Under Title 17, Section 2500, California Code of Regulations all suspected outbreaks are reportable.
Definition of Outbreak:
NOTE: If residents are PCR positive 8-14 days after admission to the facility, they should initiate and/or be attributed to an ongoing outbreak, even if they are still in the SNF's Green or Yellow Zone.
Single confirmed COVID-19 RESIDENT case in a SNF
Confirmed COVID-19 HCP case in a SNF
NOTE: Staff case should not be linked to outbreak if s(he) did not work for 5 or more days before his/her symptoms onset or specimen collection date and did not work for at least 10 days after.
Contacts are defined as below:
Healthcare Personnel (HCP):
Facility to identify all close contact HCP (includes clinical and ancillary staff), and determine risk status using the guide outlined in LAC DPH Guidance for Monitoring Healthcare Personnel and a companion guidance, CDC Criteria for Return to Work for Healthcare Personnel with Confirmed or Suspected COVID-19 (Interim Guidance).
Document the contacts on the COVID-19 Line List template (see Report Forms section) and submit it to DPH as requested by DPH
Visitors:
For the most up to date guidance on visitation in SNFs, please see Communal Dining, Group Activities, and Visitation section. Facility to identify and instruct any visitors that may have been a close contact to a confirmed case and who were partially vaccinated and unvaccinated at the time of the visit to self-quarantine and self-monitor for symptoms for 14 days after last exposure.
Getting vaccinated against COVID-19 is critical to protecting both residents and staff in SNFs. The latest COVID-19 vaccine clinical recommendations are located on CDC’s website: Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Approved or Authorized in the US. Below are key COVID-19 vaccine guidance and resources for SNFs in LA County.
Definition of Up to Date:
An individual is up to date with COVID-19 vaccines when they have received all doses in the primary series (i.e., are fully vaccinated) and all recommended boosters, when eligible.
They are also considered up to date if they have:
Definition of Fully Vaccinated:
A person is considered fully vaccinated ≥2 weeks following the receipt of:
Proof of vaccination: Staff and visitors can only be considered fully vaccinated or up to date if they show acceptable proof of vaccination that confirms the above definitions. Proof of vaccination for staff and visitors includes the following as per AFL 21-28 and AFL 22-07.
Track, Increase, and Maintain COVID-19 Vaccination & Booster Coverage
Residents:
Staff:
*Please read the full orders for description of who is included in “workers”.
The purpose of these visitation guidelines is to help each facility develop a resident-centered visitation policy that balances the need to protect staff and residents from COVID-19 transmission with the need to provide timely care that optimizes residents’ physical and psychological health in alignment with state and federal requirements.
The following recommendations for communal dining, group activities, and visitation are based upon the most recent CDPH All Facility Letter (AFL) and CMS Quality Safety & Oversight memo (QSO):
Criteria for Communal Dining, Group Activities, and General Visitation
For facilities to allow any gathering, facilities must meet
these baseline CMS criteria:
1 Per CMS Guidance, contingency PPE capacity strategy is allowable, such as CDC’s guidance Optimizing Supply of PPE and Other Equipment during Shortages. However, facilities’ crisis capacity PPE strategy does not constitute adequate access to PPE.
Communal Dining and Group Activities
Communal dining and group activities should resume for residents in the Green Cohort* provided the facility meets the baseline criteria. These activities may take place indoors and outdoors as long as there is no outbreak at the facility. If there is an outbreak at the facility, only outdoor activities are permitted. Facilities must continue to follow all infection prevention and control measures to conduct communal dining and group activities safely.
* If there is no outbreak in the facility, the following residents in the Yellow Cohort may follow the Green Cohort permissions for communal dining and activities (as long as they are asymptomatic and are not close contacts/considered exposed to a case):
See Table 1 Communal dining & group activities
NOTE: The guidance in this section does not apply to residents engaging in one-on-one treatment, e.g., rehabilitation therapy, that is not conducted in a communal/group setting. Rehabilitation therapy should occur in-room for Red Cohort residents and is preferable for Yellow Cohort residents. Regardless of setting of rehabilitation therapy, in-room or in a common area e.g., rehabilitation room/gym, all Infection Prevention and Control Guidance must be followed including universal source control, physical distancing, hand hygiene, donning and doffing of PPE appropriate for the resident’s cohort status, enhanced environmental disinfection, etc.
The facility should adhere to the following measures for all communal dining and activities:
If there is a COVID-19 outbreak in the facility, then the following applies:
Visitation
General visitation should be supported by the facility provided the facility meets the baseline criteria above.
Resident Rights: Facilities may not restrict visitation without a reasonable clinical or safety cause, consistent with resident rights in the federal regulation Title 42 CFR section 483.10(f)(4)(v), as stated in CDPH AFL 22-07 and CMS QSO 20-39-NH-Revised. Furthermore, residents or their designated representative when the resident does not have capacity, should be involved, and have their preferences prioritized in the determination of essential visitors (e.g., caregivers/essential support persons, compassionate care visitors). Failure to facilitate residents’ visitation rights, without adequate reason related to clinical necessity or resident safety, would constitute a potential violation of this federal regulation, and the facility would be subject to citation and enforcement actions.
Below are recommendations for testing and cohorting in SNFs based upon California Department of Public Health (CDPH) requirements outlined in recent CDPH AFLs:
NOTE: Interpretation of COVID-19 viral test results does not change after an individual has received COVID-19 vaccination.
General Requirements
Testing of Symptomatic Residents or Staff.
Response Testing. If a single positive COVID-19 case is identified among either staff or residents, the SNF must conduct comprehensive testing of all residents and staff regardless of vaccination status to identify potential asymptomatic infections. All residents and staff should be tested once every 3-7 days (this can be an extension of routine screening testing of residents once weekly in the section below). Response testing can be once weekly for all staff and residents being tested, regardless of the routine screening testing schedule, unless specified by the outbreak investigation to be more frequent. If testing capacity is limited, testing may be prioritized for the residents and staff in the same area (e.g., nursing station, floor, etc.) as the COVID-19 positive individual. Any close contact and exposed residents of confirmed COVID-19 cases will need to be quarantined accordingly in the Yellow Cohort (see below). All residents and staff who test negative will need to be included in response testing until there are at least 2 weeks with no additional infections identified. After 2 weeks of negative testing for residents, the facility could restart routine testing for residents as outlined below, in consultation with local Public Health.
Routine Screening Testing
Routine screening testing must be conducted according to the LA County Health Officer Order as described below. Please note when there are differences in testing requirements, the most conservative testing guidance must be followed. If any resident or staff tests positive, the SNF must report the positive case to LAC DPH and proceed with response testing as described above. Routine screening testing is resumed when no new cases are identified from two sequential weeks of response testing. If COVID-19 point of care antigen tests are used as an alternative to PCR tests, then they should be administered at least twice per week and confirmatory PCR testing should follow LA County's SNF antigen testing guidelines; otherwise, the following guidance still applies.
As of 05/25/2022, all staff, regardless of vaccination status, should be tested twice weekly, until further notice. Antigen testing is acceptable to fulfill this requirement. Staff who work one shift per week or less should be tested prior to each shift.
Figure 1. Testing Schematic
Refusal of Testing
Facilities should have 3 separate cohorting areas as described below and shown in Figure 2.
Table 3. Quarantine Guidance for the Yellow Cohort
Indication to quarantine in Yellow Cohort | Room Placement | Duration of Quarantine | Testing |
---|---|---|---|
Close contacts and those exposed to a
confirmed case in the same unit/wing
regardless of whether the close contact
occurred inside or outside the facility,
e.g., while "out on pass" Exception: asymptomatic residents who recently recovered from a prior COVID-19 infection within the last 90 days should remain in the Green Cohort |
Quarantine in place. All exposed residents should remain in their current rooms to avoid movement of residents that could lead to new exposures. | At least 14 days following the last exposure (day 0). PCR test collected on day 12-14 should result negative before moving to Green Cohort. | PCR testing three times on day 1, day 5-7, AND day 12-14 after the last exposure (day 0). |
New admission/re-admission OR Left the facility >24 hrs AND Are not up to date with COVID-19 vaccines Exception: asymptomatic residents who recently recovered from a prior COVID-19 infection within the last 90 days should be placed in the Green Cohort |
New admission/re-admission: If not up to date, do not mix this group w/ any other resident groups in the Yellow Cohort (e.g., do not room with exposed/ close contacts, or symptomatic residents). Left facility >24 hours: Place with other new admissions/re-admissions (preferable) if not up to date. Otherwise, quarantine in place, avoid movement of residents that could lead to new exposures. |
Up to date: Do not need to quarantine. NOT up to date: 14 days from date of admission. PCR test collected on day 12-14 should result negative before moving to Green Cohort. |
Up to date: PCR testing total of two times; immediately on admission (<72 hrs) AND on day 5-7 after admission. NOT up to date: PCR testing total of two times; immediately on admission (<72 hrs) AND on day 12-14 after admission. |
Symptomatic | Prioritize for single occupancy rooms. | At least 10 days AND at least 24 hrs since last fever without fever-reducing medication AND improvement in symptoms | One PCR test performed immediately |
Atypical symptoms of possible COVID-19 (e.g., delirium/confusion, change in functional status, change in oral intake, and new or worsening falls) | Quarantine in place, avoid movement of residents that could lead to new exposures. | No minimum duration | One PCR test performed immediately |
Asymptomatic with indeterminate test results (excluding new admissions, re-admissions, close contacts, or exposed residents) | Prioritize for single occupancy rooms | At least 2 days have passed since collection of confirmatory negative test without development of new symptoms | Collect confirmatory PCR test within 48 hours of the initial indeterminate test |
Moderately to severely immunocompromised who are newly admitted/readmitted, frequently leave the facility (e.g., for chemotherapy), or leave the facility >24 hours | Consider applying same guidance as for residents not up to date with COVID-19 vaccines who are new admissions/re-admissions, frequently leave the facility, or leave the facility >24 hrs. | ||
Not up to date with COVID-19 vaccines: | |||
Frequent outside visits (e.g.,
dialysis) Exception: asymptomatic residents who recently recovered from a prior COVID-19 infection within the last 90 days should be placed in the Green Cohort |
Do not mix this group with any other resident groups in the Yellow Cohort (e.g., do not room with exposed/close contacts, symptomatic residents). | Until resident is up to date with COVID-19 vaccines and/or no longer frequently leaving the facility. | As per routine screening testing guidance |
NOTE: If a test result is positive for COVID-19, the resident should be moved into the Red Cohort for isolation. |
Figure 2. Cohorting
Special Staffing Considerations in Cohort Areas
Below are general and COVID-19 specific recommendations. For more information on infection control recommendations, visit https://www.cdc.gov/infectioncontrol/basics/index.html.
General Requirements
Universal Source Control
Residents
Staff
Physical Distancing
Hand Hygiene (HH)
Respiratory Hygiene/Cough Etiquette:
Transmission Based Precautions and Personal Protective Equipment (PPE)
HCP should follow transmission- based precautions for each cohort including standard precautions and wearing of appropriate PPE while providing resident care as detailed below.
Figure 3. PPE in Each Cohort
Environmental cleaning:
In addition to CDC guidelines, the recommendations below are referenced from the California Department of Public Health AFL for Environmental Infection Control for the Coronavirus Disease 2019 (COVID-19).
Monitoring
All HCP should routinely self-monitor for symptoms of possible COVID-19 and the facility should screen all HCP for symptoms of COVID-19 prior to the start of shifts as per the LAC DPH COVID-19 Infection Prevention Guidance for Healthcare Personnel. For return to work for HCP refer to the following sections:
Facilities are required to follow transfer and home discharge rules as listed on the LAC DPH website (http://publichealth.lacounty.gov/acd/NCorona2019/InterfacilityTransferRules.htm).
Return to Work Protocol for HCP with Confirmed COVID-19
Table 3. Work Restrictions for HCP with SARS-CoV-2 Infection (Isolation)Vaccination Status | Routine | Critical Staffing Shortage |
---|---|---|
Up to date (i.e., fully vaccinated and boosted or fully vaccinated but not yet booster-eligible) | 5 days* with negative diagnostic test† same day or within 24 hours prior to return OR
10 days without a viral test |
<5 days with most recent diagnostic test† result to prioritize staff placement‡ |
Unvaccinated, OR Those that are vaccinated and booster-eligible but have not yet received their booster dose | 7 days* with negative diagnostic test† same day or within 24 hours prior to return OR 10 days without a viral test |
5 days with most recent diagnostic test† result to prioritize staff placement‡ |
*Asymptomatic or mildly symptomatic with improving symptoms, and meeting negative test criteria; facilities should refer to CDC guidance for HCP with severe to critical illness or moderately to severely immunocompromised.
† Either an antigen test or nucleic acid amplification test (NAAT) can be used. Some people may be beyond the period of expected infectiousness but remain NAAT positive for an extended period. Antigen tests typically have a more rapid turnaround time but are often less sensitive than NAAT. Antigen testing is preferred for discontinuation of isolation and return-to-work for SARS-CoV-2 infected HCP and for HCP who have recovered from SARS-CoV-2 infection in the prior 90 days; NAAT is also acceptable if done and negative within 48h of return.
‡ If most recent test is positive, then HCP may provide direct care only for patients/residents with confirmed SARS-CoV-2 infection, preferably in a cohort setting.
HCP whose most recent test is positive and are working before meeting routine return-to-work criteria must maintain separation from other HCP as much as possible (for example, use a separate breakroom and restroom) and wear a N95 respirator for source control at all times while in the facility. In addition, healthcare facilities should make N95 respirators available to any HCP who wishes to wear one when not otherwise required for the care of patients or residents with suspected or confirmed COVID-19.
Special situations for long-term care facilities to consider
Exception: asymptomatic residents who recently recovered from a prior COVID-19 infection within the last 90 days should be placed in the Green Cohort.
Dialysis residents consider substituting metered dose inhalers for nebulizers to reduce the risk of aerosolization.
AND
For facilities that are conducting response driven testing
DPHN/OI must be notified of a death and the facilities will need to complete and submit a death report form to ACDC.
Healthcare providers are asked to report all fatalities related to COVID-19, including out of hospital deaths of presumed cases.
Providers are required to report deaths in any person:
* Suspected cases are not counted towards a facility's COVID-19 death count until investigated and determined to be a COVID-19 associated death.
For additional information on reporting COVID-19 Associated Deaths, please visit publichealth.lacounty.gov/acd/ncorona2019/reporting.htm#deaths.