The Family Presence Policy Suite


All AHS teams have now transitioned from using the COVID-19 access directive and guidance to the AHS Provincial Family Presence Policy Suite.

A comprehensive Staff and Physician FAQ, along with the information below, was created to help teams throughout this change. As our organization continues to move into its pandemic recovery phase this page will be updated with new information.

What Is Included In The Family Presence Policy Suite?

The Policy Suite contains two key documents, which we encourage you to review:

What Access Requirements Are In Place?

Due to the vulnerable nature of healthcare sites, certain communicable disease precautions for DFSPs and visitors remain in place. These include:

  • A clear distinction between the role of a DFSP and a visitor (with priority access for DFSPs when limits are in place).
  • Continuous masking in accordance with the Use of Masks During COVID-19 Directive.
  • Performing hand hygiene when entering and exiting the site, the patient’s room or a washroom.
  • Continuing to recommend that DSFPs and visitors minimize movement throughout the facility, postpone coming to the site if they are unwell, and physically distance from others not from their household where possible.
  • Site entry screening to support the above precautions will remain in place.
    • Those coming to site are encouraged to self-screen using the Provincial DFSP and Visitor Screening Questionnaire for all AHS Sites before they arrive.
    • Please note: Close contact status (as an exclusion criteria for access) has been removed from the screening questionnaire. Anyone with symptoms will be restricted for a minimum of five (5) days from the onset of symptoms, or until their COVID-19 symptoms improve and they are fever-free for 24 hours (without the use of fever-reducing medications), whichever period is longer. Exemptions continue to include:
      • Compassionate exemptions for COVID-19 positive and symptomatic visitors of patients who are at end of life.
      • DFSPs of minor children and dependent adults in need of medical attention.
  • Virtual visitation will remain an option and should be encouraged.

What Does Removing Access Restrictions Mean For Your Site?

While sites are no longer be required to limit the number of DFSPs and visitors per patient, or restrict visitor access, an implementation approach has been determined by site leadership as each service area has its own unique needs.

If the service area can accommodate open access, they should do so. However if limitations are required at your site (for example, due to an outbreak), leaders should consider the following criteria when developing an implementation approach:

  • Access limits cannot be more restrictive than those for pandemic response.
  • The appropriate number of people who can be at the bedside simultaneously will be determined in collaboration with staff, patients, DFSPs and visitors.
  • Needed approvals must be secured from site and zone leadership as outlined in the Managing Limits to Family Presence Procedure.
  • Removal of limits on or before 14 days (from implementation).
  • End-of-life and potential loss-of-life circumstances require open access for DFSPs and visitors.
  • Confirming a patient’s DFSPs and how they will access the patient in order to provide support.
  • Space limitations
    • In settings where space is limited (such as ambulatory clinics, community health clinics, emergency care and urgent care centres), one (1) DFSP per patient is recommended.
    • If space is limited in a waiting room, DFSPs can be accommodated once a patient is admitted to a treatment area. However, when possible, all attempts should be made to keep patients and their DFSP together. Seniors, minors, patients with mobility and/or cognitive challenges, and AMH patients should be given priority to have their DFSP remain with them in-person in the waiting room. Two DFSPs can being accommodated in these settings when involving minors, dependent adults or when pre-arranged with the clinic area. Examples of when two DFSPs are ideal include:
      • Pediatric ambulatory appointments;
      • Need for DFSPs to assist the patient with patient care;
      • End-of-Life care or Goals of Care Designation (GCD) discussions;
      • Significant diagnosis/change in medical status leading to poor prognosis;
      • Behaviour challenges requiring two caregivers;
      • Medical or equipment needs requiring two caregivers;
      • Involvement of Social Services; and/or
      • When requested by the care team.

Note – infants 6 months or younger are to be counted as one individual with their parent/guardian.

Please note that access limits can never exceed those for pandemic response.


Contact the provincial Engagement & Patient Experience team at for questions on implementation of the Policy.