Under Title 17, Section 2500, California Code of Regulations all suspected outbreaks are reportable.
Definition of Outbreak:
Single confirmed COVID-19 RESIDENT case in a SNF
Confirmed COVID-19 HCP case in a SNF
NOTE: Any HCP who has not recently worked at the facility and tested positive should be linked to the outbreak under the following circumstances:
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
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.
Definition of Fully Vaccinated:
A person is considered fully vaccinated ≥2 weeks following the receipt* of either:
* This guidance can also be applied to COVID-19
vaccines that have been listed for emergency use by the World Health Organization (e.g. AstraZeneca/Oxford and Sinopharm). COVID-19 vaccines that receive WHO’s Emergency Use Listing (EUL) have met international standards for safety, efficacy and manufacturing and are deemed suitable for use during a public health emergency.
NOTE: Staff and visitors can only be considered fully vaccinated if they show acceptable proof of vaccination that confirms the above definition.
Track, Increase, and Maintain COVID-19 Vaccination Coverage
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) 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:
1Per 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 are only permitted outdoors at this time for residents in the Green Cohort and certain Yellow Cohort residents* provided the facility meets the baseline criteria. Given Los Angeles County’s rapid increase in COVID-19 cases and hospitalization rates that are already impacting SNFs, indoor communal dining and group activities are currently restricted for residents of all cohorts until further notice. This applies to all residents regardless of vaccination or booster status, the resident’s COVID-19 status, or the facility’s outbreak status.
* If there is no outbreak in the facility, the following residents of the Yellow Cohort may follow the Green Cohort permissions for communal dining and group 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 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.
Facility should adhere to the following measures for all outdoor communal dining and group activities:
If there is a COVID-19 outbreak in the facility, then the following applies:
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 20-22 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.
If the visit is conducted outdoors between a fully vaccinated resident of the Green Cohort and their fully vaccinated visitor, then they do not have to wear a face mask nor physically distance and can include physical contact.
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 do not change after an individual has received COVID-19 vaccination.
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. 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 latest CDPH AFL 20-53, AFL 12-28, and 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.
Retesting Previously Positive Staff/Residents
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|
|Regardless of vaccination status:|
|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" (unless recovered from a prior COVID-19 infection within the last 90 days)||Quarantine in place. All exposed residents should remain in their current rooms to avoid movement of residents that could lead to new exposures.||14 days from date of last possible exposure/close contact||PCR testing on day 5-7 after last exposure/close contact|
Left the facility >24 hrs
(unless recovered from a prior COVID-19 infection within the last 90 days)
|New admission/re-admission: Do not mix this group w/ any
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). Otherwise, quarantine in place, avoid movement of residents that could lead to new exposures.
Fully vaccinated: PCR test collected on day 5-7 should result negative before moving to Green Cohort.
Not fully vaccinated: 14 days from date of admission. PCR test collected on day 14 should result negative before moving to Green Cohort.
Fully vaccinated: PCR testing on day 5-7 from date of admission.
Not fully vaccinated: PCR testing immediately on admission (<72 hrs) AND on day 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|
|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 non-fully vaccinated residents who are new admissions/re-admissions, frequently leave the facility, or leave the facility >24 hrs.|
|Not fully vaccinated:|
|Frequent outside visits (e.g., dialysis)||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 fully vaccinated 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.
Universal Source Control
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
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).
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. Please also refer to this guidance for more detailed information regarding the management of close contacts to confirmed cases including household exposures outside of work. For staffing shortages, refer to Facilities Experiencing Staffing Shortages.
Return to Work for Symptomatic HCP and for HCP with Confirmed COVID-19
Facilities are required to follow relevant sections in the LAC DPH Guidance for Monitoring Health Care Personnel.
Facilities are required to follow transfer rules as listed on the LAC DPH website (http://publichealth.lacounty.gov/acd/NCorona2019/InterfacilityTransferRules.htm).
Special situations for long-term care facilities to consider
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.