontinued, but the resident with COVID-19 remains symptomatic (i.e., persistent symptoms or chronic symptoms above baseline), they can be housed on a regular unit but should remain in a private room until symptoms resolve or return to baseline. These individuals should remain in their rooms to the extent possible during this time period.? If they must leave their rooms, facilities should reinforce adherence to universal source control policies and social distancing [e.g., perform frequent hand hygiene, have the resident wear a cloth face covering or facemask (if tolerated) and remain at least 6 feet away from others when outside of their room]. Visits – outdoor, indoor, windowAre tents considered outdoor visitation?Tents are considered outdoor visitation. Enclosed 4-wall tents will have less air circulation than open air tents. If outdoor temperature or weather requires that the tent sidewalls be rolled down or reattached to the canopy, leave one or more sides open or rolling up the bottom 12 inches of each sidewall to enhance ventilation while still providing a wind break. Also refer to the Outdoor Visitation Guidance: Outdoor Visitation for LTCF?(PDF)Can we open the windows for a window visit?Window should not be open for window visits. Facilities may utilize technology, such as phones or intercom to facilitate window visits.Do we have to provide privacy for visits, and do we need to monitor visits? Residents must be allowed privacy for visits and any monitoring must be done at a distance that would allow for continued privacy. Are we allowed to have heaters for outdoor visits? Please check with your local fire district for questions regarding use of outdoor heaters and guidance from WA DOH. Does plexiglass eliminate the need for 6 ft social distancing requirement or requirement to wear a face covering?Plexiglass does not eliminate the need for 6 feet physical distancing or requirement to wear a face covering. Plexiglass may be used as an intervention in addition to these or in circumstances that will not allow 6 feet physical distancing (e.g., registration desk, etc.).Are there considerations for memory care?CDC has some additional considerations for memory care: Travel advisoryIs the 14 day quarantine required?On November 13, 2020, Governor Inslee issued a travel advisory for Washington State:Persons arriving in Washington from other states or countries, including returning Washington residents, should practice self-quarantine for 14 days after arrival. These persons should limit their interactions to their immediate household. This recommendation does not apply to individuals who cross state or country borders for essential travel.Washingtonians are encouraged to stay home or in their region and avoid non-essential travel to other states or countries. Avoiding travel can reduce the risk of virus transmission and bringing the virus back to Washington.“Non-essential travel” includes travel that is considered tourism or recreational in nature. “Essential travel” includes: work and study, critical infrastructure support, economic services and supply chains, health, immediate medical care, and safety and security. Because this is an advisory, it is not required, but recommended.What if staffing levels do not allow a facility to impose a 14 day quarantine?Facilities should encourage staff to adhere to the Governor’s travel advisory and follow CDC’s Strategies to Mitigate Healthcare Personnel Staffing Shortages. If a person is coming from another state to work here, do they need a 14 day quarantine?If travel is essential, defined as travel for work and study, critical infrastructure support, economic services and supply chains, health, immediate medical care, and safety and security, the travel advisory does not apply.Are facilities required to have a policy regarding management of staff who leave the state for non-essential travel?Facilities are not required to have a policy, but may consider facility policies to address, in consultation with their Human Resources and Legal departments.What about staff participating in gatherings within the state?Staff should be encouraged to practice COVID mitigation measures consistent with Safe Start guidance, Governor’s proclamations, and state and local guidance.PhasesHow do we know which phase the facility is in? The facility or agency needs to reference the LTC Safe Start requirements document to determine their phase, take direction from their LHJ or consult with their Field Manager for guidanceWhen does a facility go back to a previous phase? Facilities should move back to previous phases per the direction of the LHJ, DOH or RCS. What activities are allowed in each phase? Please refer to LTCF Safe Start guidance for activities allowed in each phase: MiscellaneousIs there a requirement for adult family homes to test all staff? No, there is no requirement for adult family homes to test all staff. Adult family homes have an opportunity to participate in one time testing of staff and residents, and should test staff and residents according to LHJ direction in the case of an outbreak.What are testing requirements for an assisted living facility if one staff case is identified?If one case is identified, assisted living facilities should consult with their LHJ and follow the guidance provided. Generally, facility-wide testing is recommended if one case is identified.Where can we find information on the number of LTCF cases?Information on the number of LTCF cases can be found from:DOH (from laboratory reporting) - (from DSHS survey) - (from NHSN reporting) - Numbers from each of these may be different as they collect data from different sources.What if the essential support personnel or resident don’t follow guidance during indoor visit? Please review the indoor visitation requirements before the visit begins. If during the visit, visitors are observed not following distancing or PPE requirements, the visit can be interrupted, requirements reviewed, and visitors notified that they must follow all requirements, or the visit will end. What if the resident does not adhere to quarantine recommendation or PPE/source control use? The facility should discuss quarantine requirements with all residents periodically so they understand them and prior to an outing that will require a quarantine period when the resident returns. If a resident is not able to or chooses not to comply with quarantine requirements the facility must continue to communicate the requirements and consult with the LHJ for other action that can be taken by the local health authority. Accommodations must be considered and implemented whenever possible without endangering other residents or caregivers.What is the requirement for notifying family of outbreaks?CMS established notification requirements for nursing homes in a QSO memo. Other facility types do not have notification requirements, however the notification requirements established by CMS should be considered as a best practice. It is best practices to notify residents and families regarding COVID outbreaks and aggregate COVID results without naming residents or staff. QSO memo 20-29 NH: How often do you need to disinfect the resident’s private room?Frequent and thorough cleaning of environmental surfaces is a core infection prevention activity. “Clean and disinfect surfaces in close proximity to the resident and frequently touched surfaces in the resident care environment on a more frequent schedule compared to other surfaces.” Ensure that environmental cleaning and disinfection procedures are followed consistently and correctly. Develop a schedule for regular cleaning and disinfection of shared equipment, frequently touched surfaces in resident rooms and common areas; Ensure EPA-registered, hospital-grade disinfectants are available to allow for frequent cleaning of high-touch surfaces and shared resident care equipment.” a facility admit residents from the hospital if there is a COVID positive resident in another unit?Yes. Facilities currently experiencing an outbreak should consider temporarily halting admissions to the facility, at least until the extent of transmission can be clarified and interventions can be implemented. Outbreaks should be managed in collaboration with the LHJ who will help guide actions to determine the extent of the outbreak. Does the temperature need to be recorded on visitor logs? No, temperature does not need to be recorded on visitor logs, but temperature should be included in the symptom screening:Screen visitors for fever (T≥100.0F), symptoms consistent with COVID-19, or known exposure to someone with COVID-19. Restrict anyone with fever, symptoms, or known exposure from entering the facility. residents who have tested positive and now recovered subject to the same restrictions?Resident who have tested positive, recovered, and have met criteria for discontinuation of Transmission-Based Precautions should be managed as other residents not in quarantine or on precautions. ................
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