Transitioning to the Family Presence Policy Suite


Throughout the COVID-19 pandemic, access restrictions have been in place to limit the number of visitors and designated family support persons (DFSPs) permitted in healthcare facilities. While these limits have been necessary to reduce the risk of transmission, we understand how challenging they have been for patients, their families and the staff who must enforce them.

On July 13, 2022, we will transition from the COVID-19 access directive and guidance to the AHS Provincial Family Presence Policy Suite, which was implemented at Continuing Care sites in August, 2021. The policy suite will provide ongoing direction for all acute care, ambulatory care, urgent care and emergency care sites.

A comprehensive Staff and Physician FAQ, along with the information below, was created to help answer your questions about this change.

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 Will Remain In Place?

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

  • Continuous masking.
  • Site-specific requirements, such as wearing additional PPE, entry screening, and performing hand hygiene.
  • A clear distinction between the role of a DFSP and a visitor.
  • In collaboration staff, patients, DFSPs and visitors will define the appropriate number of people who can be at the bedside simultaneously.
  • We will continue 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 on site where possible.
  • Symptom screening will remain in effect at all AHS sites. Exemptions will include:
    • Compassionate exemptions for COVID positive, symptomatic or close contact visitors of patients who are at end of life.
    • DFSPs of minor children and dependent adults in need of medical attention.
    • DFSPs of obstetrical patients who are asymptomatic close contacts of COVID-19.
  • Virtual visitation will remain an option.

What Does Removing Access Restrictions Mean For Your Site?

While sites will no longer be required to limit the number of DFSPs and visitors per patient, or restrict visitor access, an implementation approach will be 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 outlined in the COVID-19 Access Guidance.
  • The maximum numbers of DFSPs that can be accommodated per patient.
  • Securing the needed approvals 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.

When Are Access Limits Permitted?

Any access limits to family presence and visitation should only be made when absolutely necessary and in accordance with the policy and procedure.

The Managing Limits to Family Presence Procedure provides staff with a consistent approach to managing the implementation of limits to DFSPs or visitors. It includes guidelines on:

  • AHS-identified circumstances where limits may be introduced,
  • how to implement limits,
  • how to address concerns about limits,
  • and more

Please note that access limits can never exceed those for pandemic response outlined in the COVID-19 Designated Support and Visitor Access Guidance.


Contact for general questions regarding the transition to the Policy. You can also each out to the provincial Engagement & Patient Experience team at for questions on implementation of the Policy.