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Reporting LAHAN Alerts

Community Care Facilities

B73 COVID-19 - Procedural Guidance for DPH Staff



Community Care Facilities - Where People Reside Overnight AND receive Care (excluding: Jails, Settings Associated with People Experiencing Homelessness, Housing Facilities Not Providing Care, Acute Care Facilities, and Skilled Nursing Facilities)

REPORTING PROCEDURES

Outbreak Definitions:

Under Title 17, Section 2500, California Code of Regulations all suspected outbreaks are reportable.

High-Risk Community Care Facility (See below for facility definition)

One or more laboratory confirmed cases (symptomatic or asymptomatic) of COVID-19 have been identified in residents within a 14-day period.

AND/OR

Two or more laboratory confirmed cases (symptomatic or asymptomatic) of COVID-19 in staff who have face to face contact with residents, within a 14-day period.

NOTE: If newly admitted residents (e.g. within 14 days of admission) are admitted to the quarantine area of the facility test positive for COVID-19, this is not considered an outbreak as it could have been acquired outside the facility.

NOTE: If a facility has cases in staff and residents but does not meet one of the above thresholds, the outbreak should NOT be opened.

Low Risk Community Care Facility (See below for facility definition)

Three or more laboratory confirmed cases (symptomatic or asymptomatic) of COVID-19 have been identified in residents within a 14-day period.

AND/OR

Four or more laboratory confirmed cases (symptomatic or asymptomatic) of COVID-19 in staff who have face to face contact with residents, within a 14-day period.

NOTE: If newly admitted residents (e.g. within 14 days of admission) are admitted to the quarantine area of the facility test positive for COVID-19, this is not considered an outbreak as it could have been acquired outside the facility.

NOTE: If a facility has cases in staff and residents but does not meet one of the above thresholds, the outbreak should NOT be opened.

DCFS-affiliated congregate care facilities (see below for definition)

At least three confirmed cases of symptomatic or asymptomatic COVID-19 (including residents and/or staff who have face to face contact with residents), within a 14-day period.
NOTE: If newly admitted residents (e.g. within 14 days of admission) are admitted to the quarantine area of the facility test positive for COVID-19, this is not considered an outbreak as it could have been acquired outside the facility.

Emergency shelters for isolation/quarantine of DCFS-affiliated youth diagnosed or suspected of COVID-19 or contacts of confirmed COVID-19 cases

At least three confirmed cases of symptomatic or asymptomatic COVID-19 in staff within a 14-day period. NOTE: Residents are not included in the outbreak definition because they are there specifically for isolation or quarantine due to COVID-19.

Epidemiologic Data for Outbreaks

  1. Confirm etiology of outbreak using laboratory PCR testing data. All symptomatic residents or staff are recommended to be tested for COVID-19.
  2. Complete the line list that includes:
    1. Names of cases
    2. Dates of onset
    3. Symptoms
    4. Dates of birth
    5. Race/ethnicity
    6. Underlying medical conditions
    7. Days and shifts staff last worked
    8. Location of staff and residents
    9. Hospitalization status
    10. Results of laboratory tests
  3. Conduct response testing weekly of negative staff and residents until no new cases for at least 2 weeks. Complete Congregate Residential Settings form at the conclusion of investigation (See Report Forms). For DCFS Emergency Shelters, surveillance testing of staff is not necessary.
  4. Obtain site floor plan, if appropriate.
  5. Create an epi-curve, by date of onset (see CDC Quick Learn Lesson: Create an Epi Curve for guidance). Only put those that have suspected or confirmed COVID-19 on the epi-curve. (Optional)

CONTROL OF CASES & CONTACTS

Investigation can be conducted over the phone. The frequency of follow-up with the facility for outbreak updates will be at least bi-weekly, but more frequently as needed and determined by Outbreak Management Branch (OMB) MD.

Inform the facility that they will be included on a public outbreak notification list posted on the LAC Public Health website until the facility demonstrates that there are no new cases at the facility for at least 2 weeks and outbreak is resolved.

Additional Guidance and Resources:

Cases

See detailed instructions below for case management of residents, as well as cases in facility staff.

Contacts

A close contact is a person with exposure to a confirmed or suspected case of COVID-19 during the period from 2 days before symptom onset until the case meets criteria for discontinuing isolation (see detailed instructions below for staff and residents). For asymptomatic cases, the date of collection of the specimen positive for SARS-CoV-2 can be used in place of onset date to determine period of isolation.

Exposures are defined as follows:

    1. Being within approximately 6 feet of a person with confirmed or suspected COVID-19 for a cumulative total of 15 minutes or more in a 24-hour period of time, without a mask (medical grade or higher level of protection such as N-95); OR
    2. Having unprotected direct contact with infectious secretions or excretions of a person with confirmed or suspected COVID-19 (e.g., being coughed on, touching used tissues with a bare hand).

See detailed instructions below for staff contacts and resident contacts in care-giving facilities and housing facilities.

  • Caregivers: All direct care-giving staff, whether licensed or unlicensed, should follow CDC and local guidelines for health care personnel. This includes nurses (RNs/LVNs/CNAs), health aids and unlicensed caregivers.
  • Visitors: Contact any visitors that may have been exposed to a suspected or confirmed case and instruct them to self-quarantine for 14 days after last exposure (see Home Quarantine Instructions for Close Contacts to COVID-19. Visitors should call their primary care provider to discuss testing options.

Note: CDC does not recommend testing, symptom monitoring or special management for people exposed to asymptomatic people with potential exposures to SARS-CoV-2 (i.e., “contacts of contacts;” these people are not considered exposed to SARS-CoV-2).

LOW-RISK AND HIGH-RISK COMMUNITY CARE FACILITY DEFINITIONS

Low-Risk Community Care Facilities:

These are short- or long-term residential facilities that meet any one of the following descriptors:

  • Residential facilities for adults licensed by the California Community Care Licensing Division (CCLD) including Residential Care Facilities for the Elderly (RCFEs) and Adult Residential Facilities (ARFs). For facility types see: www.cdss.ca.gov/inforesources/community-care/ascp-centralized-application-units. See below for separate definition of DCFS-affiliated congregate care facilities.
  • Residential behavioral health treatment facilities, such as substance use or mental health treatment facilities.
  • Group homes for adults not licensed by the State, which provide housing and assistance with activities of daily living or other need.

High-Risk Community Care Facilities:

Facilities that provide caregiving services primarily to residents with at least two or more of the following:

  • Residents older than 65 years of age.
  • A memory care unit or at least 25% residents with dementia or severe mental illness diagnosis.
  • Provide medical care to residents who are non-ambulatory.
  • Serve residents that require regular direct on-site medical care.

DCFS-affiliated congregate care facilities

  • CCLD-licensed residential facilities caring for minors age 6 through 17 and non-minor dependents age 18 through 21 in out-of-home care, including Short-Term Residential Therapeutic Programs, Community Treatment Facilities and Transitional Shelter Care Program Facilities.

Emergency shelters for isolation for DCFS-affiliated youth diagnosed or suspected of COVID-19 and for quarantine of youth contacts of confirmed COVID-19 cases

  • Small apartments where individual youth or youth from the same household are housed for short term stays due to isolation or quarantine needs.
  • Supervision is provided 24 hours daily onsite by disaster service workers in 8 to 12 hour shifts with staff sleeping onsite and providing assistance with meals, bathing, recreation, etc.

ADMINISTRATIVE CONTROL MEASURES IN COMMUNITY CARE FACILITIES DURING AN OUTBREAK

  1. Always encourage all staff and residents to follow physical distancing and adhere to hand hygiene guidance as much as possible.
    1. Signage should be posted to reinforce frequent hand washing, cover your cough, and maintain physical distancing.
    2. Provide accurate and updated Public Health materials to facility- including posters, handouts, etc. available at http://publichealth.lacounty.gov/acd/ncorona2019/printmaterials.htm.
  2. Ensure universal source control at the facility including staff, visitors, and residents. Non-medical grade masks  at minimum for residents/visitors, or medical grade (surgical mask) or N-95 for caregivers.
    1. Source control is required by all persons in all indoor resident areas, common or shared areas, walkways, or where residents and/or staff congregate,with exceptions listed for visitation and group activities/communal dining.
    2. Staff working alone in closed areas do not need source control unless they are moving through common spaces where they may interact with other staff or residents.
    3. Medical grade surgical/procedure masks should be worn by any resident that is confirmed or suspected to have COVID-19.
    4. All residents should wear masks when outside their room. This includes residents who regularly leave the facility for care (e.g. hemodialysis patients).
    5. Residents who, due to age or underlying cognitive or medical conditions, cannot wear masks, outside their room should not be forcibly required to wear masks and should not be forcibly kept in their rooms. However, masks should be encouraged as much as possible. Children under 2 should not be required to wear masks.
    6. When staff are in resident rooms, residents should cover their noses and mouths as much as possible. Residents can use tissues for this or masks.
  3. Increase environmental cleaning throughout the facility to 3 times a day (if possible) with emphasis on high touch surfaces and objects such as doorknobs, bannisters, countertops, faucet handles, and phones, particularly in the unit where case(s) were located. Use EPA-registered cleaning agents and follow the label directions.
  4. Identify a mechanism for the facility to obtain SARS CoV-2 samples and to send these specimens from the facility to a commercial clinical laboratory. If a facility is unable to obtain DPH recommended SARS CoV-2 testing through a commercial laboratory or does not have clinical staff on site to administer the test, see Testing Recommendations below.
  5. For high-risk and low-risk community care facilities and DCFS-affiliated congregate care facilities, response testing should be initiated if they meet the criteria in the Outbreak section above, and targeted testing should only be used if the facility does not have the resources to perform mass testing. Refer to Community Care Facilities guidance.
  6. Plan for ways to continue essential services if on-site operations are reduced temporarily.
    1. Restrict group activities, field trips, and communal dining in accordance with Community Care Facilities guidance. For youth in DCFS-affiliated congregate care facilities, communal dining can be maintained as long as youth are assigned to cohorts appropriately by COVID status/exposure status and groups are small and stable.
    2. Staff may eat together in staff breakrooms or a separate designated area, but physical distancing of six feet or more between persons, as well as wearing medical grade (surgical masks) unless eating, must be enforced at all times while eating. Wipes should be provided for staff to clean up after finishing their breaks.
  7. Plan for employee absences and create a back-up/on-call system.
  8. Immediately implement symptom screening for all staff, visitors, and, if feasible, residents—including temperature checks if possible. Residents should have their temperature taken or self-monitor their temperature every 24 hours.
    1. Every individual entering the community care facility (including residents, staff, visitors, outside healthcare workers, vendors, etc.) regardless of reason, should be asked about COVID-19 symptoms and if possible, have their temperature checked. An exception to this is Emergency Medical Service (EMS) workers responding to an urgent medical need. They do not have to be screened, as they are typically screened separately.
    2. Records are to be kept of staff and resident temperature checks. Temperature checks are not required when the facility is not having an outbreak.
    3. Facilities should limit access points and ensure that all accessible entrances have a screening station.
    4. Anyone with a fever (100.4° F or 38° C) or symptoms (fever, chills, cough, shortness of breath, new loss of taste or smell, muscle or body aches, headache, sore throat, congestion or runny nose, nausea or vomiting, diarrhea) may not be admitted entry.
  9. Restrict all volunteers and non-essential personnel (e.g. barbers) during an outbreak.
  10. Post a notification letter at the entrance of the facility and community area.
  11. Visitors are allowed to visit with the following restrictions. See LAC DPH COVID-19 Guidance for Community Care Facilities or LAC DPH COVID-19 Guidance for Group Homes, Foster Family Agencies, Temporary Youth Shelter Facilities and Short-term Residential\Therapeutic Programs:
    1. Those with fever symptoms, or close contact with a COVID positive person should not be permitted to enter the facility at any time (even in end-of-life situations).
    2. Post signs explaining visitor restrictions.
    3. Set-up alternative methods of visitation such as through videoconferencing through Skype or FaceTime.
    4. Those visitors that are permitted should be screened for fever and respiratory symptoms, must wear a mask while in the building, and should restrict their visit to the resident’s room or other location designated by the facility. They should also be reminded to frequently perform hand hygiene and to practice physical distancing while in the facility.
    5. Non-essential visitation should follow guidelines in the Community Care Facilities guidance. Indoor and in-room visits are permitted for Green Zone residents regardless of vaccination status, but outdoor visits should be encouraged for safety. All visits should be scheduled in advance, monitored by staff for compliance with policies, all visitors should be screened for COVID-19 symptoms and temperature taken if possible, and signs should be posted throughout the facility with guidelines for visiting and entrance and exit routes. Visits between fully vaccinated residents and fully vaccinated visitors may be conducted with face masks and may choose to not physically distance, and may include physical contact (e.g., hugs, holding hands) while in the resident's room with both parties performing hand hygiene before and after contact. Residents who are fully vaccinated may engage in brief physical contact with visitors who are not fully vaccinated if both parties wear masks and perform hand hygiene before and after contact, and maintain physical distancing otherwise.
  12. For youth in DCFS-affiliated congregate care facilities, there are several important considerations concerning visitors and visitation:
    1. Court mandated visits may involve visits to youth onsite at the facilities or visits offsite. Legally these visits supersede HOO mandates for isolation and quarantine.
      • For youth who are COVID positive and finishing their isolation period, the facility needs to request that the DCFS social worker assigned to the youth request postponement of the court mandated visit until the isolation period is over.
      • For youth who were exposed to a COVID-positive individual and are under quarantine in the yellow zone, the facility needs to request that the DCFS social worker assigned to the youth request postponement of the court mandated visit until the isolation period is over.
      •  For youth residing in a facility with an open outbreak but who are not under isolation or quarantine orders (youth in the GREEN ZONE), visitations should be allowed to proceed.
    2. Onsite and off-site family visits that are not court-mandated should also be allowed or postponed according to the distinctions above. Youth in the RED and YELLOW zones should postpone visits until after their isolation/quarantine terms have been completed. Youth in the GREEN ZONE can continue to have visits if so approved by the facility staff and the assigned DCFS case-worker.
  13. Provide education and job-specific training to staff regarding COVID-19, including:
    1. Signs and symptoms.
    2. Modes of transmission of infection.
    3. Correct infection control practices and personnel protective equipment (PPE) use.
    4. Staff sick leave policies and recommended actions for unprotected exposures (e.g., not using recommended PPE, an unrecognized infectious patient contact).
    5. How and to whom COVID-19 cases should be reported.
  14. Ensure that your facility has the capacity to isolate residents with COVID-19 and quarantine residents who are close contacts of a COVID-19 case.
  15. Establish a COVID-19 area within the facility, if possible:
    1. The COVID-19 area (Red Zone) is for residents who have confirmed COVID-19 and must have a designated bathroom. The area must be physically separated from the area for those who do not have COVID-19. If not possible to separate physically because the facility is structured to have individual resident apartments or rooms with their own bathrooms, all that is needed is appropriate signage outside the apartment or room designating the color status of the resident and the appropriate PPE needed to care for that resident, along with a PPE cart for that room.
    2. All staff, equipment, and common areas should be kept separate as much as possible.
    3. LAC DPH does not recommend transferring patients to hospitals unless they require higher level of care and does not recommend transfer between facilities unless the facility is unable to isolate cases adequately.
  16. Facility should accept back COVID+ patients ready to be discharged from acute care hospitals in accordance with Interfacility Transfer Rules. transfer rules.
  17. The facility should consult with the District Public Health Nurse IDPHN)/Outbreak Investigator (OI) assigned to the facility regarding closure of the facility to new/returning admissions.
  18. Have a resident and family notification process for when a case of COVID-19 is identified.
  19. Have the ability to identify residents who could be discharged to home in the event of COVID-19 introduction to the building.
  20. As much as possible, have employees work at only one facility in order to reduce interfacility spread of COVID-19.
  21. For any transfers out of the building, notify EMS and the receiving facility of possible exposures.
  22. Cancel and re-schedule all upcoming non-essential medical appointments or consider telemedicine routine care appointments when available.
  23. All care-giving staff that provide direct resident care in these facilities are considered similar to healthcare personnel (HCP).
  24. All caregivers should wear a face mask (or N-95) while they are in resident care areas, walkways, and common or shared areas where residents and/or staff may congregate.
  25. For all resident encounters, caregivers should at minimum wear a mask (medical grade, surgical mask, or higher). If resident is unable to cover nose/mouth (i.e. practice source control), caregivers should also use eye protection for that encounter. Full PPE (facemask or higher, gloves, gown, and eye protection) is recommended while providing care to a resident in the Yellow or Red zones. For conservation of PPE, please refer to CDC guidance (www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html).

    Note: The rationale for mask and eye protection is to try to prevent caregiver exposure. Medical grade or surgical masks can be worn for an extended period but should be discarded after they become saturated with moisture.

  26. Review and follow the CDC’s “Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings”.
  27. If unsafe for residents to eat unsupervised (e.g. prone to aspiration) or cannot feed themselves, or if staffing is insufficient to support one to one feeding, residents may eat outside their rooms as long as physical distancing guidelines can be followed.
  28. Designate caregivers who will be responsible for caring for suspected or known COVID-19 residents. Ensure they are trained on the infection prevention and control recommendations for COVID-19 and the proper use of PPE.
  29. If staffing scarcity requires staff to work with COVID-19 positive and negative residents, staff should be careful to change required PPE between patients, and adhere to donning and doffing recommendations (www.publichealth.lacounty.gov/acd/docs/CoVPPEPoster.pdf), though N95 and face shields may be worn throughout the day consistent with CDC PPE conservation contingency strategies (www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html). If staff must care for residents in multiple cohorts, they should visit the Red Cohort last and should doff PPE and perform hand hygiene prior to moving between cohorts.
  30. In an outbreak situation, admission of new residents (new admissions) and returning residents (readmissions) should be permitted unless closure is approved by the Area Medical Director (AMD). This rule applies to DCFS-affiliated congregate care facilities as well as other CCFs.
  31. The decision to close admissions should be recommended only after a number of factors have been considered. Consider closing the facility to admissions if some or all of the following are concerns:/li>
    1. Inadequate infection prevention & control concerns from licensing
    2. Concerning rates of adverse outcomes including hospitalizations and deaths
    3. Evidence of concerning viral transmission based on response testing of residents
    4. Inability to cohort residents per protocol
      • Inability to effectively quarantine new admissions and readmissions
      • Inability to effectively dedicate COVID and non-COVID areas and staff in the facility
    5. Lack of effective infection control practices as evidenced by a virtual or on-site infection control visit
    6. Inadequate supply of PPE
    7. Staffing shortages or inability of current staff to properly care for COVID-19 positive residents are reported

OUTBREAK RESPONSE RECOMMENDATIONS FOR SUSPECTED OR CONFIRMED CASES

  1. All ill persons (residents or staff) with symptoms suggestive of respiratory illness should be presumed to have COVID-19 and SARS-CoV2 testing should be done.
    1. For suspected or confirmed residents, immediately mask and initiate quarantine/isolation. Use face covering if mask is not available. If possible, initiate contact and droplet precautions and eye protection (mask, gloves, face shield/goggles, disposable/washable gown).
    2. Symptomatic/confirmed staff should be asked to go home immediately and seek care as appropriate. Immediately mask the staff and isolate in room with door closed if need to remain on premises.
    3. In the case of two or more unknown respiratory cases in 72 hours at facility, encourage testing of routine respiratory pathogens including influenza testing if appropriate to establish alternative diagnosis./li>
  2. Facilities should initiate contact investigation around each confirmed case (staff or resident) to identify all close contacts (staff and residents) during the infectious period of the case(s).
  3. Document all staff and resident case and contacts on the a target="_blank" href="http://publichealth.lacounty.gov/acd/Diseases/EpiForms/COVID_ResidentialLineList_Resident_Staff.xlsx">COVID-19 Line List for Congregate Residential Settings for Residents and Staff (Excel).
  4. Designate areas in your facility for the placement of suspected (Yellow Zone) and confirmed (Red Zone) residents. Refer to Guidelines for Proper Grouping of Residents and Community Care Facilities Guidance.
  5. Note: The actual isolation area will depend on each building but define the area by your local workflow (e.g. the unit the resident is located would be a logical decision).

      1. Case(s) should be isolated in single-person room(s). Move roommates into other rooms within the isolation area, if possible. Otherwise, cohort case(s) together in a separate room with the door closed and a dedicated restroom.
      2. Cohort staff (keep the same, limited number of staff caring for the Red Zone residents and ensure they do not interact with residents/staff in other zones, as much as possible).
      3. Move suspected residents into the Yellow Zone.
  6. Designate a Yellow Zone, if possible, for residents who have been identified as contacts to case(s) at your facility.
    1. Residents should use masks or face coverings. If possible, initiate contact, droplet, and eye protection precautions in the Yellow Zone.
    2. Place asymptomatic residents identified as close contacts in the Yellow Zone regardless of vaccination status.
    3. Post signage of your Yellow Zone.
    4. Cohort staff as much as possible to minimize transmission./li>
  7. Residents in the Yellow and Red Zones should:
    1. Not be allowed visitors and should have limited contact with staff and other residents. See above for special considerations for court-mandated visitation for youth in DCFS-affiliated congregate care facilities.
    2. Stay in a separate room as much as possible and away from residents who are vulnerable to severe illness related to COVID-19. Individuals vulnerable to severe illness related to COVID-19 include those who are age 65 and above, or with underlying medical conditions such as chronic lung disease or moderate to severe asthma, chronic heart disease, diabetes, end stage kidney or liver disease or weakened immune systems such as cancer patients, those on immunosuppressive therapy and HIV/AIDS.
    3. Use a separate bathroom.
  8. Quarantine in the Yellow Zone ends 14 days from the last day the resident was in close contact with a laboratory confirmed case. Refer to Proper Grouping of Residents Guidelines. For youth in DCFS-affiliated facilities, quarantine in the Yellow Zone ends 10 days from the last day the resident was in contact with a symptomatic case or the date the resident tested positive for an asymptomatic resident.
  9. If Yellow Zone residents develop symptoms of respiratory illness (fever and cough or shortness of breath), then SARS-CoV2 testing should be done and they should be moved to the Red Zone if positive. If negative, they should stay in the Yellow Zone until their quarantine period is over and symptoms have resolved.
  10. If, during the quarantine period, there is contact with a person with suspected or confirmed COVID-19 (being within 6 feet for a cumulative total of ≥15 minutes in a 24 hour period, or touching body fluids or secretions without using the appropriate precautions) the quarantine period will have to restart. Body fluids or secretions include sweat, saliva, sputum, nasal mucus, vomit, urine, or diarrhea. /li>
  11. Continue to monitor all residents for fever and respiratory symptoms (i.e. cough, sore throat, shortness of breath) until 14-day after the last COVID-19 exposure at facility. Last COVID-19 exposure at facility is until the last COVID-19 case (staff or resident) is placed under isolation. Any breach in isolation of COVID-19 case would constitute an ongoing exposure at facility and monitoring period will need to be extended additional 14 days from that time.
  12. Special situations for facilities to consider:
    1. For residents receiving dialysis outside of the facility, notify their dialysis center and request that they be dialyzed in “isolation.”
    2. Consider substituting nebulizers for metered dose inhalers.
  13. Instruct the facility to notify District Public Health Nurse (DPHN) assigned to the facility immediately if any resident or staff report fever or respiratory symptoms.
  14. Notify DPHN immediately if any caregivers or resident contact tests positive for COVID-19.

Management of Caregiver Exposure in Community Care Facilities

  1. Identify all caregiver close contacts and assess their exposure. For guidance on management of caregiver contacts, refer to LAC DPH Guidance for Monitoring Healthcare Personnel and companion guidance, CDC Criteria for Return to Work for Healthcare Personnel with Confirmed or Suspected COVID-19 (Interim Guidance).
    1. If caregiver was wearing only a face covering (and not a face mask or higher) during close contact, then they are considered exposed. Otherwise, assess exposure risk according to CDC Interim Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel with Potential Exposure to COVID-19.
    2. Instruct exposed caregiver to self-quarantine for 14 days after last exposure (see Home Quarantine Instructions). Fully vaccinated asymptomatic staff who have been exposed to a COVID positive individual do not need to quarantine and may continue to work while observing the proper precautions (mask, physical distancing, hand hygiene). Unvaccinated and partially vaccinated staff who have been exposed to a COVID positive individual should self-quarantine for 14 days after last exposure, but may continue to work if there is a severe staff shortage and the staff is asymptomatic and observing the proper precautions. For caregivers working in DCFS-affiliated congregate care facilities, self-quarantine is 10 days since last exposure.
    3. Instruct exposed caregiver to notify all other employers of the type and nature of their exposure.
  2. If caregiver must remain on site to mitigate critical staffing shortage, asymptomatic exposed contacts can continue to work under the following conditions:
    1. They must wear a mask during the quarantine period (14 days for all CCF caregivers EXCEPT those at DCFS-affiliated congregate care facilities; quarantine for caregivers at DCFS-affiliated facilities is 10 days).
    2. Self-monitor for symptoms.
    3. If caregiver becomes symptomatic, caregiver must immediately be sent home for self-isolation (see a target="_blank" href="http://www.publichealth.lacounty.gov/acd/ncorona2019/covidisolation/">Home Isolation Instructions).
  3. Document all caregiver contacts on the COVID-19 Line List for Congregate Residential Settings (Excel) (See Report Forms section).
  4. Monitor and follow-up caregiver contacts for symptoms during, or at the end of monitoring period, to check-in and respond to concerns, if possible.
  5. For confirmed caregiver cases who are symptomatic, ensure the caregiver self-isolates for at least 10 days since symptoms first appeared AND at least 24 hours after the resolution of fever without the use of fever-reducing medications and improvement of symptoms (such as cough and shortness of breath). Caregivers with high risk exposures (exposure to high-hazard aerosol-generating procedure without mask or eye protection) to COVID-19 should be excluded from work for 14 days. Caregivers can return to work after 14 days if they have never had symptoms.
    1. If possible, identify facility staff who can monitor sick staff with daily “check-ins” using telephone calls, emails, and/or texts.

Management of Staff Exposure in Community Care Facilities

  1. Identify all staff who had close contact with resident within 48 hours before the onset of symptoms and assess potential exposure. If staff was wearing a cloth face covering during close contact, they are considered exposed. If wearing a face mask, and not directly exposed to body secretions of the case, they are not considered exposed.
    1. a. Instruct exposed staff to self-quarantine (14 days after last exposure for all CCFs except DCFS-affiliated congregate care facilities for which 10 day quarantine can be used (see Home Quarantine Guidance)).
    2. Instruct exposed staff to notify all other employers of the type and nature of their exposure.
  2. If staff must remain on site to mitigate critical staffing shortage, asymptomatic exposed staff including those who are unvaccinated and partially vaccinated, can continue to work under the following conditions:
    1. They must wear a mask during the quarantine period.
    2. Self-monitor for symptoms.
    3. If staff becomes symptomatic, staff must immediately be sent home for self-isolation (see a target="_blank" href="http://www.publichealth.lacounty.gov/acd/ncorona2019/covidisolation/">Home Isolation Instructions).
  3. Document all staff contacts on the COVID-19 Line List for Congregate Residential Settings (Excel) (See Report Forms section).
  4. Monitor and follow-up staff contacts for symptoms during, or at the end of monitoring period, to check-in and respond to concerns.
  5. Monitor all staff (regardless of contact with a case) for fever, cough, and shortness of breath. Symptomatic staff may not work.

TESTING RECOMMENDATIONS

  1. DPH testing recommendations should be communicated to the facility administrator/manager or medical director.
    1. For all community care facilities, mass testing should be initiated if one COVID-19 positive individual (resident or staff) is identified, and targeted testing should only be used if the facility does not have the resources to perform mass testing. Refer to Community Care Facilities guidance. Also refer to the Targeted Testing guidance.
    2. For testing at DCFS-affiliated congregate care facilities, mass testing is also recommended if one COVID-19 positive individual (youth or staff) is identified. If consent cannot be obtained for testing of the youth, youth should be placed in the Yellow Zone and monitored for 14 days.
    3. Wider testing for early intervention may be considered in certain circumstances to help identify additional cases at a point in time and determine scope of outbreak at the facility. These include:
      1. In high-risk Community Care Facilities.
      2. Identification of contacts cannot be reliably conducted such that all residents are considered exposed (e.g. in a memory care unit).
      3. AMD or designee determines broader testing is required after performing a transmission risk and infection control assessment.
    4. For DCFS Emergency shelter facilities, mass testing should be initiated if one COVID-19 positive staff is identified: mass testing should include all staff and non-COVID-positive youth who worked or resided in the apartment while the COVID-19 positive staff was infectious.
  2. Based on the California Department of Social Services Provider Information Notice (CDSS PIN) 21-28-ASC and Community Care Facilities Guidance, diagnostic screening testing of 25% of unvaccinated or partially vaccinated staff every 7 days is recommended. If using PCR testing, this should be done once a week, and if using antigen testing, this should be done twice a week. PCR is preferred. If one COVID-19 positive individual (resident or staff) is identified, or more, PCR testing of all residents (excluding independent Continuing Care Retirement Communities-unless they have been in communal settings with other residents) and staff should be done every 7 days, regardless of vaccination status. Testing of all residents and staff may be discontinued after 2 rounds of negative testing. Facilities can then revert back to diagnostic screening testing.
  3. For DCFS-affiliated congregate care facilities, surveillance testing of 25% of staff every 7 days is also recommended if feasible. Surveillance testing is not recommended for DCFS Emergency Shelter staff. /li>
  4. Facilities should conduct their own testing if they can do so. The facility should first be referred to the Laboratories Providing Diagnostic Testing to find a lab—there are resources that provide onsite collection services. The facility should also be referred to the Community Care Facilities Testing Toolkit. If the facility is unable to find a lab to do testing within 1 week, despite attempting to do so, facilities should be referred to DPH community testing (strike) team.
  5. For symptomatic caregivers, ensure they are not working and recommend the following: /li>
    1. Testing is recommended through their Primary Care Provider or through Los Angeles County https://covid19.lacounty.gov/testing/.
  6. Requests for DPH strike team testing can be requested if facilities are unable to conduct targeted or wider testing on their own. However, requests will be prioritized by ACDC in communication with OMB based on risk and scope of outbreak, and consensus that testing will change management, as well as DPH capacity and resources for testing supplies and staff. Decisions for testing through DPH will be made on a case-by-case basis with the OMB MD. Retesting will be done by the facility when indicated./li>
    1. For an urgent need for testing outside of the priority, the request must come from the OMB Area Medical Director (AMD).
  7. Diagnostic Screening Testing: Per CDSS PIN 21-28-ASC and LAC DPH Community Care Facilities guidance, facilities that currently do not have any diagnosed COVID-19 cases in residents or staff should conduct diagnostic screening testing of 25% of not fully vaccinated staff every 7 days (e.g. choose different staff to test every 7 days). This recommendation also applies to DCFS-affiliated congregate care facilities if feasible. Surveillance testing for DCFS Emergency Care facilities is not recommended.

DISCONTINUATION OF TRANSMISSION-BASED PRECAUTIONS AND DISPOSITION OF PATIENTS WITH COVID-19

For more details, refer to CDC Discontinuation of Transmission-Based Precautions and Disposition of Patients with COVID-19 in Healthcare Settings.

  1. If discontinuing isolation for symptomatic or asymptomatic cases in the Red Zone, facilities are advised to do the following:
    1. Symptoms-based strategy:
      1. For those with symptoms: at least 1 day (24 hours) has passed since recovery, defined as resolution of fever without the use of antipyretic medications and improvement in respiratory symptoms (e.g., cough, shortness of breath); AND
      2. For those with symptoms: at least 10 days have passed since symptoms first appeared if the patient has not been hospitalized and is not immunosuppressed. For symptomatic youth in DCFS-affiliated congregate care facilities, 10 days of isolation from the date symptoms first appeared is sufficient if criteria (i) has been met and the individual is not hospitalized or immunosuppressed.
      3. For those with symptoms: at least 20 days have passed since symptoms first appeared if the patient is immunosuppressed (actively receiving chemotherapy for cancer, HIV with CD4 count <200, immunodeficiency disorder, prednisone dose >20mg/day for more than 14 days, receipt of immunosuppressive medications [biologic agents, etc.] for treatment of autoimmune disease, or other cause of immunosuppression as determined by the patient’s primary physician).
      4. For those without symptoms: at least 10 days have passed since the date of positive test for patients who are not immunosuppressed. For asymptomatic youth in DCFS-affiliated congregate care facilities, 10 days of isolation from the date symptoms first appeared is sufficient if criteria (i) has been met and the individual is not hospitalized or immunosuppressed.
      5. For those without symptoms: if the patient is immunosuppressed (actively receiving chemotherapy for cancer, HIV with CD4 count <200, immunodeficiency disorder, prednisone dose >20mg/day for more than 14 days, receipt of immunosuppressive medications [biologic agents, etc.] for treatment of autoimmune disease, or other cause of immunosuppression as determined by the patient’s primary physician), the patient should be isolated for 20 days.
    2. Test-based strategy is not currently recommended and may be considered for severely immunocompromised patients in consultation with an Infectious Disease expert.
  2. If transmission-based precautions have been discontinued, but the resident has persistent symptoms from COVID-19 (e.g., persistent cough), they should be placed in a single room, be restricted to their room, and wear a facemask (if tolerated) during care activities until all symptoms are completely resolved or at baseline.

Transfers to and from Community Care Facilities

Refer to Interfacility Transfer Rules During COVID-19 Pandemic.

Interfacility transfers should be limited as much as possible, while still maintaining appropriate levels of care for all patients.

Patients/residents should not be sent to the Emergency Department (ED) to obtain SARS CoV-2 testing.

  1. For residents not needing hospital admission: Refer to Return-to-Facility Discharge Rules for Patients in the Emergency Department.
  2. Residents who developed symptoms of COVID-19 in the facility and are transferred to acute care hospital may return to the facility of origin once clinically stable if staffing levels in the facility are adequate. They should be placed in COVID-19 dedicated area (Red Zone) within the facility.
  3. New COVID-negative admissions to the facility should be restricted based on the assessment of the AMD or AMD delegated physician and depends upon the layout of the facility and the capacity for the facility to separate COVID-positive residents from negative residents and whether there is evidence of ongoing transmission (i.e., new symptomatic cases) in the facility.
    1. Asymptomatic fully vaccinated residents can go directly to the Green Zone without a COVID-19 test, provided they did not have close contact to a person with laboratory confirmed COVID-19 in the last 14 days.
    2. Asymptomatic residents who are not fully vaccinated should be tested for COVID-19 and placed in the Yellow Zone.
    3. Exposed and/or symptomatic residents, regardless of vaccination status, should be quarantined for 14 days (Yellow Zone). They should be placed in a single room, ideally, or with another resident in the Yellow Zone if a single room is not available. COVID-19 PCR testing should be done at admission, either by the transferring facility within 72 hours of transfer, or by the receiving facility upon entering quarantine, per CDSS PIN 20-23-ASC. An additional test may be done at the end of the 14-day quarantine period prior to rejoining the general population.
    4. For DCFS-affiliated congregate care facilities, new admissions should be placed in quarantine for 10 days in the YELLOW ZONE. This also applies to youth who leave the facility without permission. If youth are known to have exposure to a COVID-19 positive individual while off-site, they should be placed in the YELLOW ZONE and tested 3-5 days after exposure. If they test negative, they should remain in quarantine in the YELLOW ZONE for 10 days.

Transfers between Community Care Facilities

LAC DPH does not recommend transferring residents to hospitals unless they require higher level of care and does not recommend transfers between community care facilities unless the facility is unable to isolate the resident adequately. Refer to Interfacility Transfer Rules During COVID-19 Pandemic. If the facility is a dedicated COVID receiving facility, they may accept transfers of COVID+ residents from other facilities.

Outbreak Closure Criteria

Outbreak can be closed once closure criteria is met:

At least 14 days have passed since last exposure to a confirmed or symptomatic case in a staff member and/or resident and/or at least 14 days have passed since the last confirmed COVID-19 case in a staff member and/or resident.

  1. PHN/OI uploads all documents into IRIS and documents in IRIS per protocol.
  2. PHN/OI or PHNS can close COVID-19 outbreak in IRIS after approval by AMD or AMD delegated physician. Closure letter will be signed by AMD or AMD delegate and placed in IRIS under the filing cabinet.

Death Reporting

DPHN/OI must be notified of a death and the facilities will need to complete and submit a death report form to ACDC.

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  • Public Health has made reasonable efforts to provide accurate translation. However, no computerized translation is perfect and is not intended to replace traditional translation methods. If questions arise concerning the accuracy of the information, please refer to the English edition of the website, which is the official version.

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