BISMARCK — Many nursing homes in North Dakota are halting indoor family visitation after a federal agency stepped in to end a month-long negotiation period in which the state tried to get an exception on newly imposed national rules.

Representatives from the state’s Vulnerable Population Protection Plan (VP3) task force relayed the news during a meeting with long-term care operators on Thursday, Oct. 22, explaining that the federal Centers for Medicare & Medicaid Services (CMS) was putting its foot down on new regulations announced in September that call for significantly tighter visitation policies at skilled nursing facilities. North Dakota has nearly 80 such facilities, where medically trained staff care for residents.

"CMS did not support our VP3 plan for visitation as they felt that allowing visitation right now with what is happening in North Dakota with our community rate was putting our residents at risk," said Bridget Weidner, a coordinator for the state’s visitation policy, during the call, relaying news from a meeting between CMS and state officials last week. "I know that’s not necessarily the answer we were hoping for, but it’s the answer we got loud and clear last Friday."

The change comes as more than half of the state's COVID-19 deaths have occurred in nursing homes, and as cases continue to climb rapidly across the state.

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Still, state officials worked hard to avoid adopting the federal visitation guidelines after they were announced on Sept. 17, and Department of Human Services Director Chris Jones said on Friday that the state intends to keep negotiating with CMS even after bringing state facilities into line with the guidelines this week.

"We're not giving up," he said, noting that his office is drafting up new proposals to the federal agency in hopes of restoring visitation at all North Dakota nursing homes. "We're not going to quit. I just don't have the answer yet."

Had North Dakota opted to hold out longer, the state risked federal fines imposed on individual nursing homes, as well as the perennially looming possibility of losing Medicaid funding.

For many other states, the new CMS visitation plan actually relaxed state-level visitation policies, but it did the opposite in North Dakota.

This unique effect was partially due to comparatively lax visitation policies that the state implemented in June, according to Jones, who argued that the CMS plan is a one-size-fits-all policy that penalizes North Dakota for being ahead of the curve on visitation.

"In some ways we’re kind of like victims of our own success. Because if you go to Minnesota, I mean they’ve been locked up since March," he said. "We’ve been doing this the whole time, and now they’re saying we’re going to have to go backwards."

Jones said CMS expressed concern about the severity of viral spread in North Dakota, especially rural areas, and didn’t see the rationale in granting an exception at this point in the pandemic.

Officials have said they don't know exactly how the virus is getting into nursing homes or whether the primary carriers are visitors or staff. Jones acknowledged that extending visitation in facilities heightens the risks of the virus getting in, but he said the state feels it needs to find a balance between restricting access and sustaining the mental health and well-being of residents.

Richard Mollot, director of the Long Term Care Community Coalition, has advocated for visitation in facilities around the country, and said that some facilities in other parts of the country have been successful in keeping the virus out even in hot spot regions.

"If there is an emergency situation, you know, like a facility got hit, the neighborhood got hit, and they have to do something more monolithic, that's understandable," Mollot said. "But within a week or so they should have gotten their act together and reinstated visitation to some degree, or they should probably be asking the state to help them move residents out."

The new CMS guidelines apply only to skilled nursing facilities, a subset of nursing homes in North Dakota regulated by the federal government. VP3 coordinator Seth Fisher said during Thursday's call that long-term care facilities operating under the state's purview should continue with the state's more open visitation policies until further notice.

According to the new CMS guidelines, a facility must cut off indoor visitation if there has been a new positive COVID-19 test within the facility within 14 days, or if the facility is conducting outbreak testing. The guidelines also require tiered reductions to visitation depending on the prevalence of the virus in the surrounding county, a metric that will leave many North Dakota facilities ineligible for indoor visitation because of the severity of the viral outbreak in much of the state.

Outdoor visitation is still allowed under all scenarios, but the onset of cold weather in North Dakota has already made those visits impractical, a point that state officials had hoped would sway federal regulators to grant an exception.

“We clearly made our point to CMS, and they clearly made a point back that they didn’t necessarily agree 100% with where our plan was going,” Weidner said of Friday’s meeting with federal regulators.

Of the close to 80 skilled nursing facilities in the state, only three in the towns of Aneta, Langdon and Larimore are still eligible to continue visitation. The rest have halted indoor visits, effective immediately, to get into line with the newly adopted policy.

Readers can reach reporter Adam Willis, a Report for America corps member, at awillis@forumcomm.com.