Nursing homes, assisted-living facilities look cautiously toward indoor visits

Until late summer, residents of nursing homes and assisted-living facilities in Colorado weren’t allowed to see any visitors.

A public health order from the Colorado Department of Public Health and Environment, issued March 12, barred all nonessential visitors and health care workers from entering long-term care facilities. Similar federal guidance was issued the following day by the Centers for Medicare and Medicaid Services.

Since July 30, though, many facilities have begun allowing residents’ loved ones to visit them outdoors with strict infection control protocols — such as face masks, symptom screening and social distancing — after the state amended its public health order to allow the outdoor visits.

Now, with the weather turning colder, long-term care facilities are looking cautiously toward the next step: indoor visitation, which the state began allowing in certain circumstances starting on Sept. 3.

Long-term care residents isolated from loved ones

CDPHE’s original public health order aimed to protect medically vulnerable and older residents of these facilities from the coronavirus — which has proved more deadly to this sector of the population than any other. People who lived in residential care facilities have comprised more than half of the state’s confirmed and probable COVID-19 deaths.

Cases and deaths at long-term care facilities have decreased since the start of the pandemic. But the isolation required to protect people from COVID-19 can be difficult for some residents, said John Adams, administrator of Accel at Golden Ridge, a facility in Golden that provides rehabilitative health care and skilled nursing.

“Some struggle with not being in contact with their loved ones,” Adams said.

As part of safety precautions, new residents at Accel must be quarantined for two weeks on the second floor.

“If they’re symptom-free — which all of them have been since we’ve been doing this — then we’ll move them downstairs to the first floor, where there is far less restriction and they can move freely outside their room and go to the therapy gym and things like that,” Adams said.

Staff tries their best to alleviate feelings of loneliness by offering activities for residents inside their rooms and helping set up video calls with loved ones.

“If they can see their loved one through a window, we’ll make that happen, where they’re at the window and they can see their family, they’re talking via the phone,” Adams said. “If they’re physically able to do that, we try to make that happen.”

The facility recently started allowing indoor visits for residents’ families who don’t mind taking the required precautions. With the mild September weather, so far, they haven’t had any takers.

“At this point, because the weather’s been nice enough, we’ve continued outdoor visitation,” Adams said.

That’s more or less in line with CDPHE’s expectations for indoor visits, though the state doesn’t keep track of how many facilities have started indoor visitation. Because of the stringent requirements involved, state health workers expected it would take a while before indoor visits became widespread.

“I think facilities are moving towards allowing indoor visitation,” Elaine McManis, deputy director of the Health Facilities & Emergency Medical Services Division at CDPHE, said in mid-September. “There are several that are pretty anxious, and of course residents and families are eager, but they have to conduct … baseline testing before they can even launch it.”

Strict guidance for indoor visitation

Indoor visits require varying precautions based on the amount of daily new COVID-19 cases added over the previous two weeks in a specific facility’s county.

If the county has reported more than 175 new cases of COVID-19 per 100,000 people over the previous two weeks, indoor visits are prohibited. Facilities in counties with 26 to 175 cases per 100,000 can offer indoor visits only if visitors prove they tested negative for COVID-19 within 48 hours of coming to the facility.

Before offering indoor visitation, all facilities must do a round of “baseline testing” of any staff or residents who left the facility in the last two weeks. Then, depending on the test positivity rate in the facility’s county, they must conduct surveillance testing on a bimonthly, weekly or biweekly basis.

“Certainly staff are leaving the building, going home to their loved ones, carrying out their days just like anybody else would away from the facility — and then they’re coming back in, and that’s why we have that surveillance testing,” McManis explained. “They pose the biggest risk of reintroducing COVID to a facility.”

Other requirements include having enough personal protective equipment to respond to an outbreak, and being free of any outbreaks before allowing visitors.

Team works to strike down outbreaks

The COVID-19 situation inside nursing homes and assisted-living facilities looks a lot different than it did at the start of the pandemic — due in part to the efforts of Colorado’s Residential Care Strike Team.

In mid-April, inpatient health care facilities comprised 90% of all COVID-19 outbreaks, according to data from CDPHE. That number has hovered around 30% since August, with schools, universities and child care centers now contributing more outbreaks to the state’s total.

The state formed the Residential Care Strike Team in late April to combat rising cases and deaths. Composed of members of CDPHE, the Department of Human Services and several other state agencies, the team works to “mitigate the spread of COVID-19 in all high-density environments serving older adults and people with disabilities.”

The team started by conducting surveys of all facilities in the state to evaluate their ability to prevent and control outbreaks, McManis said.

“We ended up seeing 1,058 facilities in 100 days,” McManis said. “That got everybody on the right foot. So I think instead of reacting, now we’re just monitoring, because we gave everybody the tools, we verified their plans and we put that into motion.”

The strike team also had facilities submit infection control plans, and team members reviewed those plans and provided feedback.

“We continue to do routine inspections on a frequency that’s prescribed either by federal or state, and that’s the boots on the ground that actually see how well it’s working or not,” McManis said. “If it’s not working, we issue citations and they have to fix it.”

As of July 26, CDPHE had issued 215 citations that involved staff not following proper hand washing or hygiene procedures, 174 that involved personal protective equipment, 155 concerning visitor screening and documentation, 122 concerning social distancing and 106 involving a facility’s failure to ensure residents wore masks outside their rooms or when interacting with staff.

“It’s possible that citations can involve fines (called Civil Money Penalties), but the majority of the citations result in a corrective action process that identifies the issue and takes steps to correct it for the future,” Peter Myers, a CDPHE spokesperson and Residential Care Strike Team branch chief, said via email.

CDPHE makes inspection records available online through a searchable database.

Learning from experience

Even if a facility follows all of the required safety protocols, it can still end up with an outbreak, McManis said: “A facility reporting a COVID case does not mean they’ve done something wrong.”

According to a Sept. 11 presentation from CDPHE’s Residential Care Strike Team, 860 deaths among people with confirmed COVID-19 were of people living in residential care facilities. Another 172 residents with probable COVID-19 had also died.

Together, those deaths comprise just over half of the state’s reported deaths among people with COVID-19 at the time.

In mid-April, Accel at Golden Ridge experienced its own outbreak, which was considered resolved two months later. The outbreak led to the deaths of six residents with confirmed COVID-19. Five staff members and 24 residents had probable or confirmed cases, according to CDPHE’s outbreak data.

“I’m extremely thankful and proud of the staff we have here,” Adams said. “Initially when COVID was being talked about and introduced and the pandemic, etc., with some there was some anxiety. But … through what they’ve learned on their own, and what we’ve done in education and having available PPE and understanding that we’re all in this together, (we) have been able to move through this.”

When cases spiked after the Fourth of July holiday, cases in residential care did increase, but not at the same rate as in the general population, said Randy Kuykendall, director of CDPHE’s Health Facilities & Emergency Medical Services Division.

“Right now, we’re seeing more cases, but the good news is, the number of deaths and hospitalizations are not going up,” he said Sept. 18. “We think that speaks to these new cases really revolving around younger populations with school starting and college, that sort of thing — which to us says we’re doing a reasonable job of collectively keeping this under control in congregate care settings.”