Visitation Policy

VISITATION PROTOCOL & PROCEDURE FOR COMPLAINTS

The Policy and Procedure has been inclusive of the following requirements:

Revised Visitation Policy and Procedure inclusive of in-person visitation during a crisis/pandemic/any situation out of the norm needing the implementation of infection control/any established CDC Regulation and/or regulations to be established by such entity for prevention of emergency/crisis situation.
Forms/Documents that clearly establish a record of compliance such as Caregiver designation form, consents for compliance of physical contact, sign in and out sheet establishing record of visitation and Acceptance of Responsibility as an Essential Care Giver/Delegation of Responsibility Form.
Establishment of circumstance/reason why visitation must be allowed.
Manner in which compliance of such policy and procedure will be implemented.
For Health Care Administration with an Initial License Application, Renewal, Change of Ownership, or upon request from AHCA when needed.
The Publishing of such information via Website as of February 24^th, 2026, in the event any of the required facilities have such and posting the document in a visible area of the facility for compliance.
Policies and Procedures of the new requirement must specify hours of visitation, duration of visitation, infection control policy, education of visitors, designation of visitation area and education on prevention to visitors, staff and residents.

FILLING VISITATION RELATED COMPLAINTS

IN THE EVENT OUR FACILITY DOES NOT MEET CRJTERIA WITH THE COMPLIANCE OF COMPLAINTS CAN BE FILED AS FOLLOWS:

Online by visiting: https://apps.ahca.myflorida.com/hcfc or
Via telephone by calling 1-888-775-6055 Monday to Friday from 8am to 5pm EST.

INFECTION CONTROL, HAND WASHING AND UNIVERSAL PRECAUTIONS POLICY AND PROCEDURE

POLICY:

Infection Control Procedures are established during visitation for the prevention, control, and investigation of communicable diseases within our facility. Our goal is to maintain visitation following the protocol while being preventive and educational regarding the situation at hand. All Protocols have been based for compliance with Rule 59A-36.007(10) the goal is for our facility to prevent the spread, and protect resident, staff, visitors from severe infections, hospitalization or death. We aim to continue a personal exchange between residents and their caregiver/responsible party implementing procedures that set protocols of compliance yet allowing a personal exchange in order to prevent any sense of abandonment, neglect, depression, distant feeling on behalf of the resident by allowing the caregiver/responsible party personal interaction with the resident.Any visitors must comply with the Procedures established in our policy therefore it shall be made clear that in order to enter the visitor must not propose danger to Residents or Staff and must be willing to comply with the specifications of the procedures established and detailed under the Procedure Section.

PROCEDURE:

INFECTION CONTROL, HAND WASHING AND UNIVERSAL PRECAUTIONS

Our facility will integrate the Standard Infection Control Policy with Special Precautions and Adjustments implemented during the pandemic outbreak along with Hand Hygiene in order to successfully achieve our goal of compliance while maintaining a healthy environment for Residents, Staff, and Visitors.

Our Facility will secure the following:

Continue the Implementation of PPE Equipment when needed. The use will be determined by possible exposure, signs and symptoms, or any other indication of exposure.
Hollowing the Hand-Washing techniques to maintain hand hygiene.
Follow CDC cough etiquette and or any respiratory protocols for prevention.
Following proper measures to disinfect, maintain facility and assistive devices clean.
Secure with proper protocols that visitors understand and agree to visitation regulations.
Designate areas for visitation, duration and number of visitors per resident.
Follow the traditional Infection Control, Special Precautions, and Hand Hygiene specified below:

All employees that come in contact with blood, body fluids, and absorbent materials contaminated with blood or fluids or sharp (needles) must use appropriate barrier precautions to prevent skin and mucous membrane exposure when contact with the above listed materials of any clients is reasonably anticipated.
Gloves must be worn for:
Touching blood/body fluid.
Touching mucous membranes/non-intact skin.
Handing items or surfaces contaminated by blood/body substances.
Performing blood drawings.

Gloves must be changed after contact with each resident.

Care should be taken not to contaminate the environment with soiled gloves.

Mask and protective eyewear or face shields must be worn for procedures that are likely to generate splashes of blood/body fluids.
Gloves, aprons/gowns must be worn for procedures that are likely to generate splashes of blood/body fluids.
Hands and other skin surfaces must be washed immediately and thoroughly if contaminated with blood/body fluids.
Hands must be washed immediately after gloves are removed.
Needles and other sharp objects:
Must not be manipulated by hand.
Needles must be recapped, broken or bent by hand.
Must be handled with extreme care during disposal.
Must be placed in a puncture-resistant container after use.
Soiled articles, linen, trash must be securely contained to prevent leaks.
Spills of blood of other body fluids should be cleaned with soap and water or household detergent.
Individuals cleaning up such spills should wear disposable gloves.
A disinfectant solution or a solution of household bleach should be used to wipe the area after cleaning.
All potentially infectious material shall be disposed according to ALF policy “Disposing of Bio-hazardous Waste”.
Precautions shall be implemented when dealing with open wounds, cuts, abrasions, hanging nails, blood, bodily fluids, urine, feces, secretions of any kind, also with anything that can be of risk or contamination indicator. Staff are encouraged to wear gloves when cleaning common areas, laundry, etc.

HAND WASHING

POLICY:

Hand washing is the single most important means of preventing the spread of infections in the facility.

PROCEDURE:

Employee’s hands must be washed for at least 20 seconds using soap and water
Before and after contact with the resident (mandatory).
After contact with blood, body fluids, or visibly contaminated surfaces.
After contact with objects and surfaces in the resident’s environment.
After removing Personal Protective Equipment (gloves, gown, facemask, eye protection).
After using the restroom.
After blowing one’s nose, sneezing or coughing.
Before eating or preparing food.
When their hands are visible soiled.
At the beginning and the end of each shift.
After contact with animals or pets.
Residents should always wash their hands for at least 20 seconds using soap and water.
Before meals.
After toileting.
The combination of soap and water, friction and time is essential to any good hand-washing procedure.
Hand washing procedure:
Standing a comfortable distance from the sink, turn the water on and adjust to the proper temperature. Cool or lukewarm water tends to remove less oil from the skin; therefore, it is less drying.
Wet hands and wrists thoroughly, holding them downward over the sink to enable the water to run toward the fingertips.
Apply large lather of soap. Cover well beyond area of contamination, at least one inch.

Portion is determined by the instructions on the dispenser.

Wash well under running water for at least 20 seconds using a rotary motion and friction, by interlacing fingers and moving the hands back and forth.
Nails should be short. Pay particular attention to areas between fingers, around nail beds and under fingernails. Nails are cleaned best by working them against the palms of the hands, or by using an orange stick, if necessary. (Use brush is not advised because it may irritate the skin when hands are washed as often as they should be in resident care).
Rinse hands thoroughly by holding them under running water with elbows higher than the hands so that the water flows downward to the fingertips. All soaps should be carefully removed to avoid roughened skin.
After final rinse and during drying, hold hands so direction of water flow is from fingertips to wrist.
Dry wrists and hands with a paper towel from the area of the wrists to the fingertips. Discard each towel after one motion from the wrists to fingertips.
Since the faucet handle is considered contaminated, turn the water off by using the paper towel to cover the handles.
Assure the effective hand washing by:
Keep fingernails short.
Remove rings and other jewelry as they shelter large numbers or organisms.
When turning the faucets and when handling the lids of garbage cans, use paper towels to keep from infecting your hands.
Do not use a communal bar of soap. This may spread infection.

UNIVERSAL PRECAUTIONS (BLOOD BORNE PATHOGENS/OSHA)

POLICY:

All employees having direct contact with residents and or material that can directly affect the life of the residents will observe universal precautions. This practice is to minimize or prevent exposure of health care workers to blood borne pathogens.

PROCEDURES:

Universal precautions, disposable gloves will be worn when handling blood, mucous membranes or on intact skin (skin with a breakdown).
Disposable gloves will be used when cleaning surfaces or articles (ex: clothing) contaminated with blood or bodily fluids.
Disposable gloves may be worn at any time and hands are likely to be contaminated by urine, feces, or other bodily fluids.
Hands are to be washed after removal of gloves.
Staff with open wounds, cuts, abrasions and hanging nails are to wear gloves when providing care for the residents.
If linen is wet, moist from bodily fluids, then staff are to wear gloves.
Staff are encouraged to wear disposable gloves when cleaning common areas, laundry, etc.
All sharp needles and syringes are immediately disposed of in sharps containers. The sharps containers are sealed when full and treated as a BIOHAZARDOUS WASTE.

INFECTION CONTROL PREVENTION MEASURES:

Residents, Staff, Visitors and any other individual having direct contact with residents and entering our Facility shall adhere to all of the Infection Control Measures established for the prevention or containment of any situation that may pose a life threating risk.

We will base ourselves on the CDC guidelines and the Regulatory Protocol from the Agency for Health Care Administration and adhering to:

Infection Control
Universal Precautions
Hand Hygiene
Use of PPE Equipment
Admission Criteria
Education of Residents, Staff, and Visitors
Documentation compliance
Encouragement of keeping vaccines up to date
Keeping a Clean Environment
Preventing Gatherings in Large Scale
Maintain a close relationship with Health Department, CDC, and Agency for Health

Administration in the event an outbreak occurs.

Maintaining Hand Sanitizer or any alcohol-based substance that has approved use as an anti-bacterial.

PROCEDURE:

The facility will provide the following Personal Protective Equipment (PPE) and will purchase additional when needed:

Gloves
Facemasks (Surgical mask, N95 mask)
Gowns
Eye Protection (goggles, face shield)

Employees who are expected to use PPE will receive training on selection and use of PPE, including demonstrating competency with putting on and removing PPE in a manner to prevent self-contamination.

The facility will provide information about communicable disease to educate residents, family members, and employees.

GENERAL STANDARD PRECAUTIONS

Keeping communicable diseases out of the facility:

Use of PPE by ALF personnel, Resident and Visitors if needed to maintain the flow of physical contact.
Keeping hands clean, hand hygiene. Provide access to alcohol-based hand sanitizer with 60-95% alcohol throughout the facility in every resident room and common areas. If there are shortages of alcohol-based hand sanitizer, hand hygiene using soap and water is still expected. Keep sinks stocked with liquid soap and paper towels.
Respiratory hygiene/cough etiquette: Make tissues and trash cans available in common areas and resident rooms for respiratory hygiene and cough etiquette and source control.
Residents, Staff, and Visitors should wear a cloth face covering or face mask (if tolerated) in the event of detection of risk.
Advise residents, staff and visitors entering the facility, regardless of symptoms, to put on a cloth face covering or facemask before entering the building in the event of risk. If a visitor or resident or staff arrives at the facility without a cloth face covering and a risk is suspected facility will provide the PPE.
Actively screening all residents and visitors by completing the sign-in-long and asking the pertinent questions prior to entering the facility after an exit. Staff will be required to answer questions about signs and symptoms upon entering the facility before each shift or after returning to work when having days off.
Actively request any (Health Care Personnel) entering the facility also sign in and answer the required prevention questions.
Facility keeps records of any contact with MD or medical staff in the event any signs and symptoms are detected in residents, staff, or visitors.
Performing infectious disease testing for all employees (i.e. clinical, housekeeping, nutrition, maintenance, administration, and contract).
For ALFs with a suspected or confirmed infectious disease case, contract HCP (Health Care Personnel) should be notified by ALF owner or designate employee and told to self-monitor for fever or respiratory symptoms daily and inform both the ALF staff and their employment agency if they have symptoms. They should also not report to work if they develop symptoms.
ALF staff should identify and maintain a list of the names, contact information, and services provided for all contract staff/HCP, in case they need to be alerted about suspected or confirmed infectious diseases cases in the facility.
Cancel all field trips outside of the facility in the event of positive.
Implementation of social distancing among residents. Social distancing means people remain at least 6 feet apart to limit potential for transmission. Work to implement social distancing among residents if risk is detected.
Cancel all group activities if social distancing cannot be kept in the event of risk.
Cancel or restrict communal dining, consider delivering meals to rooms or staggering mealtimes to accommodate social distancing while dining in the event of risk.
Implement universal facemask use by all (source control) when they enter the facility; if facemasks are in short supply, they should be prioritized for direct care personnel.
All ALF staff and HCP should be reminded to practice social distancing when in break rooms or common areas in the event of risk.
Environmental cleaning and disinfection and reprocessing of reusable or share resident medical equipment (glucometers, nebulizers, thermometers, blood pressure cuffs/machines, etc.).
Ensure adequate cleaning and disinfection supplies are available.
Provide EPA-registered disinfectants so that commonly used surfaces can be wiped down. Routinely (at least once per shift) clean and disinfect surfaces and objects that are frequently touched in common areas (door handles, faucets, toilet handles, light switches, handrails, countertops, chairs, tables, remote controls, shared electronic equipment)
Any individuals that are permitted to enter will be instructed to perform hand washing or sanitizing; should maintain social distancing, limit their interactions with others in the facility and surface touched; restrict their visit to the resident’s room or other location designated by the facility; and wear a cloth face covering or facemask as supply allows. Also, they will be advised to monitor signs and symptoms of communicable disease and appropriate actions to take if signs and/or symptoms occur.
Strengthen hand hygiene adherence. Provide access to alcohol-based hand sanitizer with 60-95% alcohol throughout the facility to facilitate hand hygiene by staff.
- Keep sinks stocked. with liquid soap and paper towels.
Evaluation of housekeeping or cleaning services provided in the ALF should include the use of appropriate protection for people providing these services in ALFs and follow CDC cleaning and disinfecting guidance.

OTHER ACTION TO TAKE DURING PREVENTION:

Immediately isolate anyone who is symptomatic
Wear all recommended PPE.
Move the resident to an isolated room and close the door.
Monitor ill residents at least 3 times daily including evaluating symptoms, vital signs, and oxygen saturation via pulse oximetry to identify and quickly manage clinical deterioration.
Notify the Health Department if one resident or employee develops symptoms, or individuals with known or suspected of an infectious disease are identified.
Transfer to Hospital if showing symptoms from any communicable disease and MD provides instruction.
Call 911 for any residents in acute distress.
Monitor Staff for signs and symptoms in the event of having positive findings replace staff immediately and request they take time off until the risk is over.
Advise unexposed Residents, Visitors, and Staff of any Risk.
Advise Visitors of risk when entering the facility.

PERSONAL PROTECTIVE EQUIPMENT (PPE)

Staff appropriately use PPE including, but not limited to, the following:

Gloves are worn if potential contact with blood or body fluid, mucous membranes, or non-intact skin.
Gloves are removed after contact with blood or body fluids, mucous membranes, or non-intact skin.
Gloves are changed and hand hygiene is performed before moving from a contaminated body site to a clean body site during resident care; and an isolation gown is worn for direct resident contact if the resident has uncontained secretions or excretions.
PPE was appropriately removed and discarded after resident care, prior to leaving room (except in the case of extended use of PPE per national/local recommendations), followed by hand hygiene.
If PPE use is extended/reused will be done according to national and/or local guidelines. If it is reused, it is cleaned/decontaminated/maintained after and/or between uses.
PPE is available, accessible and used by staff.
The Administrator or ALF Owner will keep track of the PPE and reordering of replacement supplies as needed.

IN TIMES OF PPE SHORTAGES:

Gowns only used during aerosol-generating procedures such as nebulization; care activities where splashes and sprays are anticipated; during high-contact resident care activities. The same gown and gloves may NOT be used for more than one resident.
The same facemask and eye protection may be used during the care of more than one resident. The mask must be discarded when:

Damp, damaged or hard to breathe through
If used during aerosol generating procedures such as nebulization
If contaminated with blood or other body fluid

Eye protection must be replaced (can be reused after cleaning and disinfection) when:

Damaged or hard to see through
If used during aerosol generating procedures such as nebulization
If contaminated with blood or other body fluid.

Assess supply of Personal Protective Equipment (PPE) and initiate measures to optimize current supply:

Maintain inventory and strict access controls on your PPE due to the risk of inappropriate use or theft.
Optimize PPE supplies, monitor daily use and identify when supplies will run low and re-order as needed.

NEW ADMISSIONS OR READMISSIONS TO THE FACILITY:

Newly admitted and readmitted residents need to be monitored for any signs and symptoms indicating risk.

For those whose infectious disease status is unknown they must be observed for evidence of infectious disease after admission and cared for using all recommended infectious disease PPE.

A newly admitted Resident will be requested to provide a copy of the vaccinations in the event it has been received. If not vaccinated, the facility will encourage the completion of the implementation of any other vaccines pending. No residents will be forced to receive a vaccine against their will or decision of any responsible party if not self.\

All recommended infectious disease PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown.

VISITATION INDOOR OR OUTDOOR

POLICY:

Our Facility allow the visitation Indoor and Outdoor yet encourage the Outdoor common area as the preferred visitation area. Open air spaces are safer when being preventive. As a facility we will consider changes or intolerable weather, temperature changes and also any special needs or health conditions of our Residents. We as a Facility are committed to creating a comfortable and accessible outdoor space for visitation. We will also consider that any common areas indoors can be used for visitations.

Our facility will not prevent indoor visitations regardless of the vaccination status. We will only reduce or limit the visitation to the facility in the event of Risk to the residents, staff or visitors. At such times our facility will calculate the available space and inform the pertinent individuals of the restriction which should be specific to amount visitors, length of time, and frequency of visitation.

In-room visitations will also be allowed yet our facility will enforce the social distancing and the communicable disease infection prevention. If a when the facility is at risk, we will also calculate the outdoor space in order to implement the needed limitations.

PROCEDURE:

Visitors will be asked to avoid visitation if ill with any communicable disease.
Visitors will be asked to consider not entering if positive to any signs a symptom.
Residents must sign a written authorization to receive consensual physical contact.
Visitors, Staff, or Residents exiting the facility must sign in and out and answer the questions on the sign in log.
Residents must Sign a Caregiver Designation Form.
If Resident cannot sign the Caregiver Designation Form such must be signed by the Responsible Party.
Visitor, Resident and Staff must understand that education of prevention will be provided.
Resident, Staff and Visitors must understand that at any time the facility can implement the use of PPE Equipment.
Resident, Staff and Visitor must understand that at any time the facility may request social distancing.
Resident Needs will be respected and taken into account for the visitations.
The facility will receive visitors from 9am to 9 pm.
ln the event of crisis the hours of visitation will be reduced from 9am to 9 pm. Only 2 visitors per resident will be allowed and a maximum of 4 visitors at a time. The visits may have a duration of 2 hours at a time, unless otherwise requested prior to the visit.
Facility will be open to special requests for visitation for individuals that cannot meet the facility schedule with a prior 24-hour request via email, phone, or mail.
Visitors and Resident understand that staff will conduct rounds during visit.
In the event if any visitor poses a risk to the Resident or to the Staff the Facility holds the right to request such visitor to exit the facility immediately.
Visitors can not be compelled to provide proof of vaccination or immunization status.
Administrator will be responsible for adherence to the visitation policy and
The facility will allow In-Person visitation in all of the following situation unless the Residents refuses:
Eminent death or life ending scenarios.
Adaptation period of new admission to the facility.
Medical Decision-making processes.
Any emotional crisis being experienced by the Resident to include but not limited to anxiety, depression, helplessness, grief, loss of appetite, or medical condition that requires the support of a caregiver.

Residents have the option to assign/designate a visitor that can be a family member, friend, guardian, community support, or any other person they see fit as the Essential Caregiver. This person must be allowed to conduct in-person visitations for a period of minimum two hours daily this does not include any other visitation allowed by the facility. The Resident understand assigning the Essential Caregiver the correct form must be completed. In the event the resident is not fit to make decisions and a POA is appointing the Essential Caregiver the POA may assign another person to conduct such visitation yet the person being assigned must sign the acceptance of responsibility.

EDUCATION:

Our facility will maintain on-site literature provided by the CDC in order to facilitate educating visitors on hand washing, proper sneezing/coughing technique. We will educate staff, residents and visitors on hand washing techniques. Our facility will post policies and procedures making them accessible to anyone that is interested in learning the protocols and compliance.

We will educate Residents, Staff and Visitors as to the proper use of PPE equipment, why it should be implemented and how to properly use.

Visitors will be educated on compliance upon the implementation of this Policy. Residents, Staff and Visitors will be provided with an overview of the policy and indicate which are the areas preferred for the visitation.

All forms that will be implemented for compliance will be explained to Resident, Visitors, Essential Caregivers, POA and Staff.

In the event there are any questions regarding compliance with the policy our facility administrator will set an appointment with the visitor, resident, and/or staff and will sit one on one to explain what is expected, how it will be implemented and any other questions that may arise.

EDUCATION SHALL BE PROVIDED VIA LITERATURE, VERBAL INSTRUCTION OF PROTOCOL, DEMONSTRATION, QUESTION AND ANSWER.

SCREENING PROCESS/IMMUNIZATION STATUS

It is the understanding of any individual in any capacity who visits the Assisted Living Facility that screening can be implemented at any time in order to secure the well-being of the Residents and/or Staff. Visitors can be subject to the questions formulated on the Visitor Departure and Return Log which directly target identification of any symptoms/signs of illness. In the event any of the questions on the questionnaire are answered as a “Yes,” the facility reserves the right to non-entry.

In the event any visitor has any of the following symptoms the assisted living will kindly request they return when symptoms are no longer persisting:

Cough
Sore Throat
Chills
Tremors
Headache
Muscle Aches
Fever
Diarrhea
Lack of Smell
Lack of Taste
Shortness of Breath
Difficulty Breathing
Any visible sign of infection, severe rash or open wound

Although, visitors may not be allowed entry upon any signs and symptoms that may provide a risk to the health of Resident and/or Staff at NO time will visitors be compelled to provide proof of vaccination or immunization Status. It shall be deemed a private the immunization choice of any visitor to the facility. In any event such topic shall not be discussed or serve as an evaluation tool for entry.

PHYSICAL CONTACT/VISIT SPECIFICATIONS

It is the right of the Resident to decide if they consent to physical contact during a visitation. In the event the Resident has a legal guardian and or a Power of Attorney and/or any legal representative such has the right to elect if the Resident may receive physical contact visits.

The facility should have the Resident Acknowledgement of Consensual Physical Contact Form in order for the Resident and/or any legal representative to choose what type of visitations the Resident will have.

In the event the Resident and/or any legal representative elects not to have physical contact the facility will have available contact via phone, zoom, or video call. The facility will assist in the coordination of any contact that may be out of the scope of the defined Physical Contact.

In the event the Resident decides to agree to physical contact the following shall apply:

Residents may have 2 Visitors at a time.
Maximum amount of time for each visit is 2hrs.
Residents may request the administration to allow on specific occasions and or with prior notice more than 2 visitors at a time. Administration will coordinate visits in order to ensure there is not an excess of visitors at any given time.

IMPLEMENTATION RESPONSIBILITY

The implementation of the visitation policy shall be the responsibility of the Administration. Facility administrator shall discuss compliance with day/night Staff in order to secure understanding of such and compliance. Administration shall conduct weekly supervision of the Staff at hand to ensure that the visitation Policy is being implemented by:

Reminding Staff that their educational material is available.
Reminding Staff that before any visitor enters the facility, we should fill the appropriate form in order to secure there are no signs illness/disease.
Conduct training for Staff regarding Visitation Policy.
Secure any documentation needed is being completed to substantiate the implementation of the Visitation Policy.
Conducting Infection Control Trainings and Implementation reminders.

In the event the Administrator is not available the delegation of authority shall handle the responsibility of the Visitation Policy Implementation.