Skilled Nursing Facilities

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

Definition of Outbreak:

1. At least one PCR laboratory confirmed case (symptomatic or asymptomatic) of COVID-19 in a SNF resident who has resided in the facility for at least 7 days
   1. If newly admitted residents who are admitted to the GREEN or YELLOW quarantine cohort are laboratory confirmed (either PCR or antigen) positive for COVID-19, this is not considered an outbreak as patients could have been exposed outside the SNF, but response testing should still be initiated.

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.

2.  Facilities should test PUI/Suspect cases (cases with symptoms of possible COVID-19) immediately.

1. Establish a case definition (i.e., fever [measured or reported] and either cough, sore throat, or stuffy nose): include pertinent clinical symptoms and laboratory data.
2. Confirm etiology of outbreak using laboratory data and thorough contact tracing.
3. Create a line list and contact information following the COVID-19 line list template above.
4. Maintain surveillance for new cases until no new cases for at least 2 weeks.
5. Create and maintain an epi-curve for the duration of the outbreak, by week of symptom onset or positive test result. Only put those that meet the case definition on the epi-curve and differentiate based on staff vs residents as well as fully vaccinated (at least 2 weeks after second dose of a 2-dose series or first dose of a 1-dose series) vs non-fully vaccinated. Recommend listing case totals by increments of 7 days (1 week).
   • Please utilize this template to generate an epi-curve.
   • An additional resource is CDC's Quick Learn Lesson: Create an Epi Curve.

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:

• Completed their primary series but are not yet eligible for a booster dose, OR
• Received one booster but are not recommended to get a 2nd booster, OR
• Received one booster but are not yet eligible for a 2nd booster.

Definition of Fully Vaccinated:

A person is considered fully vaccinated ≥2 weeks following the receipt of:

• The final dose of a Pfizer or Moderna COVID-19 vaccine primary series; OR
• A single dose of a Johnson and Johnson/Janssen COVID-19 vaccine; OR
• A full series of a COVID-19 vaccine that has been listed for emergency use by the World Health Organization [WHO]; OR
• The full series of an accepted COVID-19 vaccine (not placebo) in a clinical trial; OR
• Two doses of any "mix-and-match" combination of an FDA authorized/approved or WHO-listed COVID-19 vaccine administered at least 17 days apart.

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.

1. COVID-19 Vaccination Record Card (issued by the Department of Health and Human Services Centers for Disease Control & Prevention or WHO Yellow Card which includes name of person vaccinated, type of vaccine provided, and date last dose administered); OR
2. A photo of a Vaccination Record Card as a separate document; OR
3. A photo of the client's Vaccination Record Card stored on a phone or electronic device; OR
4. Documentation of COVID-19 vaccination from a healthcare provider; OR
5. Digital record that includes a QR code that when scanned by a SMART Health Card reader displays to the reader client name, date of birth, vaccine dates and vaccine type.
6. Additional option for staff only: documentation of vaccination from other contracted employers who follow these vaccination guidelines and standards.

Track, Increase, and Maintain COVID-19 Vaccination & Booster Coverage

1. All facilities must track all vaccine doses, including additional primary and booster doses, for all staff and residents including verifying vaccination status of new staff hires and new admissions. If a person’s vaccination status is not verified, they are considered unvaccinated.
   1. It is recommended that facilities maintain the following information at minimum in secure/encrypted electronic documents (such as a password protected spreadsheet) for all current residents in a single file and all current staff in a single file:
      1) vaccination status (e.g., up to date, fully, partially, un-vaccinated, or not yet assessed)
      2) the dates of all vaccination doses, including additional primary and booster doses, OR date the person declined. This will a) help facilities anticipate when individuals are due for additional primary or booster doses, b) help facilities’ ability to efficiently implement guidance in this document that depends on vaccination status, and c) allow for easier reporting on vaccination surveys from Public Health, CDPH, and/or NHSN.
2. All facilities should increase and maintain vaccination coverage, including boosters, for both staff and residents by re-offering the vaccine, providing education, hosting listening sessions including to persons who have previously declined, etc. Please see Best Practices for Improving Vaccination in SNFs for more detailed strategies including building vaccine confidence. Also, as per CMS QSO 21-19-NH Interim Final Rule – COVID-19 Vaccination Immunization Requirements for Residents and Staff, facilities must document when COVID-19 vaccine education took place and provide samples of educational materials used for both staff and residents.

Residents:

1. Immediately assess all residents on admission, and at regular intervals during their time in the facility, for their COVID-19 vaccination and booster status.
2. Facilities are recommended to utilize the California Immunization Registry (CAIR2) to help look up verification of vaccination status for residents. Other proof is also acceptable including those listed in the CDPH Vaccine Records Guidelines & Standards.
3. For residents coming from a hospital, including stays in the emergency department or observation, please ask the hospital to offer COVID-19 vaccine to the resident prior to transfer as per CDPH AFL 21-20.
4. If a resident is not up to date with COVID-19 vaccines, immediately contact the facility’s long-term care (LTC) pharmacy to schedule an appointment or delivery of vaccine to get the resident vaccinated.
   1. If the resident is unvaccinated, the first dose should be administered within a week of admission.
   2. Second doses, additional primary doses, or booster doses should be administered per the CDC recommended schedule. Everyone ages 50 years and older who received any COVID-19 booster dose should receive a second booster dose at least 4 months after their first booster dose using an mRNA COVID-19 vaccine. Everyone ages 12 years and older who are moderately or severely immunocompromised should receive a second booster dose at least 4 months after their first booster dose using an mRNA COVID-19 vaccine.
   3. If the LTC pharmacy is not able to vaccinate new resident(s) in a timely manner, please notify Public Health at COVID-LTC-Test@ph.lacounty.gov for additional resources.

Staff:

1. Per CDPH’s Public Health Officer Order on “Health Care Worker Vaccine Requirement" and LAC DPH’s Health Officer Order on Health Care Worker Vaccination Requirement all workers* in skilled nursing facilities (including subacute facilities) are required to complete a primary COVID-19 vaccine series and receive a booster dose. Workers not yet eligible for boosters must be in compliance no later than 15 days after becoming eligible for the booster dose. Workers who have completed their primary series who provide proof of subsequent COVID-19 infection may defer booster administration for up to 90 days after infection. See AFL 21-34.3. Workers that are eligible for a second booster dose should be encouraged to receive it.
2. Staff who are not vaccinated and/or boosted against COVID-19 due to qualified medical reasons or religious exemptions must undergo routine screening testing and have additional PPE recommendations. Please see relevant sections below. There are no exemptions from testing requirements for those with qualified medical reasons or religious exemptions to COVID-19 vaccination.

*Please read the full orders for description of who is included in “workers”.

1. Conduct entry screening.
   1. All persons, regardless of vaccination status, should be screened for signs and symptoms of COVID-19 infection, including a temperature check. Persons requiring signs and symptoms screening include facility staff, essential visitors, and general visitors. Symptoms include but are not limited to the following: 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, or not feeling well. Anyone with fever or signs or symptoms of COVID-19 infection is prohibited from entry.
   2. All visitors (general and essential) must be screened prior to entry for any history of close contact to a COVID-19 case within the past 14 days. See SNF Visitation Guidance for definitions of essential visitors and general visitors.
   1. Anyone reporting recent close contact exposure is prohibited from entry, regardless of vaccination status.
   2. This 14-day duration is purposefully longer than the shorter quarantine option for the general public given the high-risk nature of these facilities.
   3. All general visitors entering the facility for indoor visitation must be screened for vaccination status (please see Communal Dining, Group Activities, Visitation for more details).
   4. Facility must counsel general visitors on their exposure risk due to visiting residents with suspected COVID-19 infection (Yellow Cohort) or confirmed COVID-19 infection (Red Cohort) for both indoor and outdoor visits.
   5. An exception to entry screening: Emergency Medical Service (EMS) workers, including ambulance transport personnel. They do not have to be screened regardless of the urgency of the situation, as they are typically screened separately and are required to be  up to date with COVID-19 vaccines or undergo regular COVID-19 screening testing per LAC DPH Health Officer Order.
2. Conduct symptom and temperature screening for all staff and residents.
   1. All staff should be checked for symptoms and fever at least once per shift, including at the beginning of shifts (see Healthcare Personnel Monitoring section below.)
   2. All asymptomatic residents should be assessed for symptoms and have their vital signs, including temperature and oxygen saturation, checked at least every 24 hours, with more frequent monitoring recommended for symptomatic residents under investigation and especially for residents with confirmed COVID-19.
   3. Records should be kept of these staff and resident symptom and temperature checks.
3. Support good workforce health.
   1. Facilities should have non-punitive sick leave policies to support staff to stay home when sick, if under isolation or quarantine orders, or when caring for sick household members. Make sure staff are aware of the non-punitive sick leave policy.
   2. Make sure that your employees are aware that they may be eligible for benefits such as paid sick leave or workers’ compensation if they become sick with COVID-19, are caring for someone with COVID-19, or if they need to quarantine due to exposure. Workers may also be eligible for paid leave to go to COVID-19 vaccination appointments or to recover from symptoms after getting their vaccination.
4. Reinforce physical distancing, hand hygiene, and universal source control as per the “Infection Prevention and Control Guidance” with exceptions as described in “Communal Dining, Group Activities, and Visitation”.
5. Enhanced environmental disinfection with EPA-approved healthcare disinfectants should be performed on high touch surfaces as described in “Infection Prevention and Control Guidance.”
6. Facilities must demonstrate they have at least a 2-week supply of PPE and other infection prevention and control supplies as well as a plan to optimize PPE supply. Please see “Infection Prevention and Control Guidance” for more details.

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):

• CDPH AFL 22-07: Guidance for Limiting the Transmission of COVID-19 in in Skilled Nursing Facilities (SNFs)
• CMS QSO 20-39-NH-revised: Nursing Home Visitation - COVID-19
• State Public Health Officer Order - Requirements for Visitors in Acute Health Care and Long-Term Care Settings

Criteria for Communal Dining, Group Activities, and General Visitation
For facilities to allow any gathering, facilities must meet these baseline CMS criteria:

• Adequate staffing: The facility must not be experiencing staff shortages; AND
• Supply of 14 days of Personal Protective Equipment (PPE) and disinfection supplies on hand: The facility must have adequate supplies of PPE for staff, such that all staff wear all appropriate PPE when indicated, and must have adequate essential cleaning and disinfection supplies; AND
• Access to adequate testing: The facility must maintain access to COVID-19 testing for all residents and staff by an established commercial laboratory; AND
• Approved COVID-19 Mitigation Plan: The facility must maintain regulatory compliance with CDPH guidance.

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):

•  Residents who are not  up to date with COVID-19 vaccines and who have frequent appointments outside the facility (e.g., dialysis)
• Residents who are severely immunocompromised as per Cohorting

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:

1. Universal source control and physical distancing
   1. All staff, regardless of vaccination status, must wear an N95 respirator, including when caring for or assisting with residents during group activities and communal dining.
   2. Physical distancing for residents and visitors:
      When all residents, visitors, and staff participating in communal dining or group activity are up to date with COVID-19 vaccines, then residents and resident-visitor groups may participate without physical distancing; however, if any resident, visitor, or staff is not up to date with vaccines is participating in a communal dining or group activity, either outdoors or indoors, then all residents and visitors, regardless of vaccination status, should maintain at least 6 feet physical distancing from other visitors and/or resident-visitor groups.
   3. Universal source control for residents and visitors:
      All residents, visitors, and staff participating in communal dining or group activity, regardless of vaccination status, should wear well-fitting face masks when not actively eating or drinking, whether indoors or outdoors.
2. Communal dining and group activities should be done in shifts with the same group of residents to allow better physical distancing and to minimize broad exposure as much as possible.
   1. Additionally, the same group of residents should be assigned to specific areas as much as possible to further minimize exposure.
   2. Use a sign-in sheet/roster of residents present during these activities to help with contact tracing should a resident later test positive for COVID-19.
3. Enhanced environmental disinfection.
   1. All communal, high-touch surfaces should be disinfected after residents or staff vacate an area. Please see “Infection Prevention and Control Guidance” section for more details.
4. Location of communal dining and group activities
   1. Outdoor settings should be prioritized for communal dining and activities whenever practical.
   2. Communal dining and group activities for residents in the Green Cohort should only take place outdoors during an outbreak, regardless of the resident’s vaccination status.
5. For further guidance on communal dining and activities during the holidays, please refer to CDPH AFL 20-86 (COVID-19 Infection Control Recommendations during Holiday Celebrations).

If there is a COVID-19 outbreak in the facility, then the following applies:

1. Outdoor communal dining and group activities may continue for permitted residents (see above and Table 1 below). Residents should wear well-fitting face masks and maintain physical distancing of at least 6 feet regardless of vaccination status when not actively drinking or eating.
2. The facility should review their infection control and prevention practices to prevent future new infections.
3. Please note Public Health may be more protective and, on a case-by-case basis, can direct facilities with active outbreaks to temporarily cease all communal dining and activities for all residents regardless of vaccination status, both indoors and outdoors, to assist with outbreak investigation and/or management.

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.

1. Healthcare personnel (HCP) are facility staff directly employed by the facility and are exceptions to visitation restrictions.
2. Essential visitors are exceptions to visitation restrictions and should be permitted visitation regardless of facility’s outbreak status or COVID-19 status of the resident receiving the visitation. Based on CDPH AFL 22-07, CMS QSO 20-39-NH-revised, and State Public Health Officer Order - Requirements for Visitors in Acute Health Care and Long-Term Care Settings, essential visitors include the following:
   • Ombudsman
   • CDPH surveyors and Public Health workers
   • Students obtaining their clinical experience as part of an approved nurse assistant, vocational nurse, registered nurse, pharmacy, social work, or other healthcare training program. Students may need to be treated as facility staff in regard to routine screening testing if they’re regularly entering the facility (at least once per week).
   • Visitors for legal matters that cannot be postponed including, but not limited to, voting, estate planning, advance health care directives, Power of Attorney, and transfer of property title if these tasks cannot be accomplished virtually.
   • Protection and Advocacy (P&A) program representatives
   • Individuals authorized by federal disability rights laws related to federal disability rights laws such as Section 504 of the Rehabilitation Act and the Americans with Disabilities Act (e.g., qualified interpreter when video remote interpretation is not possible or sufficient).
   • Compassionate care visitors
     1. Visitors for residents in critical condition including end-of-life situations
     2. Support persons for residents experiencing weight loss, dehydration, failure to thrive, psychological distress, functional decline, or struggling with a change in environment.**
     3. Support persons for residents with physical, intellectual, developmental disability, or cognitive impairment.**
     4.  ** NOTE: The determination of which residents may benefit from in-person visitation and who is the appropriate support person(s) should be made by an interdisciplinary team that includes the care team, resident, and/or resident representative(s), e.g., family, caregivers, ombudsman, etc.
3. General visitors: General visitors are defined as visitors who do not fall under the definition of HCP or Essential Visitors. Facilities should support general visitation for all residents regardless of cohort status, COVID-19 status, vaccination status, or the facility’s outbreak status. However, Public Health may be more protective and, on a case-by-case basis, can direct facilities with active outbreaks to temporarily cease all general visitation for all residents, both indoors and outdoors, to assist with outbreak investigation and/or management.
   • As of 05/25/2022, until further notice: all general visitors ≥ 2 years old must demonstrate proof of one of the following prior to entering the facility for all indoor visits, regardless of the visitor’s vaccination status, the resident's vaccination status, or the facility’s outbreak status as per the LAC DPH’s “Order of the Health Officer for Control of COVID-19: Prevention of COVID-19 Transmission in Skilled Nursing Facilities”:
     1. A negative COVID-19 PCR test result taken within 2 days prior to entry; OR
     2. A negative FDA-authorized COVID-19 antigen test result taken within 1 day prior to entry. All point of care COVID-19 viral tests, including both CLIA-waived and over the counter (OTC) self-tests, should be conducted in presence of facility staff who can verify the test result belongs to the visitor and conducted on the appropriate date/time prior to entry.
     3. Visitors who visit for multiple consecutive days are required to show proof of negative SARS-CoV-2 test at least every third day (e.g., test on day 1, day 4, day 7, and so on).
     4. Visitors who show documentation of recovery from a recent COVID-19 infection ≤90 days (i.e. a positive COVID-19 antigen or PCR test result on a sample taken within the last 90 days, but not within the last 10 days) are exempt from the above testing requirement.
   • If a visitor is not prepared with the above proof upon arrival to the facility, the visitor should not be refused entry and the facility, if possible, should be prepared to:
     1. Provide an FDA-approved COVID-19 antigen to be taken by the visitor that is confirmed negative prior to their entry; OR
     2. Offer outdoor visitation that will not require entering the facility for visitors who are unable/unwilling to provide proof or submit to same-day testing at the facility.
   • Please note that the above testing requirements do not apply to essential visitors as defined above nor do they apply to emergency medical services (EMS) personnel including ambulance transport personnel regardless of the urgency of the situation.
   • Once Los Angeles County reaches moderate level of transmission for at least 2 consecutive weeks, general visitors seeking indoor/in-room visits who are up to date with COVID-19 vaccines do not need to show proof of a negative SARS-CoV-2 test prior to entry.
   • See Table 2 General visitation
4. Visitor Requirements:
• All visitors, essential and general, must adhere to the measures laid out in CDPH AFL 22-07 including the core principles of COVID-19 infection prevention or the facility may remove them from facility premises and restrict their entry.
• For general visitation that is conducted indoors and in-room, visitors must show acceptable proof prior to entering the facility. Please see #3 (General visitors), part b for more details.
  NOTE: Essential visitors are exempt from a facility’s visitation requirements and may have access to a resident in any zone regardless of vaccination status. However, if they are regularly visiting a facility, e.g., once a week or more, then they may be required to be undergo routine screening testing as described below.
• In addition to AFL 22-07, the following apply to all visitors, essential and general, of SNFs in Los Angeles County:
  1. In a visitor log, visitors should document their name, contact information, and locations within the facility premises they are visiting in order to assist with contact tracing if needed.
  2. All visitors should be instructed to notify the facility if they develop COVID-19 signs and symptoms and/or have a positive test within 14 days of visiting the facility. Facilities should take all necessary actions including infection control precautions based on findings.
5. Facility responsibilities: Facilities should do as much as possible to support safe in-person visitation:
   •  Facilities should ensure 6 ft physical distancing at all times between resident-visitor groups while also considering individual resident needs (e.g., end-of-life situations).
   • Facilities should limit movement of visitors within the facility to encourage visitors to go directly to and from the resident’s room or designated visitation area.
   • Facilities should disinfect rooms and designated visiting areas after each resident-visitor meeting.
   • Facilities are encouraged to regularly communicate visitation guidelines and expectations with residents, family, caregivers, designated decision makers, etc.
   • Facilities should place clear signage for visitors in relevant languages throughout the facility regarding education on COVID-19 signs and symptoms, infection control precautions including hand hygiene and universal masking, specified entries/exits and routes to designated visitation areas, etc.
6. Facilities should continue to support other visitation options as described in AFL 22-07 to help keep residents and loved ones connected and minimize social isolation among residents.
7. The following infection prevention and control measures must be followed for all visitation, essential and general:

1. Are residents who have roommates allowed to receive essential visitation in-room e.g., for compassionate care and end of life visitation?
   • Answer: In general, in-room visitation is discouraged where there is a roommate. However, based on CMS guidance (CMS QSO 20-39-NH), for essential visitation situations including for compassionate care/end of life visits where there is a roommate and the health status of the resident prevents leaving the room, facilities should attempt to enable in-room visitation while adhering to core principles of infection prevention (see Visitation and Infection Prevention and Control Considerations sections).

Below are recommendations for testing and cohorting in SNFs based upon California Department of Public Health (CDPH) requirements outlined in recent CDPH AFLs:

• AFL 20-52 Coronavirus Disease 2019 (COVID-19) Mitigation Plan Implementation and Submission Requirements for Skilled Nursing Facilities (SNF) and Infection Control Guidance for Health Care Personnel (HCP) AFL
• AFL 20-53 COVID-19 Mitigation Plan Recommendations for Testing of Health Care Personnel (HCP) and Residents at Skilled Nursing Facilities (SNF) AFL
• AFL 21-28 COVID-19 Testing, Vaccination Verification and Personal Protective Equipment for HCP at SNFs AFL

NOTE: Interpretation of COVID-19 viral test results does not change after an individual has received COVID-19 vaccination.

General Requirements

1. Establish a relationship with a commercial lab to do PCR testing with a turn-around time (TAT) of 48 hours or less for COVID-19. Refer to LAC DPH's Laboratory Information to find a lab providing COVID-19 PCR testing. If the 48-hour TAT cannot be met, then the facility should document its efforts to obtain faster turnaround testing results including communication with the local and state health departments.
2. COVID-19 Antigen point of care testing may be used to complement PCR testing per LA County Antigen Testing Guidance.
3. Establish cohorting plan as part of CDPH-required COVID-19 mitigation plan.
4. Report weekly to Public Health the number of staff and residents tested each week for COVID-19, the number who are asymptomatic and test positive, and the number who are symptomatic and test positive, as per the May 26, 2020 Board of Supervisors Motion.
5. Thorough documentation to demonstrate compliance with testing regulations in accordance with CDPH AFL 20-53.

Testing of Symptomatic Residents or Staff.

1. Every staff member or resident with symptoms of COVID-19 should be tested as soon as possible, regardless of vaccination status. Be aware that older adults may have atypical symptoms of COVID-19 infection including but not limited to delirium (or confusion), change in functional status, change in oral intake, and new or worsening falls with or without fever or more typical symptoms.
2. All symptomatic residents should be presumed infectious pending test results and should be in quarantine in a private room in the Yellow Cohort, if possible, with priority given to residents with typical COVID-19 symptoms (acute respiratory symptoms). However, if a private room is unavailable, then the symptomatic resident and their roommates should remain in their current rooms with appropriate transmission-based precautions as appropriate for the Yellow Cohort.
3. During the influenza season, residents with acute respiratory symptoms should also be tested for influenza as per LAC DPH's guidance on management of influenza in context of COVID-19 in SNFs.
4. Any staff or resident testing positive for COVID-19 should then prompt response testing (see below).
5. All symptomatic staff must be immediately restricted from working (see Healthcare Personnel Monitoring and Return to Work sections below).

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.

1. Staff including regular essential visitors: Routine screening testing of asymptomatic staff includes essential visitors who visit the facility at least once a week.
   1. Outside test results are acceptable if documentation of test date and test result can be provided. However, results from antigen self-tests are not acceptable unless the test is done on site at the facility observed by facility staff who can verify the test result corresponds to the appropriate person for the appropriate date/time.
   2. Please note the absence of test results should not delay or prevent essential visitation.
2. Residents: As of 05/25/2022, all residents, regardless of vaccination status, should be tested once weekly. Antigen testing is acceptable to fulfill this requirement.
3. Retesting Previously Positive Staff/Residents
1. Staff or residents who previously tested positive and are asymptomatic are not included in the above testing requirements and should not be retested for 90 days since the date of symptom onset or date of the first positive test indicating COVID infection.
   • Exception: If a staff or resident develops new symptoms consistent with COVID-19 ≤ 90 days of the initial positive test, if an alternative etiology cannot be identified, then retesting can be considered in consultation with the medical director, infectious disease, or infection control experts.
2. Staff who previously tested positive and are asymptomatic will be back in the routine screening testing pool after 90 days of the date of previously positive test or date of symptom onset.
3. Staff and residents who previously tested positive and are asymptomatic will be back in the facility-wide response testing pool and/or in response to an exposure after 90 days of the date of previously positive test or date of symptom onset.
4. Staff or residents who previously tested positive who re-test positive 90 days or more AFTER the first infection should be managed as a new infection; the person should be isolated and would be exempt from testing for another 90 days.

Figure 1. Testing Schematic



Refusal of Testing

1. Staff: The following restrictions only apply to staff directly employed by the facility.
   1. Staff who have signs or symptoms of COVID-19 and refuse testing are prohibited from entering the facility until return to work criteria are met.
   2. If outbreak testing has been triggered and a staff member refuses testing, the staff member should be restricted from entering the facility until the outbreak has been closed.
2. Residents:
1. Residents (or resident representatives) may exercise their right to decline COVID-19 testing in accordance with the requirements under 42 CFR § 483.10(c)(6). In discussing testing with residents, staff should use person-centered approaches when explaining the importance of testing for COVID-19. Facilities must have procedures in place to address residents who refuse testing.
   • Residents who refuse testing AND who have signs/symptoms of COVID-19 or who are close contact/considered exposed must be placed in the Yellow quarantine cohort (preferably in a single room if symptomatic), until the time-based criteria for discontinuing transmission-based precautions have been met.
   • If outbreak testing has been triggered and an asymptomatic resident refuses testing, the facility should ensure the resident maintains appropriate > 6 feet distance from other residents, wears a mask, and practices effective hand hygiene until the outbreak has been closed.

1. Do DPH staff also have to get tested as part of the facility staff testing requirement?
   • Answer: No. Neither CMS nor CDPH testing requirements include DPH staff. Please see updated testing guidance on regular visitors who enter the facility more than once per week (under "Routine testing of staff and residents."
2. When can targeted testing be considered?
   • Answer: Targeted testing can be considered in selected scenarios only when a facility’s testing capacity is limited in consultation with ACDC.
3. We have staff who work only 2 consecutive days every week; do they also need to be tested twice per week (e.g., when administering POC antigen tests twice per week for routine screening testing)? Also, in general, what is the minimum time frame that should occur between tests?
   • Answer: Ideally, per CDPH, results from prior test should be available by the time the next test takes place. We realize that many laboratory’s TAT may not support this, so the recommendation is for a minimum of 48 hours between testing. All facility staff should get tested twice weekly, and this can be achieved by testing at an outside testing site as long as the facility receives appropriate documentation from the staff. If using antigen testing, testing twice weekly on the 2 consecutive days of work prior to each shift is acceptable.
4. If a recently positive resident has finished isolation, still <90 days of prior infection, and asymptomatic is then exposed by being a close contact (e.g. roommate of a positive case) or by being in the same unit/wing where a positive case in either staff or resident was identified, do they still need to be quarantined and tested?
• Answer: Yes, they should still need to be quarantined for 14 days on Yellow Cohort status with appropriate transmission-based precautions signage (N95 respirator, eye protection, gown, glove, hand hygiene) and closer monitoring of symptoms and vital signs including oxygen saturation, but does not need to be tested. If the resident at any point becomes symptomatic, they should be treated as any other symptomatic resident and be tested in the Yellow Cohort.

Facilities should have 3 separate cohorting areas as described below and shown in Figure 2.

1. Green Cohort: This cohort is reserved for residents who do not have COVID-19. To be in this cohort, residents must have either completed quarantine, cleared isolation, recovered from a prior COVID-19 infection without new COVID-19 symptoms, tested negative and remained asymptomatic after last negative testing, or they are up to date with COVID-19 vaccines as per below:
   •  Residents up to date with COVID-19 vaccines who frequently leave the facility for medical appointments (e.g. dialysis residents). Please see "Routine Screening Testing" for additional testing guidance.
   • Newly admitted or re-admitted residents who are up to date with COVID-19 vaccines.
   • Residents who leave the facility for more than 24 hours and are up to date with COVID-19 vaccines.
   • Residents, regardless of their vaccination status, who leave the facility for less than 24 hours
     • Additionally, residents not up to date with COVID-19 vaccines who leave the facility for less than 24 hours should remain in Green Cohort with additional testing recommendations as described in "Routine Screening Testing".
2. Red Cohort (Isolation Area). This area is only for residents who have laboratory-confirmed COVID-19 with or without symptoms, regardless of vaccination status. Residents may be transferred to the Green Cohort once they have completed the appropriate isolation period as follows:
• For symptomatic residents:
• At least 24 hours have passed since last fever without the use of antipyretic medications; and
• Improvement in symptoms (e.g., cough, shortness of breath); and
• At least 10 days have passed since symptoms first appeared.
  • EXCEPTION: At least 20 days have passed since symptoms first appeared for residents with severely immunocompromising conditions. Please see below for a list of severely immunocompromising conditions.
• For asymptomatic residents with laboratory-confirmed COVID-19:
  • Regardless of vaccination status, these residents need to be isolated. Additional evaluation including repeat testing should be conducted in consultation with Public Health as soon as possible.
  • Unless cleared by Public Health, asymptomatic residents should isolate for 10 days since the date of first positive COVID-19 diagnostic test without the development of symptoms of COVID-19.
    • EXCEPTION: At least 20 days have passed since date of first positive COVID-19 diagnostic test for residents with severely immunocompromising conditions. Please see below for a list of severely immunocompromising conditions.
  • If they develop symptoms during this 10-to-20-day period, the isolation period should be restarted from the onset of symptoms per the symptomatic resident criteria outlined above.
• The following are considered severely immunocompromising conditions as per CDC: actively receiving chemotherapy for cancer, hematologic malignancies, being within one year from receiving a hematopoietic stem cell or solid organ transplant, untreated HIV infection with CD4 count <200, combined primary immunodeficiency disorder, taking immunosuppressive medications (e.g., drugs to suppress rejection of transplanted organs or to treat rheumatologic conditions such as mycophenolate, rituximab, prednisone dose >20mg/day for more than 14 days), or other severely immunocompromised condition as determined by the resident’s primary/treating physician.
3. Yellow Cohort (Mixed quarantine & symptomatic cohort)
   • This cohort is for the following residents:
   • Residents who have symptoms, including atypical symptoms, of COVID-19 pending test results, even within 90 days of prior COVID-19 infection, regardless of vaccination status.
   • Newly admitted or re-admitted residents ^ that are not up to date with COVID-19 vaccines.
   • Residents who leave the facility for 24 hours or longer and that are not up to date with COVID-19 vaccination. This could be for a non-medical reason (e.g., “out on pass” with family or loved ones) or a medical reason (e.g., emergency department visit) ^
   • Close contact to a known COVID-19 case ^ regardless of vaccination status.
   • All residents on the unit or wing where a case was identified in a resident or HCP ^ regardless of vaccination status. All exposed residents can remain in their current rooms unless sufficient private rooms are available. Signage indicating appropriate transmission-based precautions should be placed outside of these residents’ rooms.
   • Residents with severely immunocompromising conditions/treatments who are newly admitted/readmitted, frequently leave the facility for medical appointments (e.g., chemotherapy), or leave the facility for 24 hours or longer for medical or non-medical reasons, regardless of vaccination status..
   • All residents with indeterminate test results.
   • Residents who frequently leave the facility for medical appointments (e.g., dialysis residents) who are not up to date with COVID-19 vaccines. These residents should be grouped together in the Yellow Cohort. ^
   • 
     ^ Exception: Asymptomatic residents who recently recovered from a prior COVID-19 infection within the last 90 days should be placed in the Green Cohort.
   • Private rooms should be prioritized for residents with typical COVID-19 symptoms (acute respiratory symptoms), close contacts, and those with indeterminate test results as they have a higher probability of infection. However, if private rooms are limited or unavailable, then symptomatic residents, especially residents with atypical symptoms, and their roommates should remain in their current rooms with appropriate transmission-based precautions as appropriate for the Yellow Cohort.
   • For multi-occupancy rooms, strategies to reduce exposures between residents should be implemented: Residents with similar risk profiles should be placed in the same room (e.g., group low risk admissions in the same room). Curtains should be placed between resident beds. Staff should change gowns and gloves with appropriate hand hygiene between each resident contact in the same room.

Table 3. Quarantine Guidance for the Yellow Cohort

 

Figure 2. Cohorting

Special Staffing Considerations in Cohort Areas

1. Staff assigned to the Red Cohort should not care for residents in other cohorts if possible. 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.
2. With prior approval from Public Health, asymptomatic staff with lab-confirmed COVID-19 infection may be allowed to work in the Red Cohort. They will need to be able to keep separated from uninfected staff. This includes having dedicated breakrooms and bathrooms until they are no longer considered infectious.

1. Can asymptomatic, non-exposed, cleared residents be transferred between buildings on the same facility premise without first going to the yellow zone as a new admission?
• Answer: Yes, only if there is no ongoing outbreak in either building and if county positivity rates are below 10%. “Premises” include, without limitation, the buildings, grounds, facilities, driveways, parking areas, and public spaces within the legal boundaries of the Facility.
2. Can a facility have more than one Yellow Cohort?
• Answer:
  • It is preferred to have one physical Yellow Cohort. However, if a facility has layout restraints, Yellow and Green Cohorts can be treated as functional cohorts. For example, a facility could cohort their partially vaccinated and unvaccinated dialysis residents in a physically different area of the facility than their main Yellow Cohort but must have all the same Yellow Cohort requirements including transmission-based precautions.
  • Additionally, multiple Yellow Cohorts may naturally be created due to entire units/wings being considered exposed as described under “Yellow Cohort”, and based on CDPH AFL 20-74, which recommends managing these exposed residents in place, and not moving them all to one Yellow Cohort.
  • Regardless of configuration of Yellow and Green Cohorts, all resident rooms must always have clear signage indicating appropriate transmission-based precautions and corresponding required PPE for entry.
3. Are floor-to-ceiling partitions a written requirement or best practice for cohorting?
• Answer: No, floor-to-ceiling partitions has not been written guidance on the federal, state, or local levels in terms of COVID-19 infection prevention & control. They do not serve an infection control role as SARS-CoV-2 is not a true airborne transmissible disease. Sometimes, facilities may consider the use of physical barriers to discourage staff movement in and out of the Red Cohort, but they do not need to be floor-to-ceiling partitions. If floor-to-ceiling partitions are considered, they should be implemented in consultation with facility engineers and OSHPD for approval as they could impact the facility’s air balance and air flow.
4. How soon can Red Cohort staff start working in the Yellow Cohort or Green Cohort?
• Answer: As long as staff is following all infection prevention and control practices including wearing appropriate PPE with correct donning and doffing, then they can start working in a different cohort/zone on a different day in a different shift. The staff should wear clean clothes for the different cohort.
5. Can staff working in the Red Cohort ever work in the Yellow and Green Cohorts?
   • Answer: Staff working in the Red Cohort should not routinely work in either the Green or Yellow Cohorts according to CDPH AFL 20-53, unless it is necessary to ensure adequate staffing levels for other residents in the facility. Staff working in the Yellow Cohort may also work in the Green Cohort as long as they strictly adhere to all other infection prevention and control guidance (e.g., PPE requirements, properly donning and doffing with each resident encounter, frequent hand hygiene) and minimize movement back and forth between Cohorts. Also, it is recommended for staff with less frequent face-to-face interaction, e.g., EVS/housekeeping, LVNs, RNs, etc., to be preferentially shared between Yellow and Green when needed over staff with more frequent face-to-face interactions, e.g., CNAs, activity aides, rehab aides, etc.

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

1. California Department of Public Health (https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/AFL-20-52.aspx) guidance requires that facilities employ a full-time, on-site infection preventionist who will monitor compliance with infection control guidance.
2. CDPH also requires SNFs to have a CDPH-approved COVID-19-specific mitigation plan and to provide infection prevention and control training and updated infection control guidance to its HCP. 

Universal Source Control

Residents

1. All residents must be provided a clean mask daily.
2. Medical-grade surgical/procedure masks are required for any resident that is COVID-19-positive or assumed to be COVID-19-positive.
3. All residents, if tolerated, should wear a mask when outside their room including those who regularly leave the facility for care (e.g., dialysis), unless they are not able to wear a mask or if they are participating in an activity where masking is not required as outlined in "Communal Dining, Group Activities, and Visitation".
4. Residents should remain in their room during an outbreak when possible and appropriate.
5. Residents who due to underlying cognitive or medical conditions cannot wear a mask should not be forcibly required to wear one (and should not be forcibly kept in their rooms). However, masks should be encouraged as much as possible.
6. Contraindications to mask wearing: a mask should not be placed on anyone who has trouble breathing, or is unconscious, incapacitated, or otherwise unable to remove it without assistance.
7. Face shields with a drape may be offered to residents who are not able to wear masks.

Staff

1. As of 05/25/2022, all staff, regardless of vaccination status, must wear an N95 respirator or higher for universal source control at all times when working in resident care areas and/or areas that residents may have access to for any purpose, including the Green Zone, until further notice.
2. Please see Cohort-Specific Transmission Based Precautions and PPE section for appropriate mask use for each cohort.

Physical Distancing

1. All staff, regardless of vaccination status, must adhere to physical distancing of at least 6 feet throughout the facility while on facility premises including in break rooms and in common areas, including when not providing resident care.
2. Residents should keep at least 6 feet apart during group activities and communal dining except during special circumstances described in “Communal Dining, Group Activities, and Visitation”.
3. All visitors, regardless of vaccination status, must practice physical distancing of at least 6 feet from persons they are not visiting (e.g. other resident’s visitors, staff, and other residents) while in resident rooms and common areas.

Hand Hygiene (HH)

1. Healthcare personnel (HCP) and all other staff members should perform HH before and after ALL resident encounters including in multi-occupancy rooms as per WHO’s 5 Moments of Hand Hygiene.
2. Facilities should have a process for auditing adherence and providing feedback on recommended HH practices by HCP.
3. All staff, residents, and visitors should perform HH frequently including every time they enter and exit the facility, resident rooms, and common areas; before and after eating; after using the restroom; etc.
4. Make sure HH supplies, such as soap and water or alcohol-based hand sanitizers (ABHS), are readily accessible and well-stocked throughout the facility including at facility entrances, near resident rooms including areas where HCP don and doff PPE, at nursing stations, on medication carts, in common areas, etc.

Respiratory Hygiene/Cough Etiquette:

1.  Support respiratory hygiene such as cough etiquette by residents, staff, and visitors.
2. Encourage all residents, staff, and visitors to perform HH after contact with respiratory secretions or contact with contaminated materials (e.g. tissues).

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

1. General
   1. Facilities must regularly audit their HCP’s adherence to appropriate PPE use.
   2. Post appropriate Transmission-Based Precautions signage outside of each resident room: http://publichealth.lacounty.gov/acd/TransmissionBasedPrecautions.htm
   3. Post signage on the appropriate steps for donning and doffing PPE in donning and doffing areas: lacounty.gov/acd/docs/CoVPPEPoster.pdf
   4. Facilities should follow CDC’s strategies to optimize the supply of PPE and equipment to have at least a 2-week supply of PPE and other infection prevention and control supplies, e.g., medical-grade surgical/procedure masks, N95 respirators, gowns, gloves, goggles/face shields, hand hygiene supplies (https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html).
   5. If there are PPE shortages, the facility should make and document efforts to acquire more supply and can consider contacting Public Health’s PPE Coordinator by email for inquiries about PPE supplies: DPHPPECoordinator@ph.lacounty.gov
2. Standard precautions for all resident care
1. Gloves should be changed between every resident encounter including in multi-occupancy rooms.
2. Hand hygiene should be performed as per CDC's 5 Moments of Hand Hygiene including before donning and after doffing gloves. Please see above section on Hand Hygiene (HH) for more details.
3. Respiratory hygiene/cough etiquette must be followed at all times including during resident care.
4. Environmental cleaning recommendations should be followed where applicable before and after patient care. This includes properly disinfecting shared equipment, e.g., blood pressure cuffs and pulse oximeters before and after vital checks.
3. Face masks and N95 respirators
   1. In all the cohorts (Green, Yellow, and Red Cohorts), all staff regardless of vaccination status must wear N95 respirators when providing resident care, working in resident care areas, or working in areas where residents may access for any purpose.
      1. If there is a need to preserve supply, N95 respirators can be worn in extended use (same N95 for duration of the shift).
   2. N95 respirators should be worn for all aerosol generating procedures (suction, ventilation, CPR, nebulizer treatments, etc.) for all cohorts including the Green Cohort regardless of the staff's vaccination status if the facility has an active outbreak.
   3. NIOSH-approved N95 respirators with an exhalation valve can be used as protection (i.e. as PPE) and source control when there is no anticipated high velocity body fluids as per CDC, in which case either a surgical N95 respirator should be used or a face shield can be worn without compromising the fit of the respirator.
   4. Initial and annual N95 respiratory fit testing is required for all staff per California Division of Occupational Safety and Health (Cal-OSHA).
   5. Cal-OSHA no longer allows for re-use (over multiple shifts) of N95 respirators or extended use (with multiple residents in the same shift) when used for respiratory protection for confirmed or suspected cases, (e.g., in Yellow and Red Cohorts). However, staff may wear N95 respirators in an extended fashion if they are not interacting with confirmed or suspect cases of COVID-19.
   6. If there is a shortage of N95 respirators, facilities should make efforts to acquire more supply including documented communication with Public Health (see contact information above). If, despite these efforts, the facility is still experiencing a shortage, facilities could consider extended and/or re-use of N95 respirators and must document their reasoning in a written risk assessment.
4. Eye protection
   1. Eye protection, which can be goggles or face shields, should be worn when staff are providing resident care, within 6 ft of residents, or while in resident rooms in all cohorts.
   2. Donning and doffing single-use eye protection for each resident encounter is recommended if there is sufficient PPE supply. However, if there is not sufficient PPE supply, extended use (worn over multiple resident encounters in a single shift) can be considered with proper storage between resident encounters that ensures no sharing between staff. If that cannot always be ensured, it’s advised to wear eye protection for the duration of the shift including in common areas, e.g., hallways.
5. Gown use
   1. Gowns should be used for each resident encounter in Yellow and Red cohorts for COVID-19 precautions. Resident care in the Green cohort is not required for COVID-19 precautions but may be needed for transmission-based precautions for another pathogen.
   2. Gowns should be changed (donned and doffed) between every patient, included those in multi-occupancy rooms) regardless of the cohort.
   3. If there is a shortage of gowns, facilities should contact LAC DPH immediately for guidance.
   4. The same gowns should never be worn for care of both COVID-19 positive and negative patients.
   5. Re-use (over multiple days) of gowns is not allowed.

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).

1.  Facilities must have a plan to ensure proper cleaning and disinfection of environmental surfaces (including high touch surfaces such as light switches, bed rails, bedside tables, etc.) and equipment in the patient room.
2. All staff with cleaning responsibilities must understand the contact time for the cleaning and disinfection products used in the facility (check containers for specific guidelines).
3. Ensure shared or non-dedicated equipment is cleaned and disinfected after use according to the manufacturer’s recommendations.
4. Routine cleaning and disinfection procedures (e.g., using cleaners and water to pre-clean surfaces prior to applying an EPA-registered, hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product’s label) are appropriate for COVID-19 in healthcare settings.
   1. For a list of EPA-registered disinfectants that have qualified for use against SARS-CoV-2 (the COVID-19 pathogen) go to: https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2
5. Set a protocol to terminally clean rooms after a patient is discharged from the facility. If a known COVID-19 resident is discharged or transferred, staff should refrain from entering the room until sufficient time has elapsed for enough air exchanges to take place (more information on air exchanges at https://www.cdc.gov/infectioncontrol/guidelines/environmental/appendix/air.html#tableb6)

1. Can gowns be worn in the common areas, e.g. hallways, nursing stations, break rooms, etc., including in the Red Zone?
   • Answer: No, that is no longer the recommendation since CDPH AFL 20-74 was released on September 22, 2020 and as stated above under “Contact Precautions”. Extended use of gowns (using the same gown with more than one resident) is no longer allowed unless the facility is experiencing a shortage of gowns, for which extended use of gowns could be acceptable only in the Red Cohort and not for residents with known MDRO’s. Thus, gowns should be donned and doffed at resident room borders with each resident care encounter even in multi-occupancy rooms. Since gowns are doffed before exiting resident rooms, there should be no gown use in common areas, e.g. hallways, nursing stations, break rooms, etc. Similarly, gowns and gloves should not be donned upon entering the Red Cohort. If extended use of gowns is practiced including for Red Cohort residents, the facility should document the gown shortage and attempts to attain more gowns.
2. Are there best practices for staff working at multiple facilities?
   • Answer: There is no written guidance on this. It would be recommended to change into new clothes/scrubs for the next facility.
3. Are there special recommendations for facilities with memory care units or dementia, behavioral, or psychiatric residents?
   • Answer: CDPH has a “COVID-19 and Memory Care Units Reference Sheet.” Additionally, the concept of micro-cohorting, i.e. sub-dividing ambulatory dementia residents into smaller groups where they’re allowed to ambulate in the hallway of a small section of a unit/wing to mitigate the spread of the virus can be a consideration. Finally, we strongly encourage the facility to engage the resident’s family, designated representative, primary physician, medical director, and/or interdisciplinary team (IDT) in encouraging compliance with infection prevention recommendations (universal masking, staying in resident rooms) in creative ways that respects residents rights while protecting others.
4. What are the recommendations for residents taking showers?
   • Facility should establish and follow a written standardized protocol for bathing & showering residents to include:
     1. In-room sponge baths are encouraged for residents in quarantine in Yellow Cohort and isolation in Red Cohort.
     2. For Yellow & Red Cohort residents who still need to shower, they should use in-room/private showers (if available). If private showers are not available, then communal shower rooms should be dedicated for cohorts of the same COVID-19 status/risk category. Red Cohort residents should never use the same communal shower area or equipment (e.g. shower benches/chairs) with non-COVID-19 residents.
     3. If a resident is able to shower independently, they should continue to do so.
     4. For Yellow & Red Cohort residents for whom showering is deemed necessary and also needs assistance, please consider the following recommendations:
        • Assisting HCP must be able to wear and maintain safe use of all recommended PPE while assisting residents with personal hygiene
        • Caution N95 respirators could slip off more easily when wet.
        • Wear water-proof PPE e.g. gowns, booties, face shields, shower cap, etc.
        • Proper donning & doffing of PPE including hand hygiene should be strictly adhered to
        • Utilize DME’s like shower chairs/benches, grab bars, etc. for residents to support themselves as much as possible so that direct contact between resident and HCP can be minimized
        • Only the minimum number of HCP needed to assist with bathing should be in the communal shower room at any moment
        • Attempt to bathe/shower resident with resident facing away from HCP as much as possible
        • Encourage resident to wear a face mask and/or face shield as much as possible, especially when resident is facing HCP
1. Showering should be spaced out to allow proper cleaning and disinfection of bathroom surfaces with EPA-approved healthcare-grade disinfectant between each use that is clearly documented, e.g. cleaning log.
   • Most facilities have 2-4 air exchanges per hour and it takes about 2-3 hours to clear out particles that are suspended in the air. Hence it would be prudent when shared showers are used (not recommend particularly during an OB), to space out use by 3 hours while cleaning and disinfecting the areas (EVS staff to use full PPE including N-95 masks).
• Please also involve HVAC service providers/consultants to evaluate for possible improvements to the exhaust system/fan to increase exhausted air from the shower room.

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:

• Symptomatic HCP
• Exposed asymptomatic HCP (quarantine)
• SARS-CoV-2 infected HCP (isolation)

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).

1. Once an outbreak has been identified, facilities should immediately implement the following measures.
   1. Immediately initiate standard, contact, droplet precautions, plus N95 respiratory use and eye protection for all suspect or confirmed residents with fever and/or respiratory symptoms.
   2. Increase environmental cleaning throughout the facility to 3 times a day (if possible) with emphasis on high touch surfaces particularly in the unit where the resident was located.
   3. If you have not already done so, ensure that you are using an approved cleaning agent: List N: Disinfectants for Use Against SARS-CoV-2.
2. Discontinue indoor group activities and communal dining for relevant residents depending on vaccination status and COVID-19 status (please see Communal Dining, Group Activities, & Visitation section). For residents where indoor communal dining is not permitted, serve meals in resident rooms. For residents where indoor communal dining and group activities are still permitted, keep the same groups together to decrease the risk of exposure. All communal dining and group activities that must still be continued should adhere to social distancing and universal source control when possible.
3. For any transfers out of the building, notify EMS and the receiving facility of possible exposures.
4. Allow visitors as per Visitation section.
5. Continue to monitor all residents for fever and respiratory symptoms (i.e. cough, sore throat, shortness of breath) until 14-days after the last COVID-19 case has recovered.
6. Lab testing of symptomatic residents should be done through a commercial lab, if possible.
7. Response testing should be done as described in testing section above.
8. Hold new admissions of residents without COVID-19 to units where ongoing transmission of COVID may be occurring. If the SNF has separate floors or buildings that do not have evidence of COVID transmission after response testing, AMD may elect to resume new admissions to the facility. Facilities should continue to re-admit returning residents. Please refer to Interfacility Transfer Rules for most up to date guidance.
9. Implement a line listing of all HCP, residents, and visitors with symptoms.
10. Notify all HCPs, regardless of vaccination status, who were exposed to the resident within 48 hours before the onset of symptoms regarding the potential for exposure and instruct them to self-monitor for fever and respiratory symptoms at least once daily for 14 days. Additionally, HCP with higher-risk workplace exposures or community exposures are managed more conservatively if they are unvaccinated OR they are vaccinated and booster eligible but have not yet received their booster dose. HCF should follow LAC DPH COVID-19 Infection Prevention Guidance for Healthcare Personnel regarding restriction from work depending on vaccination status (http://publichealth.lacounty.gov/acd/ncorona2019/healthfacilities/HCPMonitoring/ ).
11. Monitor all HCP (regardless of contact with a case) for fever, cough, and shortness of breath. Symptomatic HCP may not work, regardless of vaccination status.
12. Instruct the facility to notify District Public Health Nurse (DPHN)/Outbreak Investigator (OI) assigned to the facility immediately if any resident or staff report fever or respiratory symptoms.
13. Notify DPHN/OI immediately if any HCP contact tests positive for COVID-19.
14. Screening of all HCPs, regardless of vaccination status, for fever (>100.0° F) and respiratory symptoms at least at the beginning of each shift should continue.
15. Symptomatic HCP with compatible symptoms and no clear alternate diagnosis should isolate at home pending clinical evaluation and testing as per the LAC DPH COVID-19 Infection Prevention Guidance for Personnel.
16. Laboratory-confirmed HCPs should be excluded from work and follow LAC DPH COVID-19 Infection Prevention Guidance for Healthcare Personnel Table 3. Work Restrictions for HCP with SARS-CoV-2 Infection (Isolation) below:

Return to Work Protocol for HCP with Confirmed COVID-19

*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

1. Residents who have possible symptoms of COVID-19 should be transferred to the YELLOW (mixed quarantine) cohort immediately and tested. They should be placed in single rooms if possible, or cohorted together until testing is performed.
2. Residents who test positive should be transferred to the RED (COVID-19 positive) cohort.
3. Symptomatic residents may be moved back into the GREEN (Non-COVID-19) cohort if they meet either of the two criteria listed in "Yellow Cohort" under "Cohorting" section. Residents who test negative for COVID-19 should be tested for influenza and other respiratory pathogens as per the LAC DPH guidance on Testing & Isolation/Quarantine for Influenza in the Context of COVID-19 in SNFs.
4. Residents up to date with COVID-19 vaccines who frequently leave the facility for medical appointments (e.g. dialysis residents) can be placed in Green Cohort.
5. Residents not up to date with COVID-19 vaccines who frequently leave the facility for medical appointments (e.g., dialysis residents) should be grouped together in the Yellow Cohort.

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. 

1. In an outbreak situation, admission of new residents (new admissions) and returning residents (readmissions) should be permitted unless closure is approved by the AMD and in communication with HFID (licensing).
2. The decision to close admissions, with approval by the AMD and in communication with HFID, should be recommended based upon a number of factors. Consider closing the facility to admissions if the following are concerns:
1. Immediate jeopardy for infection prevention & control concerns by HFID
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
1. Inability to effectively quarantine new admissions and readmissions
2. Inability to effectively dedicate COVID and non-COVID areas 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 reported

For facilities that are conducting response driven testing

1. The outbreak cannot be closed until two weeks of testing are completed, demonstrating no additional transmission among residents.
2. If a single new case in a resident who has not tested positive in the past 90 days is identified after two weeks of negative testing, the facility should be opened as a new outbreak.
• Once the NEW outbreak has been opened under a NEW outbreak number, DPHN/OI can manage the facility with the following abbreviated procedures:
1. Contact the facility to reinforce infection control recommendations.
2. Determine if there are any infection control barriers or deficiencies with cohorting, staffing, PPE, etc.
3. Ensure facility is able to conduct response testing.
4. Monitor site for new cases weekly until investigation can be closed.
5. Documentation to include the epi form, line list, and clearance letter. The notification letter and HOO are optional upon the discretion of the MD assigned to the investigation.
• NOTE: A facility with a single case should accept new admissions as long as there are no infection control barriers/challenges, the facility is able to properly cohort residents, the facility has an adequate quarantine area to receive the residents, and is compliant with response testing requirements.
• If >2 cases are identified at the facility or if the facility admits to substantial infection control barriers or deficiencies, then consider managing the OB with standard OB procedures, including check-ins and onsite/virtual visits as appropriate.

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:

1. Who tested positive for COVID-19 within 90 days prior to death; OR
2. Clinically suspected of having died from COVID-19 (either directly attributable to COVID-19 or a secondary complication of COVID-19) regardless of prior testing results; OR
3. Who was a resident of a congregate living facility with an ongoing COVID-19 outbreak, regardless of testing*

* 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.