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Adult Day Care Centers

B73 COVID-19 - Procedural Guidance for DPH Staff



REPORTING PROCEDURES

Outbreak Definitions

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

All cases of respiratory illness (characterized by fever and cough or shortness of breath) of unknown etiology are assumed to be COVID-19 cases until test results confirm otherwise.

Outbreak Definition: At least 3 laboratory-confirmed cases with symptomatic or asymptomatic COVID-19 infection within a 14-day period in a group* with members that are epidemiologically linked, do not share a household, and are not a close contact of each other outside of the campus. Epidemiological links require cases to be present in the same setting during the same time period while infectious.

*Groups include persons that share a common membership, e.g., adult day care centers, same classroom, school event, school-based extracurricular activity, academic cohort, athletic teams, clubs.

Epidemiologic Data for Outbreaks

  1. Collect epidemiologic data in the form of a line list for staff:
    1. Name
    2. Date of birth
    3. Gender
    4. Position/job title
    5. Date last worked
    6. Direct patient contact (Y/N)
    7. Exposure (work/household/unknown)
    8. Influenza vaccination (Y/N); if yes, date of vaccination
    9. Date of symptom onset
    10. Fever (Y/N) or highest temperature (oF)
    11. Cough (Y/N)
    12. Myalgia/body aches (Y/N)
    13. Chills (Y/N)
    14. Sore throat (Y/N)
    15. Shortness of breath (Y/N)
    16. Other (please specify)
    17. Chest x-ray confirmed pneumonia (Y/N)
    18. Doctor visit (Y/N)
    19. Specimen collection date
    20. Specimen type (NP, OP, sputum, other)
    21. Diagnosis/lab result
    22. Final diagnosis (COVID, influenza, pneumonia, other)
    23. Hospitalized (Y/N)
    24. Died (Y/N); if yes, date

  2. Collect epidemiologic data in the form of a line list for participants:
    1. Name
    2. Date of birth
    3. Gender
    4. Date last attended center
    5. Direct contact with staff (Y/N)
    6. Exposure (work/household/unknown)
    7. Influenza vaccination (Y/N); if yes, date of vaccination
    8. Date of symptom onset
    9. Fever (Y/N) or highest temperature (oF)
    10. Cough (Y/N)
    11. Myalgia/body aches (Y/N)
    12. Chills (Y/N)
    13. Sore throat (Y/N)
    14. Shortness of breath (Y/N)
    15. Other (please specify)
    16. Chest x-ray confirmed pneumonia (Y/N)
    17. Doctor visit (Y/N)
    18. Specimen collection date
    19. Specimen type (NP, OP, sputum, other)
    20. Diagnosis/lab result
    21. Final diagnosis (COVID, influenza, pneumonia, other)
    22. Hospitalized (Y/N)
    23. Died (Y/N); if yes, date

  3. Document suspected and confirmed cases on the Case Line List and contacts on the Contact Outbreak Line List in the COVID-19 Line List for Non-Residential Congregate Settings (see Forms).
  4. Maintain surveillance for new cases until no new cases for at least 14 days.
  5. Create an epi-curve, by date of onset (see CDC Quick Learn Lesson: Create an Epi Curve for guidance). Only put those that meet the case definition on the epi-curve. (Optional)
  6. Complete COVID-19 Outbreak Non-Residential Settings Form at the conclusion of investigation (see Forms).

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 weekly, but more frequently as needed and determined by the Outbreak Investigation Branch (OMB).

Public Health is encouraging targeted testing to prevent spread of COVID-19 in adult day care centers. This strategy is aimed to supplement infection control, universal source control, and physical distancing measures. With the targeted testing strategy, when there is a known COVID-19 case, all confirmed cases and contacts are tested whether the contacts have symptoms or not.

Refer suspected cases and contacts of confirmed cases to their primary care provider to discuss testing options. If the facility is able to provide or facilitate testing, cases and contacts of confirmed cases may take advantage of that service.

For facilities that are providing or facilitating testing, refer to the LA County COVID-19 Testing Strategy. They can also be referred to the LA County Department of Public Health Targeted Testing Guidance for Congregate Residential Facilities. Even though adult day care centers are not residential, they provide care for those that may live in congregate residential facilities.

Facilities with 10% or more of staff member and/or participant cases will be closed down until isolation periods for the cases are over. The facility can be reopened after all positive cases have completed their isolation periods and changes have been instituted in the facility that follow Public Health guidelines for infection prevention.

Cases

A confirmed case of COVID-19 is a person with a laboratory test positive for SARS- CoV-2.

All cases of respiratory illness (characterized by fever and cough or shortness of breath) of unknown etiology are suspected cases of COVID-19 at this time.

  • Cases in Staff:
    1. Instruct suspected and confirmed cases of COVID-19 to self-isolate at home. They should not return to the setting for at least 10 days after symptom onset and 24 hours after fever has resolved without the use of fever reducing medicines and symptoms have improved. For asymptomatic cases, the date of collection of the specimen positive for SARS-CoV-2 can be used in place of onset. See Home Isolation Instructions.
    2. If the staff member came to work while ill, they should be separated from others with door closed, masked, and directed to go home right away.
    3. Determine when the staff member was first symptomatic and when they were tested.
    4. Refer suspected cases to their primary care provider to discuss testing options, unless testing is being provided or facilitated at the center.
    5. Determine which days and shifts the staff member was working at the center.
    6. If staff member has severe symptoms, call 9-1-1. Notify EMS and the receiving healthcare facility of possible exposures.
    7. Remind staff member that hospitalized and fatal cases of work-related COVID-19 must be immediately reported to Cal OSHA (see dir.ca.gov/dosh/Serious-injury-FAQ.htmland www.osha.gov/SLTC/covid-19/standards.html).
    8. Consider alternative work options like teleworking if staff member is well enough to do so and can continue their duties through telework.
    9. Instruct staff member to notify all other employers of their illness. Document suspected and confirmed cases and contacts of these cases in a line list with the details listed under Reporting Procedures above.
    10. Close off areas used by cases and do not use these areas until after cleaning and disinfecting (see DPH Cleaning Matrix). Open outside doors and windows to increase air circulation in the areas and then begin cleaning and disinfecting. Cleaning should include cleaning of frequently touched surfaces and objects. Use cleaning chemicals with EPA-registered disinfectant labels with claims against emerging viral pathogens (see epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2).
    11. Adult day care center administrators should work with Public Health to determine if short-term closure of the affected area(s) is needed to prevent the spread of COVID-19.
    12. Reinforce prevention measures across the center.
    13. Have administrators send a notification letter to all participants and their families notifying them of detected cases and to use judgment in attending the center during the monitoring period.
    14. Do not require a healthcare provider’s note for staff members who are sick with respiratory illness to validate their illness or to return to work.
    15. Even if COVID-19 testing is negative, utilize the symptom-based clearance strategy in number 1 above for return to work.
    16. Utilize return to work protocols for healthcare professionals (HCP) if the staff member provides direct clinical care to patients. Refer to DPH Guidance for Monitoring Healthcare Personnel and CDC's Criteria for Return to Work for Healthcare Personnel with SARS-CoV-2 Infection (Interim Guidance).
      Restrict contact with vulnerable* persons until 14 days after symptom onset.

      * 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.

  • Cases in Participants:
    1. Instruct participants and/or families/caregivers that suspected or confirmed participants with COVID-19 should isolate at home. They should not return to the adult day care center for at least 10 days after symptom onset and 24 hours after fever has resolved without the use of fever reducing medicines and symptoms have improved. For asymptomatic cases, the date of collection of the specimen positive for SARS-CoV-2 can be used in place of onset. See Home Isolation Instructions.
    2. If the participant showed symptoms after drop-off at the adult day care center, they should be separated from others with door closed, masked, and be taken home immediately. Exceptions to masking would be if the participant is not able to keep the mask or face covering on due to severe mental illness, dementia, difficulty breathing, or unconsciousness.
    3. Determine when the participant was first symptomatic and when they were tested.
    4. Refer suspected cases to their primary care provider to discuss testing options, unless testing is being provided or facilitated at the center.
    5. Determine which days the participant attended the adult day care center while infectious.
    6. If participant has severe symptoms, call 9-1-1. Notify EMS and the receiving healthcare facility of possible exposures.
    7. Document suspected and confirmed cases and contacts of these cases in a line list with the details listed under Reporting Procedures above.
    8. Close off areas used by cases and do not use these areas until after cleaning and disinfecting (see DPH Cleaning Matrix). Open outside doors and windows to increase air circulation in the areas and then begin cleaning and disinfecting. Cleaning should include cleaning of frequently touched surfaces and objects. Use cleaning chemicals with EPA-registered disinfectant labels with claims against emerging viral pathogens (see epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2).
    9. Adult day care center administrators should work with Public Health to determine if short-term closure of the affected area(s) is needed to prevent the spread of COVID-19.
    10. Have administrators send a notification letter to all participants and their families notifying them of detected cases and to use judgment in attending the center during the monitoring period.
    11. Do not require a healthcare provider’s note for participants to validate their illness or to return to adult day care center.
    12. Even if COVID-19 testing is negative, utilize the symptom-based clearance strategy in number 1 above for return to the adult day care center.
    13. Advise participants to restrict their contact with vulnerable* persons until 14 days after symptom onset.

      * 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.

Contacts

A contact is a person with exposure to a confirmed or suspected case of COVID-19 during the period from 48 hours before symptom onset until the case meets criteria for discontinuing home isolation (See Home Isolation Instructions). For asymptomatic cases, the date of collection of the specimen that was positive for SARS-CoV-2 can be used in place of symptom onset.

  1. Exposures are defined as follows:
    1. A staff member of the adult day care center, another participant at the adult day care center, a household member, an intimate contact, or a caregiver of a confirmed or suspected COVID-19 case.
    2. Being within approximately 6 feet of a person with confirmed or suspected COVID-19 for a prolonged period of time (for a total of 15 minutes or more within a 24-hour period).
    3. Having unprotected direct contact with infectious secretions or excretions of a person with confirmed or suspected COVID-19 (e.g., being coughed or sneezed on, sharing utensils or saliva, or providing care without using appropriate protective equipment).

  2. Quarantine Instructions for Contacts:
    1. Contacts who are asymptomatic should be instructed to self-quarantine for 14 days after last exposure. Exposures include contact that occurs during the period from 48 hours before symptom onset until the case meets criteria for discontinuing home isolation. See Home Quarantine Guidance.
    2. If quarantined contacts develop symptoms of respiratory illness (fever and cough or shortness of breath), then they should begin self-isolation. See Home Isolation Instructions.
    3. Do not require a healthcare provider’s note for contacts under quarantine to validate their illness or to return to the adult day care center.

  3. Targeted Testing for Contacts:
    1. Public Health is encouraging targeted testing to prevent spread of COVID-19 in adult day care centers. This strategy is aimed to supplement infection control, universal source control, and physical distancing measures. With the targeted testing strategy, when there is a known COVID-19 case, all suspect cases and contacts of confirmed cases are tested whether they have symptoms or not.
    2. Instruct contacts to get tested as soon as possible. Refer contacts to their primary care provider to discuss testing options, unless testing is being provided or facilitated at the center.

Vendors and Visitors: Contact any vendors and visitors that may have been exposed to a suspected or confirmed case, especially those who are at higher risk for severe infection. Instruct them to self-quarantine for 14 days after last exposure (see above Quarantine Instructions for Contacts). Clients, vendors, and visitors should call their primary care provider to discuss testing options.

Document contacts in a line list see reporting procedures above.

Do not require a healthcare provider’s note for staff to return to work. Do not require a healthcare provider’s note for participants to return to the adult day care center.

Direct Clinical Care Activities Caregivers

Some participants at the adult day care center require assistance with activities of daily living.

These include: bathing, toileting, dressing, feeding themselves, walking, and transferring from one position or place to another (bed to chair, lying down to sitting up, etc.). Staff that help participants with any of these activities can easily be exposed if not wearing the correct PPE.

  1. Caregiver protection:
    1. Cloth face coverings are sufficient for all staff members when they are in walkways and common or shared areas where participants and/or staff may congregate or areas in the adult day care center where participants are participating in communal dining or activities.
    2. For all caregiving activities, caregivers should at minimum wear a mask (surgical mask or higher). If participant is unable to cover nose/mouth (i.e. practice source control or is being fed), caregivers should also use eye protection. Gloves and gown may also be recommended if there is risk of exposure to bodily secretions or fluids.

  2. Management of caregiver exposures in caregiving 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).
      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 14-day quarantine period.
      2. Monitor for symptoms twice daily.
      3. If caregiver becomes symptomatic, the person must immediately be sent home for self-isolation (see Home Isolation Instructions).
    3. Document all caregiver contacts on the COVID-19 Line List for Congregate Residential Settings (See Report Forms 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 AND 3 days since recovery (fever has resolved without the use of antipyretics and symptoms have improved). 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.

Outbreak Control Measures

  1. Reinforce good hand hygiene among all staff, participants, vendors, and visitors.
  2. Emphasize respiratory etiquette (cover cough and sneezes, dispose of tissues properly).
  3. Sick persons with respiratory illness, even with mild symptoms, should be restricted from entering the adult day care center and urged to stay home and self-isolate.
  4. Screen all persons entering he adult day care center for symptoms, temperature, and COVID-19 contacts.
  5. Urge staff members, participants (or families/caregivers of participants), vendors, and visitors to quarantine at home if someone in their house is sick.
  6. Emphasize importance of early detection of cases and removing them from contact with others.
  7. Ensure adequate and easily accessible supplies for good hygiene, including:
    1. Tissues and trash receptacles.
    2. Alcohol based hand sanitizer dispensers throughout the adult day care center.
    3. Handwashing stations, fully stocked with soap and paper towels.
  8. Minimize, where possible, close contact and the sharing of objects such as cups, food, and drink.
  9. Discontinue in-person group events and consider virtual group events; otherwise ensure that there are 6 feet between people and everyone participating is wearing a face covering.
  10. Close off areas used by cases and do not use these areas until after cleaning and disinfecting. Open outside doors and windows to increase air circulation in the areas and then begin cleaning and disinfecting. Cleaning should include cleaning of frequently touched surfaces and objects. Use cleaning chemicals with EPA-registered disinfectant labels with claims against emerging viral pathogens (see www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2).
  11. Signage should be posted throughout the adult day care center to reinforce frequent hand washing, cover your cough, wear a face covering, and maintain social distancing.
  12.  Increase routine cleaning and disinfection of all frequently touched surfaces and objects, such as doorknobs, railings along the wall, telephones, remote controls, light switches, etc.
  13.  Implement strategies to protect staff who are at higher risk for adverse health complications. This may include strategies such as telecommuting, staggering shifts, and cross training staff.
  14.  Instruct adult day care center to maintain daily log, if feasible, with who is present in the center with dates and time periods, and screening results.

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 or participant.

  1. PHN uploads all documents into IRIS and documents in IRIS per protocol.
  2. PHN 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 delegated physician.

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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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