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Document: Missouri Guidance for Long-Term Care Facilities to Establish Essential Caregiver Programs and Allow Visitors

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Long-term care facilities may soon begin reopening their doors to families of their patients.

Missouri on Thursday released revised guidance for visits at the facilities, which have prevented visitors since early this spring amid the COVID-19 pandemic.

Shortly after the novel coronavirus first entered the United States, it became apparent it was most dangerous for elderly and those patients with underlying health conditions.

One of the most striking aspects of the virus was it caused a high number of deaths in congregate living facilities, which contained exactly those patients.

Authorities quickly closed those facilities to visitors.

Despite the closures, the virus has led to numerous deaths. Of 14 COVID-19-related deaths in Cole County, seven had occurred in long-term care facilities, as of Friday evening.

And Missouri, Cole County and Jefferson City had risen in rankings of areas showing new coronavirus case activity.

But, following a May 18 order by Missouri Department of Health and Senior Services Director Dr. Randall Williams, congregate living facilities were required to report positive cases within 24 hours. And the state implemented a "boxed-in" testing strategy — which rushes resources to hotspots, or targeted areas that have seen faster spread of the virus than other areas. The strategies appear to have slowed the spread and prevented some deaths.

Now, the state is looking to ease restrictions on visitation within long-term care facilities, according to a DHSS news release.

The guidance recommends ways to safely conduct visits in the facilities. It requires facilities to allow visits by outside medical providers. Infection control, screening guidelines and personal protective equipment must be used during visits.

"We have worked hard to strengthen our prevention and mitigation strategies in long-term-care facilities, and we understand the importance of spending time in-person with families and caregivers," Gov. Mike Parson said in the news release. "These visits serve as an important part of residents' overall well-being."

The guides suggest outdoor visits should be limited to residents who are COVID-19 negative or asymptomatic and not suspected to have the coronavirus. Previously, COVID-19-positive patients who have been released from isolation may also have outdoor visits.

Under the guidance, facilities may offer general (primarily indoors) visits if:

They have not had any COVID-19-positive staff or resident cases, or if it has been 14 days since the last facility-acquired positive cases. Facility-acquired cases include staff who test positive (if a staff person was in the facility in the 10 days prior to the positive test) and residents who test positive while residing in the facility.

The facility limits visits to only residents who are COVID-19-negative or asymptomatic and not suspected to have COVID-19, or who previously were COVID-19 positive, but have been released from isolation.

It creates (for indoor visits) indoor spaces for residents in a room that is easily accessed without visitors traversing through the building and is not accessible by other residents.

It allows visits in the resident's private room if the resident is bed-bound and for health reasons cannot leave their room. Any visitors to residents' private rooms must use full PPE, including a gown, mask and gloves at all times while in the facility. This PPE may be provided at the facility's expense.

It allows residents, their guardians or legal representative to designate up to five visitors total.

It allows no more than two visitors at a single time, with social distancing; and requires hand hygiene before and after each visit for the resident and visitors and use of a cloth face covering or face mask for both the resident and the visitors. If the resident cannot wear a face mask, plastic partition or Plexiglas barrier may be considered.

It sets a limit on the total number of visitors allowed in the facility at any given time.

It schedules visitors by appointment and monitors for adherence to proper use of masks and social distancing.

It accommodates visitors who experience work and/or child care barriers.

It screens each visitor upon arrival. Screenings should determine whether the visitor has ever been diagnosed with COVID-19 and is asymptomatic. Facilities may encourage visitors to be tested on their own prior to coming to the facility (within two or three days) with proof of negative test results and date of test.

It will not allow visitors with symptoms or who are unable to demonstrate infection-control techniques.

Facilities should also consider having visitors sign a consent form, noting an understanding of the facility's visitation and infection prevention and control policies. They should keep visitor logs — noting the names of visitors, who they visited, staff who assisted the visit, dates of visits, and contact information in the event of a subsequent COVID-19 outbreak among staff or residents.

Facilities should sanitize any areas, including tables, chairs and partitions, between each and every visit using an Environmental Protection Agency-approved disinfectant in accordance with instructions for dilution and contact times.

Any facility that has a resident test positive for COVID-19, or has a staff person that tests positive for COVID-19, if the staff person was in the facility in the 10 days prior to the positive test, should cease all general indoor visitation except for compassionate care situations. Indoor general visitation should not resume until the facility achieves a continuous 14-day period without a facility-acquired resident or staff COVID-19 case (if the staff person was in the facility in the 10 days prior to the positive test), excluding dedicated units/wings accepting COVID-19 cases from the community.

Similar rules should apply to essential caregivers, who are individuals including clergy members who have been given consent by the resident or their legal representative to provide health care services or assistance with activities of daily living to help maintain or improve the quality of care or quality of life of a facility resident. Care or services provided by the essential caregiver is included in the plan of care or service plan for the resident and may include assistance with bathing, dressing, eating and/or emotional support.

Facilities should require residents designate who essential caregivers are, if they have one. They should also limit the number of caregivers a resident has, according to the guidance.

One essential caregiver may be designated for each resident. One additional caregiver may be designated if that individual is a clergy member. Only one essential caregiver should be present at any given time. Essential caregivers should complete facility-designated infection prevention and control training, including proper PPE and mask use, hand hygiene and social distancing.

They should use PPE at all times.

Essential caregivers should be screened similarly to other visitors, preventing admission if they do not meet screening criteria.

The caregivers should notify the facility of they develop COVID-19 symptoms within 14 days of visiting the facility.

The facility should maintain logs, noting the names of caregivers, and other information similar to logs kept for other visitors.

The facility should work with the caregiver to establish a mutually agreeable schedule that addresses the facility obligations, including the number of essential caregivers in the building at the same time.

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