Finding the Right Balance: An Evidence-Informed Guidance Document to Support the Re-Opening of Canadian Nursing Homes to Family Caregivers and Visitors during the Coronavirus Disease 2019 Pandemic

Abstract

During the first few months of the coronavirus disease 2019 (COVID-19) pandemic, Canadian nursing homes implemented strict no-visitor policies to reduce the risk of introducing COVID-19 in these settings. There are now growing concerns that the risks associated with restricted access to family caregivers and visitors have started to outweigh the potential benefits associated with preventing COVID-19 infections. Many residents have sustained severe and potentially irreversible physical, functional, cognitive, and mental health declines. As Canada emerges from its first wave of the pandemic, nursing homes across the country have cautiously started to reopen these settings, yet there is broad criticism that emerging visitor policies are overly restrictive, inequitable, and potentially harmful. We reviewed the nursing home visitor policies for Canada's 10 provinces and 3 territories as well as international policies and reports on the topic to develop 10 provi-informed, data-driven, and expert-reviewed guidance for the re-opening of Canadian nursing homes to family caregivers and visitors.

Nursing homes have experienced the worst of the coronavirus disease 2019 (COVID-19) pandemic in Canada, with residents of these homes accounting for approximately 80% of Canadian COVID-19 deaths.¹ Between March and April 2020 when outbreaks and deaths intensified in Canadian nursing homes, governments across the country implemented strict blanket “no visitor” policies as part of their infection prevention and control (IPAC) strategies for nursing homes.^{2 , 3} As the community prevalence of COVID-19 continues to decrease in Canada, and regions across the country begin phased re-openings, experts and advocates have grown increasingly concerned that subsequent visiting policies and family caregiver access to nursing home settings remain overly restrictive, causing substantial and potentially irreversible harm to the health and well-being of residents.⁴ A more balanced approach is needed that both prevents the introduction of COVID-19 into nursing homes but also allows family caregivers and visitors to provide much needed contact, support, and care to residents, to maintain their overall health and well-being.

We reviewed the emerging nursing home visitor policies issued by Canada's 10 provincial and 3 territorial governments (Supplementary Table 1) as well as international policies and guidance on the topic to recommend evidence-informed and data-driven guidance to support a balanced, risk-mitigated re-opening of Canadian nursing homes to family caregivers and visitors.⁵ Although this guidance is specific to nursing homes, many of the guiding principles and planning assumptions presented in this document could be applied to other congregate settings such as retirement homes and group homes.

These efforts should be executed with the support and input of family caregivers, existing resident, and family councils as well as from nursing home medical directors, administrators, involved primary care, and specialist providers, and local IPAC and public health leadership. We also recognize that reopening nursing homes will require additional resources including government funding for personal protective equipment (PPE), COVID-19 testing, and addressing chronic staffing shortages to support visitor protocols. Importantly, homes must ensure that existing care resources are not reduced to support this implementation, which could negatively impact resident care, especially for those residents who do not have family caregivers or visitors.

Definitions

Family caregiver is any person whom the resident and/or substitute decision-maker identifies and designates as their family caregiver. As essential partners in care, they can support feeding, mobility, personal hygiene, cognitive stimulation, communication, meaningful connection, relational continuity, and assistance in decision-making.⁴

Essential support worker is a person performing essential support services (eg, food delivery, inspector, maintenance, or personal care or healthcare services such as phlebotomy or medical imaging).⁶

General visitor is neither a family caregiver nor an essential support worker and is “visiting” primarily for social reasons.⁶

Guiding Principles and Planning Assumptions about Visitor Policies and Access

In reviewing the literature, consulting with national and international experts (Acknowledgments section), and hearing from both residents, and their family caregivers and visitors through various forums, we have identified 6 core principles and planning assumptions as foundational and fundamental to any current and future guidelines. These recommendations focus on family caregivers and general visitors rather than essential support workers and nursing home staff, and are made with the acknowledgment that the approach to visiting may need to be dynamic based on the community prevalence of COVID-19.

1. Policies must differentiate between “family caregivers” and “general visitors”. Residents, substitute decision makers and their families should have the authority and autonomy to determine who is essential to support them in their care.

It is imperative that visitor policies identify and distinguish “family caregivers” from “general visitors” who are visiting primarily for social reasons. Although socialization is certainly important, family caregivers as partners in care should be prioritized to support resident health and well-being. Family caregivers are those individuals who assume essential caregiving responsibilities for a spouse, family member, or friend who needs help because of limitations in their physical, mental, or cognitive functioning, and are essential to meeting the needs of residents especially in the face of chronic staffing shortages.7, 8, 9, 10, 11, 12 Family caregivers also help ensure that all residents receive culturally safe and appropriate care, especially for LGBTQ2S+ and Indigenous residents and/or those with language barriers. Importantly, although the term family caregiver is widely used, it is important to recognize that approximately 15% of all caregivers are not related to their care recipients, including some who may be privately hired.⁷ The importance of identifying family caregivers is that they are not accessing the nursing home primarily for social reasons, but rather to provide services and care such as assistance with feeding, medical decision-making, and management of responsive behaviors among residents living with dementia.¹³

Although the definition of family caregiver has been operationalized in various ways, in a resident-centered and caregiver-partnered long-term care system, residents must have the sole authority and autonomy to determine who is essential to support them in their care; substitute decision-makers should make this determination for incapable residents.⁴ This differs from approaches such as those used in Australia that have relied on identifying family caregivers as those individuals with a clearly established and regular pattern of involvement in contributing to the care and support of residents prior to the COVID-19 pandemic.¹⁴ This definition fails to recognize that some individuals may be willing and able—or need to—assume caregiving responsibilities to assist with special care needs and staffing shortages that have been further aggravated during the COVID-19 pandemic, or provide care that they may not have been able to previously. It also fails to recognize that as conditions change during a pandemic, so too might a resident's desire or need for support change, and their ability to designate family caregivers must be flexible, consistent with their ongoing right to choose. It also fails to address that limiting or eliminating congregate dining and recreational activities during the COVID-19 pandemic may now necessitate that those who were once “general visitors” become “family caregivers” to better address unmet resident needs.

Other definitions being proposed also violate the principles of resident-centered and caregiver-partnered care, including those that identify family caregivers as those individuals providing services that would otherwise require a private duty caregiver; this definition could be open to interpretation and a source of disagreement between nursing homes, residents, and their families.^{13 , 15}

Given there are both diverging definitions and interpretations of who constitutes a family caregiver, residents, substitute decision-makers and their families must retain the authority and autonomy to designate their own family caregivers and this should be clearly documented in the resident's care plan and record.⁴ Initially, each resident should be supported in allowing the reintroduction of at least 2 family caregivers, and these individuals should receive a caregiver identification card or badge.^{16 , 17}

2. Restricted access to visiting must balance the risks of COVID-19 infection with the risks of social isolation to resident health, well-being and quality of life.

Strict blanket “no visitor” policies were enacted early on during the pandemic with the recognition that visitors were potential vectors for the introduction of COVID-19 infection into nursing homes and transmission back into the wider community.¹⁸ When these policies were implemented, nursing homes were more vulnerable to COVID-19 outbreaks for several reasons: (1) the extent of asymptomatic transmission and atypical presentations of COVID-19 were not fully appreciated, (2) access to timely and comprehensive COVID-19 testing was limited, impairing homes ability to identify outbreaks, and determine scale and scope, including symptomatic and asymptomatic cases, (3) many homes had not fully adopted robust IPAC approaches including universal masking of staff and enabling them to work at only one healthcare setting, and (4) access to PPE was more limited.19, 20, 21

Now that many homes are working to address these deficiencies, it is essential that we also focus on the considerable detrimental effects of the ongoing lockdown of nursing homes and restricted access to family caregivers and general visitors.^{22 , 23} Many residents have experienced severe and potentially irreversible functional and cognitive declines, deteriorations in physical and mental health, severe loneliness and social isolation, worsening of responsive behaviors and increased use of psychotropic medications and physical restraints.23, 24, 25, 26 Worse, many residents have died alone without family present to support end-of-life needs. Although virtual visiting was implemented to try and meet the psychosocial needs of residents, it is no substitute for family caregivers who prior to the lockdown were providing substantial care and support for many residents.

These negative outcomes have raised concerns that the risks associated with ongoing blanket visitor restrictions outweigh the benefits associated with preventing COVID-19 outbreaks in nursing homes, particularly in Canadians jurisdictions with low rates of community transmission.² In addition, these restrictions may be violating the autonomy of residents and their right to make informed and risk-based decisions which prioritize their access to visitors over the risks of them contracting COVID-19. In Ontario, the Long-Term Care Homes Act recognizes the right of every resident to “receive visitors of his or her choice…without interference,” which is legally required and enforceable under contract as set out in the Act.²⁷ There are also several active legal challenges across the country arguing that fundamental resident and human rights are being violated.^{28 , 29}

Importantly, many homes have made improvements in IPAC and there are now basic processes in place to support the safe reintegration of family caregivers and general visitors. There is also now a much greater understanding of public health guidance and recommendations including universal masking as well as increased access to testing for the general public, which would further reduce the risk of COVID-19 being introduced into nursing homes. Finally, as partners in care, most family caregivers may already be trained and experienced in IPAC and PPE procedures because other infectious outbreaks are not uncommon occurrences in nursing homes.

3. Visitor policies should prioritize equity over equality and be both flexible and compassionate.

Visitor policies must prioritize equity over equality, recognizing that a “one size fits all” approach is neither optimal nor practical. Whereas equality would mean giving all nursing home residents the same access to visitors, equity means giving nursing home residents the right amount of access they need to maintain their health and well-being.³⁰ Importantly, visitor policies must not prioritize the convenience of the nursing homes over the best interests of their residents in receiving the care and support of family caregivers and visitors.

Nursing homes must reserve the right to create and implement visitor screening protocols consistent with local public health guidance and procedures for visits that maintain the safety and well-being of all residents and staff members. However, blanket implementation of policies must be avoided, and instead policies uniquely supporting family caregivers and general visitors must be both flexible and compassionate, recognizing that some of the new conditions and procedures surrounding visiting may not work for all residents, family caregivers and visitors.^{14 , 31 , 32} This includes providing flexibility around the timing of visits (eg, some visitors may have work and other caregiving duties), the location of visits (eg, some residents and/or visitors may not be able to tolerate outdoor visits because of inclement weather and/or bedbound status), the length or frequency of visits (eg, as some visitors may be traveling long distances, longer visits should be considered), absolute restrictions on physical contact (eg, some residents with cognitive impairment and/or behavioral issues may neither be able to understand nor comply with physical distancing).¹⁴

Furthermore, as procuring ample PPE may be challenging for many members of the public, both family caregivers and general visitors must be able to receive the necessary PPE to facilitate these visits from the home itself. Homes must maintain ample PPE supplies so as to not create situations where a lack of supply could restrict access to visitors and negatively impact resident quality of life. Homes will require additional funding and resources to support this.

4. Governments, public health authorities, and nursing homes must provide regular, transparent, accessible, and evidence-based communication and direction about visitor policies and access.

Many nursing home residents and their families and friends have grown increasingly frustrated about a lack of transparency and regular communication regarding the development and implementation of visitor policies and restrictions.¹⁴ To foster trust and maintain public, resident, caregiver, and staff confidence, it is imperative that governments, public health authorities, and nursing homes be transparent about the following information: who is responsible for decision-making, which evidence and metrics are being used to develop and monitor responses to visitor policies, and what are the timelines and outcomes for progression and regression of phased responses. Further, if increased visitor restrictions are required (ie, there is an outbreak), they should be implemented in a transparent manner with the same open and clear communication provided to residents as well as their family caregivers and family members.¹⁴

5. Robust data related to re-opening nursing homes to family caregivers and general visitors should be collected and reported.

It is imperative that individual homes, with the support of local health authorities and public health units, collect and report data on COVID-19 cases as it relates to reopening. In Canada, the National Institute on Aging Long-Term Care COVID-19 Tracker could support this (https://ltc-covid19-tracker.ca).³³ It is recognized that many decisions about balancing different risks to residents, staff, family caregivers, and visitors to nursing homes are difficult. However, it is also true that it is less difficult to impose restrictions than it is to remove them. Public health and governmental authorities should also be actively working to use modeling and evidence to remove visitor restrictions as quickly as possible as regional community prevalence declines.

Further, the existing Resident Assessment Instrument–Minimum Data Set 2.0, which is already collected on at least a quarterly basis for all residents and reported to the Canadian Institute for Health Information, could be leveraged to assess the impact of both restricted visitor access and the reintegration of visitors on resident health and well-being.³⁴ Previous experience in 26 nursing homes in the Netherlands that reopened to visitors pointed to substantial improvements in resident well-being without a single new case of COVID-19; this motivated the Dutch government to allow all nursing homes in the Netherlands to judiciously reopen their homes to visitors.³⁵

6. A mechanism for feedback and a process for rapid appeals should be established.

Clinical anecdotes, caregiver experiences, and a rapid response expert advisory group from the federally funded Canadian Foundation for Healthcare Improvement have identified that there are marked inconsistencies in how regional visitor policies are being interpreted and implemented.⁴ Residents, family caregivers, and visitors in all jurisdictions need access to a feedback and rapid appeals process. Recognizing that ombudspersons and existing nursing home complaint and support lines do not function as arbitrators in these situations, homes should create a mediating appeals mechanism comprised of both nursing home staff and members of existing resident and family councils to help resolve disagreements around visitor policies and the designation of family caregivers.

Summary and Recommended Visitor Policies

During the first few months of the COVID-19 pandemic in Canada, its nursing homes implemented strict no-visitor policies to reduce the risk of introducing COVID-19 in these settings. There are now concerns that the risks associated with restricted access to family caregivers and visitors have started to outweigh the potential benefits associated with preventing COVID-19 infections with this blunt public health intervention. Many nursing home residents have sustained severe and potentially irreversible physical, functional, cognitive, and mental health declines. As Canada emerges from its first wave of the COVID-19 pandemic, nursing homes across the country have cautiously started to reopen these settings, yet there is broad criticism that emerging visitor policies are overly restrictive, inequitable, and potentially harmful. To find the right balance between infection prevention and supporting resident health and well-being, the 6 core principles and planning assumptions described in this guidance document were used to create recommended, evidence-informed, and expert-reviewed visitor policies for family caregivers (Table 1 ) and general visitors (Table 2 ) to nursing homes.

Table 1.

Recommended Nursing Home Visitor Policy and Access for “Family Caregivers”

Domain	Recommended Policy
1. Defining an “family caregiver”	• Residents, substitute decision makers and their families must retain the authority and autonomy to determine who is essential to support them in their care and designate their own family caregivers.4
	• Governments, public health authorities and homes must not define who is a family caregiver, especially on the basis of either an individual’s caregiving involvement and role prior to the pandemic or by identifying those individuals providing services that would otherwise require a private duty caregiver.
2. Allowable number of designated family caregivers	• A resident may designate at least two family caregivers. • Similar to guidance from Alberta Health Services, a resident may identify a temporary replacement family caregiver if the primary designated family caregivers are unable to perform their roles for a period of time; the intent is not for designates to change regularly or multiple times but to enable a replacement, when required.36
3. Allowable number of family caregivers in the nursing home at one time	• One family caregiver per resident should be allowed in the home at a time. • Under extenuating circumstances (i.e., end-of-life), this allowable number should be flexible.
4. Allowable locations within the nursing home	• As essential partners in care, family caregivers should have access to areas both outside and inside the home (similar to staff members) but must maintain physical distancing from other residents and staff. They should be provided with an individualized caregiver identification and/or badge, and must abide by all IPAC and PPE requirements and procedures concerning staff members of the home.17,18
5. Allowable access during a COVID-19 outbreak	• In order to promote relational continuity and meet the ongoing needs of residents, family caregivers should still have access to the home during a COVID-19 outbreak, as long as the following conditions are met:
	- The family caregiver attests that they understand and appreciate they are entering a home under outbreak and that they may be at increased risk of COVID-19 infection
	- They must be trained in IPAC procedures and the proper use of PPE and abide by all outbreak-related policies that apply to staff members of the home.
6. Allowable frequency and length of time for family caregiver presence	• No restrictions as long as it does not negatively impact the care of other residents or the ability of other family caregivers to provide care and support.
7. Screening and testing requirements	• As partners in care, family caregivers should be subjected to the same COVID-19 screening requirements as nursing home staff. If asymptomatic COVID-19 testing is recommended, family caregivers should be provided with the same access to testing as staff members of the home.
8. IPAC and PPE requirements	• As partners in care, family caregivers should receive an orientation and be educated and trained to follow the same IPAC and PPE requirements and procedures as staff members of the home, including remaining masked at all times.3 The Ottawa Hospital has designed a PPE training video specifically for family caregivers: www.youtube.com/watch?v=GkAYc5wcn0c&feature=youtu.be
	• Homes must maintain ample PPE supply to enable family caregivers’ participation in care.
	• Failure of family caregivers to comply with these procedures could be grounds for loss of their rights to participate in care as family caregivers, which should be appealable.

Table 2.

Recommended Visitor Policy and Access for “General Visitors”

Domain	Recommended Policy
1. Number of allowable visitors at one time	• Outdoors: similar to guidance from the Saskatchewan Health Authority, outdoor visits can include more than one visitor at a time, provided that physical distancing can be maintained. Additionally, family members from the same household and/or bubble should not have to physically distance from one another.
	• Indoors: one visitor per resident in the home at a time. Similar to guidance from the British Columbia Centre for Disease Control, a visitor who is a child may be accompanied by one parent, guardian or family member.37
2. Allowable locations of visits and access during an outbreak	• Outdoor visits should be prioritized, when possible and feasible, to both minimize the risk of COVID-19 transmission and to maximize the number of possible visitors. Provinces like Manitoba plan to construct outdoor, all-season visiting shelters.38 • When outdoor visits are not feasible for either the resident or the visitor (e.g. for cognitive, psychiatric or physical reasons), the home must provide an indoor alternative which provides ample open space for physical distancing and adequate ventilation. • Exceptional circumstances may sometimes necessitate the visitor meeting the resident in their room, but this should be a last resort if none of the previously noted alternative options are deemed feasible.
3. Allowable access during a COVID-19 outbreak	• If the home goes into COVID-19 outbreak status, general visits may need to be temporarily suspended (if advised by the local public health authority), but if the outbreak does not involve the entire home, consideration should be given to suspending visits only on the floor or unit under outbreak. Virtual visits must be upscaled during suspensions of in-persons visits.
4. Allowable frequency and length of time for visits	• As per the Ontario Ministry of Long-Term Care, visits should be at least 60 minutes/visit and residents should have access to visitors at a minimum of once per week.39
5. Screening and testing requirements	• Visitors must pass an active screening questionnaire (which may include an on-site temperature check) but there should be no requirement for COVID-19 testing for outdoor and physically distanced visits. If exceptional circumstances necessitate a visitor entering the resident’s room, they should be subject to the same screening and testing requirements as family caregivers.
6. IPAC and PPE requirements	• Visitors must remain masked (cloth or surgical/procedure for outdoor visits and surgical/procedure for indoor visits) at all times and maintain at least 2 metres of physical distance from the resident they are visiting. Visitors should be encouraged to bring their own cloth masks for outdoor visits, but appearing without a mask should not be a barrier to visiting.
	• If masking of visitors causes distress to the resident (e.g. for cognitive or mental health reasons) or poses difficulties with either recognizing (e.g. cognitive impairment) or understanding the resident (e.g. hearing-impaired residents who rely on lipreading) a face shield which wraps around the chin or a transparent mask can be considered as alternatives.
	• Consideration may be given to allowing brief hugs and handholding while maintaining as much distance as possible between the faces of the resident and visitor, and ensuring the availability of alcohol-based hand sanitizer for prompt and effective hand hygiene both immediately before and after these encounters.40
	• Homes must maintain ample PPE supply to enable resident visits.
	• Failure of visitors to comply with procedures could be grounds for a loss of visiting rights, which should be appealable.
7. Accommodations for visitors while on-site at the nursing home	• Visitors must have access to bathrooms (an accessible outdoor sheltered bathroom or designated indoor bathroom). • Outdoor visiting must occur in weather protected settings (e.g. a shaded area with hydration for hot weather, a sheltered area for rain, or a heated area for colder weather).
8. End-of-life considerations	• Residents designated as being “critically ill” or at “end-of-life” (<14-day life expectancy) should be provided with the same level of access that would be rendered to a family caregiver. If visitors need to enter the home under these circumstances, they should be subject to the same conditions and procedures as “family caregivers”.

Appendix

Supplementary Table 1.

Nursing Home Visitor Policies for Canada's 10 Provinces and 3 Territories (as of July 14, 2020)

Province/Territory	Distinguishes between Family Caregivers and General Visitors Definition of family caregiver	Visitor Allowances and Requirements for Family Caregivers 1. How many family caregivers can be designated per resident? 2. How many family caregivers are allowed in the home at one time? 3. Allowed in nursing home while under outbreak 4. Allowable frequency and length of time for visits 5. Screening and testing requirements 6. IPAC and PPE training and requirements 7. End-of-life/compassionate visit considerations	Visitor Requirements and Allowances for General Visits 1. How many visitors are allowed at one time? 2. Indoor and/or outdoor visits 3. Allowable frequency and length of time for visits 4. Screening and testing requirements 5. IPAC and PPE training and requirements 6. Accommodations for residents who are bedbound and/or have dementia (at risk of violating physical distancing) 7. Accommodations for visitors (eg, access to bathrooms and PPE)	Dates and Link(s) to Guideline(s)/Directive(s)
Alberta ∗Residents allowed outside as long as they are physically distancing.	Yes, defined as: - Where the resident's quality of life and/or care needs cannot be met without the assistance of the “designated essential visitor”. - May be a family member, friend, religious, and spiritual advisor or paid caregiver.	1. A resident may have only 1 designated essential visitor. However, a resident may identify a temporary replacement designated essential visitor for approval if the designated essential visitor is unable to perform their role for a period of time. This intent is not for this designate to change regularly or multiple times but to enable a replacement, when required. 2. One visitor per resident. 3. Not specified. 4. No frequency or time restriction specified. 5. Health screening, questionnaire, and temperature check. No testing requirement. 6. Must wear a mask (type not specified) at all times (indoors and outdoors), hand hygiene, PPE, and IPAC guidance will be provided. 7. End-of-life considerations: - Designated essential visitor is permitted to visit “as much as required”. - There is no limit on the number of different individuals who can visit overall, but visits must be coordinated with the care team and the site. - Up to 2 designated family/support persons at a time are allowed to visit as long as physical distancing can be maintained between the family/support persons.	1. Designated Essential Visitor and up to one additional person can visit at one time. 2. Outdoor visits only. 3. Not specified. 4. Health screening, questionnaire and temperature check. No testing requirement. 5. Continuously wear a mask (type not specified) at all times (indoors and outdoors), hand hygiene, PPE and IPAC training will be provided. 6. Not specified. 7. PPE will be provided.	1. May 7, 2020: https://open.alberta.ca/dataset/1a2011e5-fc79-43b4-aab0-1c276b16b99b/resource/35ab8044-8c19-480a-9799-ef4f9b95c376 2. June 29, 2020: https://www.albertahealthservices.ca/assets/healthinfo/ipc/hi-ipc-covid19-infosht-visiting-pts-pandemic.pdf 3. July 8, 2020: https://www.albertahealthservices.ca/topics/Page17001.aspx
British Columbia ∗May leave the home for medically necessary care or treatment.	Yes, defined as: - Visits considered paramount to resident care and well-being, such as assistance with feeding, communication, personal care, emotional support, or mobility. - Existing registered volunteers providing services as described above only.	1. Not specified. 2. Essential visits limited to 1 visitor per resident at a time. A visitor who is a child may be accompanied by 1 parent, guardian, or family member. 3. Essential visits can occur with a patient with COVID-19 or client. 4. No frequency or length of time specified. 5. Screened for signs and symptoms of illness. No testing requirement. 6. Instructed “when to perform hand hygiene, respiratory etiquette, and safe physical distancing” and “how to put on and remove any required PPE” 7. Essential visits include visits for compassionate care, including critical illness, palliative care, hospice care, end-of-life, and medical assistance in dying.	1. Residents can visit with 1 designated family member or friend. 2. Three locations: - Outdoor location for visiting (when weather permits) - Indoor designated location (summer and especially fall/winter) - Individual room visits (focused on limited mobility of a resident) 3. Frequency and time limits are not specified, but visits must be booked in advance. 4. Screening for signs and symptoms. 5. Visitors must bring and wear a mask (type not specified), wash hands before and after, and maintain physical distancing. They will be directed on how to put on and remove PPE if necessary. 6. Visits with those with mobility challenges will be assessed on an individual basis. 7. Not specified.	1. May 19, 2020: https://www2.gov.bc.ca/assets/gov/health/about-bc-s-health-care-system/office-of-the-provincial-health-officer/reports-publications/covid-19-infection-prevention-control.pdf 2. June 30, 2020: http://www.bccdc.ca/Health-Info-Site/Documents/COVID19_LongTermCareAssistedLiving.pdf
Manitoba ∗Off-site visits not recommended.	Yes, defined as: - Close family and/or friends who have a clearly established pattern of involvement in providing care and support to the resident's emotional well-being, health, and quality of life.	1. Residents may designate a reasonable number of close family members and/or friends for visits, but goal would be kept it to minimum. 2. Only 1-2 designated visitors allowed in at a time (depending on risk status of the home). 3. Yes, under strict guidelines. 4. No frequency or length of time specified. 5. Testing not required. Screening before entry, but no temperature checks. 6. Depending on risk level, must wear appropriate PPE for the setting, Outbreak status requires medical mask, all else requires nonmedical mask, physical distancing, hand hygiene, and IPAC guidance. 7. End-of-life visits will be considered on a case-by-case basis. Up to 2 designated visitors may visit together if physical distancing can be maintained.	1. Maximum of 2 visitors at 1 time. 2. Outdoors only. No off-property visits are permitted. 3. No length of time or frequency specified. 4. Screening but no temperature checks. No testing required. 5. Nonmedical mask (cloth) encouraged, physical distancing, hand hygiene, and IPAC guidance. 6. Not specified. 7. Not specified.	1. June 22, 2020: https://sharedhealthmb.ca/files/covid-19-pch-visitation-principles.pdf 2. June 22, 2020: https://sharedhealthmb.ca/files/covid-19-visitor-triage-process-for-long-term.pdf 3. June 22, 2020: Plans to build outdoor, all-season vitiation structures at long-term care homes: https://news.gov.mb.ca/news/index.html?item=48497&posted=2020-06-22 4. July 8, 2020: https://sharedhealthmb.ca/files/covid-19-highlights-ltc.pdf
New Brunswick	No clear distinction is made.	1. Not specified. 2. Not specified. 3. Not specified. 4. Not specified. 5. Not specified. 6. Not specified. 7. Palliative patients are permitted to select 2 visitors to comfort and support them. - The 2 individuals selected will be the only visitors permitted, and only 1 visitor is permitted at a time. - If a visitor requires a support person to visit (eg, frail elderly spouse or individual with a disability), this person counts as the second chosen visitor. - In exceptional cases, the support person can visit at the same time while respecting physical distancing in the home. - There can be no change in the 2 visitors chosen.	1. Two visitors at a time for outdoor visits. One visitor for indoor visits (unless the visitor requires support, in which case, 2 visitors will be permitted). 2. Both indoor and outdoor visits permitted. 3. No specified frequency. Limit of 1 h for visits 4. Health screening. No testing required. 5. Must wear a nonmedical mask or face covering at all times, physical distancing, follow IPAC guidelines, hand hygiene, and limit interactions with staff, patients and other visitors. 6. Not specified. 7. Not specified.	1. June 4, 2020: https://www2.gnb.ca/content/gnb/en/news/news_release.2020.06.0324.html 2. June 22, 2020: Horizon Health Network https://en.horizonnb.ca/home/media-centre/horizon-news/20200622-covidvisitorguidelines.aspx 3. June 24, 2020: Vitalité Health Network https://www.vitalitenb.ca/en/news/visits-resuming-vitalite-health-network-facilities 4. June 24, 2020: https://www.cbc.ca/news/canada/new-brunswick/covid-19-roundup-pandemic-1.5624973 5. July 3, 2020: https://www2.gnb.ca/content/gnb/en/corporate/promo/covid-19/recovery.html
Newfoundland and Labrador	Yes, defined as: - Residents can identify a support person/designated visitor that can be a loved one, friend, paid caregiver, or other person of the resident's choosing. This individual should remain constant for the duration of the visiting restrictions.	1. One support person per resident. 2. One person per resident. Total caregivers in the home at one time will be limited by a booking system. 3. Not permitted when home is in outbreak. 4. May only visit once per day. No length of time for visits specified. 5. Must undergo screening process upon entry and complete the self-assessment questionnaire. 6. Must wear a “procedural” mask, follow proper hand hygiene, PPE training will be provided, practice physical distancing, and limiting their social interactions outside the home (people in their ‘bubble’) to minimize their personal risk and risk to the resident. 7. First stage of visiting for end of life: - Six designated visitors where one is primary support person (not limited to once a day visits) and 5 are visitors (can visit once a day). - Two individuals can be present during a visit. May exceed 2 when children age 18 y and under are visiting. - A Pastoral support person is in addition to the designated visitors. As the resident nears end-of-life: - All immediate family will be permitted to visit and not limited to 1 visit per day.	1. Each resident can identify a support person and up to 5 designated visitors. The 6 individuals should remain constant for the duration of the visiting restrictions. A maximum of two people can visit per day, and 2 visitors can attend at the same time. 2. Type of visit is dependent on individual home and homes can choose between: - In-home visiting - Window visiting (more than 1 visitor at a time) - Outdoor visiting (more than 1 visitor at a time and visitors are not limited to the resident's support persons/designated visitors) 3. Not specified, at the discretion of each home. 4. For outdoor visits, self-assessment required. For indoor visits, screening by staff. Not specified for window visiting. 5. For outdoor visiting, physical distancing must be maintained and visitors must wear a “procedural” mask. They are not permitted to wear their own masks. Hand hygiene. 6. Not specified. 7. Visitors will be provided a procedural mask upon entry to the home.	1. July 13, 2020: https://www.gov.nl.ca/covid-19/guidelines-for-support-person-designated-visitors/
Nova Scotia	No clear distinction, however, visitors who are performing essential support care services for the resident (ie, similar to a personal support worker) are permitted to visit.	1. One person per resident. 2. One person per resident. 3. Not specified. 4. Not specified. 5. Must be screened upon entry and includes temperature checks. 6. Can only visit the one resident and no others. Must be supported by staff in appropriately using PPE. 7. Compassionate exceptions will be made for those visiting very ill or palliative residents.	1. Maximum of two visitors at a time. 2. Outdoor visits only in designated areas on the grounds. 3. No frequency or length of time for visits specified. 4. Must be screened for symptoms upon entry. 5. Must wear a nonmedical mask and maintain physical distancing. Must follow IPAC guidelines. May remove mask once at the designated visiting area if physical distancing can be maintained and if needed for effective communication. 6. Creative solutions: - Some homes to set up large, 3-sided plexiglass cube that will shield residents from their visitors to allow for enhanced communication; - Plans to add disposable gloves that would ‘poke through’ the plexiglass allowing families to hug; - Large, marquis-style tents that will be put up in the gardens and available in the rain or shine. - Some homes have attendants sit with residents with dementia during the visit to help with physical distancing and communication. 7. Staff can provide PPE if necessary.	1. April 11, 2020: https://novascotia.ca/dhw/ccs/documents/COVID-19-Management-in-LTC-Directive.pdf 2. June 8, 2020: https://novascotia.ca/dhw/ccs/documents/COVID-19-Management-in-Long-Term-Care-Facilities-Directive.pdf 3. June 10, 2020: https://novascotia.ca/news/release/?id=20200610004 4. June 15, 2020: https://globalnews.ca/news/7066924/nova-scotia-long-term-care-homes-visits/ 5. July 6, 2020: https://www.thechronicleherald.ca/news/provincial/outdoor-visits-going-well-at-new-waterford-long-term-care-home-469760/
North West Territories	Yes, defined as: - Essential visitor is defined as “a person who is permitted to visit in accordance with organizational/Health and Social Services Authority direction/guidance (ie, palliation or end-of-life, etc.).”	1. Only 1 designated essential visitor per resident. 2. Maximum of 5 visitors at any one time in the home. 3. Admission of essential visitors must be suspended when COVID-19 detected in the home or the community/region where the home is located. 4. Not specified. 5. Active screening. No testing requirements. 6. Staff must support, train, and monitor essential visitors for compliance in hand hygiene, healthy respiratory practices, physical distancing, and appropriate use of PPE. Medical masks must be worn. 7. Essential visitors include those visiting palliative residents or those at end-of-life. - Limited to 2 visitors at any one time.	General visitors still not allowed.	1. https://www.nthssa.ca/en/services/coronavirus-disease-covid-19-updates/visitor-restrictions-and-processes-during-covid-19 2. June 18, 2020: https://www.hss.gov.nt.ca/professionals/sites/professionals/files/resources/interim-outbreak-management-covid-19-long-term-care-facilities.pdf. 3. July 6, 2020: https://www.gov.nt.ca/covid-19/en/services/gnwt-services/visitation
Nunavut	Not specified, only states that on June 29, 2020, visitors must be immediate family (including grandchildren and great-grandchildren).	Not specified.	1. No more than two visitors (immediate family only) per resident at a time. 2. Not specified. 3. Not specified. 4. Not specified. 5. Not specified. 6. Not specified. 7. Not specified.	1. July 6, 2020: https://www.gov.nu.ca/health/news/covid-19-department-health-services-update
Ontario ∗Off-site visits not permitted.	Yes, defined as: - Essential visitors include family or volunteers providing care services and other healthcare services required to maintain good health.	1. Not specified. 2. Not specified. 3. Essential visitors are the only type of visitors allowed when a resident is self-isolating or symptomatic, or a home is in outbreak. 4. Not specified. 5. Active screening when entering the home. 6. Essential visitors must use a surgical/procedure mask while in the home, including while visiting a resident that does not have COVID-19 in their room. 7. Essential visitors include those visiting a very ill or palliative resident.	1. One visitor per resident. General visitors are defined as ‘any family member, close friend, or neighbor.’ 2. Outdoor visits only. 3. Once a week, visits can be time-limited but cannot be restricted to less than 30 minutes. 4. Visitors must pass an active screening questionnaire administered by home staff. Must attest to home staff that the visitor has tested negative for COVID-19 within the previous 2 weeks and subsequently not tested positive. The home is not responsible for providing the testing. 5. Visitors should use a face covering if the visit is outdoors. If the visit is indoors, a surgical/procedure mask must be worn at all times. 6. For bed-bound residents, where possible staff should transfer them out of the home. Homes are encouraged to establish or maintain virtual visits. Where it is not possible or advisable for in-person visits (ie, for those who have cognitive issues), virtual options should be continued. 7. Outdoor visitors cannot enter the home to use the washrooms. PPE will be provided by the home as needed.	1. June 11, 2020: https://files.ontario.ca/mltc-resuming-visits-long-term-care-homes-en-2020-06-11-v3.pdf?_ga=2.127429517.186347961.1592838312-197570308.1465177986 2. June 10, 2020: http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/directives/LTCH_HPPA.pdf 3. June 16, 2020: http://health.gov.on.ca/en/pro/programs/ltc/directive3_faq_20200616.aspx
Prince Edward Island ∗Residents must remain within the grounds of their home.	Yes, defined as: - An “essential support person” may be designated for residents with a history of responsive behaviors who are at risk of escalating to the point of crisis at the discretion of the home's staff. - The designated essential support person identified to provide physical and emotional well-being must have a demonstrated history of de-escalating the resident. - This visit may include supporting communication needs for persons with hearing, visual, speech, cognitive, intellectual or memory impairments.	1. One designated essential support person per resident, at the discretion of care team. 2. One designated essential support person per resident at one time. 3. No visitors are permitted on designated COVID-19 units. 4. Limited to 1 h. 5. All visitors will be screened for COVID-19 symptoms but there are no testing requirements. 6. Must practice physical distancing, wear a mask (medical grade), follow IPAC guidelines, and hand hygiene. 7. End-of- life visiting can occur bedside in residents' rooms: - Maximum of 6 designated visitors will be selected per resident. - Only 2 of the 6 may visit at one time. A member of the clergy may visit at the same time as the 2 designated visitors. - Exception for last hours of life (all 6 can visit together along with clergy member). - No limitation on length of time of visit.	1. Up to 6 designated visitors, however, maximum of 2 visitors can visit at 1 time. Temporary replacement designated visitors may be identified if the original visitors are unable to perform their role for a period of time. 2. Both outdoor and indoor visits permitted in designated visiting areas. 3. Limited to 1 h as frequently as the home can handle. 4. All visitors will be screened for COVID-19 symptoms. Must practice physical distancing, wear a mask (non-medical grade for outdoor visits and medical grade for indoor visits) or face shield, follow IPAC guidelines and hand hygiene. 5. Not specified. 6. PPE will be provided as necessary. Masks, tissues, alcohol-based hand rub, and no-touch receptacle provided at each entrance.	1. June 11, 2020: https://www.princeedwardisland.ca/sites/default/files/publications/pei_guidelines_for_the_management_and_control_of_covid-19_in_ltc.pdf 2. July 2, 2020: https://www.princeedwardisland.ca/sites/default/files/publications/2020-07-02_cpho_directive_on_visitation_to_ltc_facilities_and_nursing_homes.pdf 3. July 7, 2020: https://www.princeedwardisland.ca/en/information/health-and-wellness/phase-4 4. July 10, 2020: https://www.princeedwardisland.ca/en/information/health-pei/long-term-care-easing-restriction-on-visitation
Quebec ∗As of June 18, residents can go on unsupervised outings out of the home.	Yes, defined as: - “Caregivers who provide or would like to provide significant assistance and support to a loved one to meet their needs and contribute to their integrity and well-being. Assistance and support may include helping with meals; supervising and being attentive to the person's overall condition; providing support with various daily or recreational activities; assistance with walking; providing moral support or comfort”. - A significant caregiver…residents must have received support from the person before visiting restrictions were put in place due to COVID-19. - Visitors are only allowed in Centres d'hébergement de soins de longue durée (LTC homes), intermediate or family-type resources (Support Program for the Autonomy of Seniors) or private seniors' homes without a COVID-19 outbreak. A visitor is anyone who wants to visit the person in the home and who does not meet the criteria to be identified as a caregiver.	1. May designate more than 1 essential family caregiver. 2. A maximum of 2 essential family caregivers from the same household can be in the home at a time. 3. Yes, as of June 18, 2020. 4. No limit on frequency or on length of time. 5. Self-monitoring of symptoms. No testing requirement. Most sign a consent form stating that “their decision was informed and voluntary, with full knowledge of the associated risks and knowing that they could become infected during their visits or even infect their loved one.” 6. Must remain continuously masked and wear PPE as required. Will be given a face shield. Training of visitors and procedural masks must be available in sufficient quantity for visits to be allowed. 7. Compassionate visits will be permitted when death is imminent (24‒48 h). A maximum of 2 visitors are allowed at 1 time.	1. Maximum of two visitors at one time from the same household. 2. Indoors and outdoors. 3. No limit on length of time or on frequency. 4. Self-monitoring of symptoms. No testing requirement. 5. Must remain continuously masked in the home and wear PPE as required. Training of visitors and procedural masks must be available in sufficient quantity for visits to be allowed. 6. Not specified. 7. Not specified.	1. July 2, 2020: https://www.quebec.ca/en/health/health-issues/a-z/2019-coronavirus/answers-questions-coronavirus-covid19/questions-answers-health-services-covid-19/#c53925 2. June 30, 2020: https://www.quebec.ca/en/health/health-issues/a-z/2019-coronavirus/caregivers-during-the-covid-19-pandemic/#c60604 3. June 23, 2020: https://www.ciussswestcentral.ca/health-alerts/coronavirus-covid-19/new-regulations-for-private-caregivers-in-chslds/ 4. June 23, 2020: https://publications.msss.gouv.qc.ca/msss/fichiers/2020/20-210-46WA.pdf
Saskatchewan ∗Residents not permitted to leave home except for outdoor visits.	Yes, defined as: - Where it is determined that the resident's quality of life and/or care needs cannot be met without the assistance of a family member or support person.	1. Can designate 2 family members/support persons. 2. Only 1 family/support person can be present in the home at a time. 3. Not specified, as per the home's policies. 4. No frequency or length of time for visits specified. 5. Screening including a temperature check and questionnaire. Testing not required. 6. Will be provided with a medical grade mask and potentially additional PPE. Must follow IPAC guidelines and hand hygiene. 7. End-of-life/compassionate care visits will be permitted. - One family member/support person can be present at a time. - A second family member or support person can be present if physical distancing can be maintained (if from the same family home, physical distancing does not apply). - Additional family members or support persons can be identified for end-of-life visits. - Religious/spiritual care providers can be present in addition to designated family member/support person if physical distancing can be maintained.	1. No maximum number of visitors at one time. 2. “Outdoor visits can include more than one visitor at a time, provided that physical distancing can be maintained. Family members from the same household do not have to physically distance from one another”. 3. No frequency or length of time specified. 4. Screening at the door or in advance. No testing requirement. 5. Maintain physical distancing. Asked to mask but are not required if it is a barrier to communication and they can maintain physical distancing. 6. Considerations will be made for residents who are not able to participate meaningfully in virtual visits or outdoor visits. 7. Not specified.	1. July 2, 2020: https://www.saskatchewan.ca/-/media/files/coronavirus/info-for-health-care-providers/general-information-for-health-care-providers/visitor-restrictions-at-health-care-facilities/covid-19-family-presence-guidance.pdf 2. July 3, 2020: https://www.saskatchewan.ca/government/health-care-administration-and-provider-resources/treatment-procedures-and-guidelines/emerging-public-health-issues/2019-novel-coronavirus/public-health-measures/guidance-for-health-care-facilities
Yukon ∗Residents may visit family or friends overnight, or for several nights, stays. Decision will be made with care team, however, currently it is not recommended.	Yes, defined as: - A “designated essential visitor can visit” inside “when staff cannot meet a resident's quality of life or care needs” and may include services for someone with cognitive impairment or dementia. - Designated essential visitors must be named by the resident or their substitute decision maker, they cannot be under age 18, and the resident care manager must confirm that they meet the criteria.	1. Each resident can have 2 designated essential visitors. 2. The essential visitor, as well as 1 other person. If the resident does not have a designated essential visitor, they can have 1 identified general visitor plus one other person. The total group size should not be more than 3 (including the resident). 3. Not specified. 4. Not specified. 5. Active screening (questionnaire and temperature check). 6. Must wear a medical mask continuously in the home. They will be provided with instruction on how to put on and take off masks with proper hand hygiene. They must also wear any other PPE, as required. 7. If the resident will die within the next 4 weeks: - The essential visitor may enter the home. Up to 5 people can be approved, but only 1-2 visitors are allowed in the care home at a time including family, religious leader(s), a child, and friends. - If the approved visitor is a child, the essential visitor or child's parent/guardian must go with them. - The resident can have up to 2 visitors in the bedroom at the same time if physical distancing is possible.	1. A ‘general visitor’ is defined as a visitor who has been named by the resident or their substitute decision maker. Identified general visitor and one other person. The total group size should be 3 including the resident. 2. Outdoor visits only with appropriate social distancing. 3. Not specified. 4. Not specified. 5. Must wear a mask during the visit. Any type of mask that meets Health Canada's recommendation for non-medical face masks are permitted. 6. Not specified. 7. Not specified	1. March 16, 2020: https://yukon.ca/en/news/chief-medical-officer-health-recommends-broad-new-measures-yukon 2. July 9, 2020: https://yukon.ca/en/health-and-wellness/covid-19-information/long-term-care-visitation-guidelines-covid-19