“When will I be allowed to visit my mother again?” That’s been the question on the minds of the families of millions of residents of nursing homes, assisted living facilities, and other senior communities who effectively have been locked down since the COVID-19 pandemic took hold two months ago.

Yesterday, the Centers for Medicare and Medicaid Services (CMS) put out what it called “recommendations” for reopening nursing homes. The notice went on for ten pages, but to save you the trouble, the short answer to the question of when is: That will be up to the individual states but not anytime soon.

Balancing infection and isolation risk

Reopening long-term care facilities to families and other visitors requires striking an extremely difficult balance. On one hand, with more than 30,000 reported COVID-19 deaths among staff and residents of nursing homes and assisted living facilities, it is essential to protect these highly vulnerable populations. And isolating residents from infected outsiders (who often show no symptoms) is necessary to do that.

On the other hand, there are enormous risks to separating these vulnerable residents from their families. Their sense of loneliness and isolation, already high in many facilities, may be extreme after having had no personal contact with loved ones for more than two months.

It also is critical for family members to serve as advocates for residents. And that has never been more important than now, when facilities are struggling with staff shortages, higher workloads, and complex new care protocols. A lot can go wrong. And not having family members serving as a resident’s eyes and ears is a recipe for tragic outcomes.

Facilities, local governments, and families desperately need careful guidance on how and when to reopen. This is especially true at a time when so much government response has been contradictory and chaotic. It is bad enough to have a free-for-all when it comes to opening the local beach for Memorial Day weekend. It is quite another matter to let people into nursing homes without clear guidelines.

Not much guidance

The CMS guidance applies only to nursing homes. But states would likely use the agency rules as a model for assisted living and other congregant care settings as well.

Yet, CMS didn’t provide much guidance at all. In contrast to its explicit March 13 order that nursing homes shut their doors to all non-medical visitors, yesterday’s notice was little more than a set of generic suggestions to states. It laid out a list of “factors that should inform decisions,” many of which facilities currently are unable to meet, or are so vague that they have limited use.

For example, the guidance says facilities should have “adequate staffing” and “no staffing shortages,” whatever that means.

It says facilities should have “access to adequate testing.”  CMS says this means nursing homes should have the capacity to test every resident once, retest residents if one shows symptoms  of COVID-19  or if a staffer tests positive, and retest weekly until all residents test negative.

Staff, volunteers, and some vendors also should be subject to an initial test, followed by a weekly follow-up. Facilities should make arrangements with labs to process the tests and return results within 48 hours.

Pixie dust

The problem, of course, it that many facilities still cannot do any of this. Many still are struggling to get test equipment, despite repeated White House promises. Making tests a precondition when they still are unavailable is policy pixie dust. Similarly, labs often still take a week or more to produce results. And small and mid-sized facilities have no leverage to get them to prioritize nursing homes samples.

The guidance says residents and visitors should wear cloth masks, and visitors should wash their hands and maintain social distancing. If some can’t or won’t, the guidance—remarkably—says facilities should “consider” restricting their access. Consider? Really?

Finally, CMS says staff should have access to personal protective equipment. It says nothing about how they should be properly trained in the use of this gear.

The CMS visitor recommendations are just the last example of Trump Administration buck-passing when it comes to COVID-19 and long-term care. Instead of clarity and needed support, there are only suggestions for how states and facilities might work it out. The message: This is your problem, not ours. What happens when the first angry family pounds on the front door of a care facility, cell phone video camera in tow, demanding to be let in? I wish I knew.