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Acute Psychiatric Hospitals

B73 COVID-19 - Procedural Guidance for DPH Staff

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Outbreak Definitions:

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

Definition of Outbreak:

  • Two or more cases of confirmed* COVID-19 among patients 4 or more days after admission for a non-COVID condition, with epi-linkage**
  • OR

  • Two or more cases of confirmed* COVID-19 among HCP AND one or more cases of confirmed* COVID-19 among patients 4 or more days after admission for a non-COVID condition, with epi-linkage**

*Laboratory-based molecular tests are also known as nucleic acid amplification tests (NAATs) an include RT-PCR tests OR Antigen tests include facility supervised point of care tests and laboratory-based tests. Please see CDC’s Overview of Testing for SARS-CoV-2 in the healthcare setting for more details on both molecular and antigen tests.

**Epi-linkage among patients or residents is defined as overlap on the same unit or ward, or other patient care location (e.g., radiology suite), or having the potential to have been cared by common HCP within a 7-day time period of each other. Determining epi-linkages requires judgment and may include weighing evidence whether or not patients had a common source of exposure. Epi-linkage among HCP is defined as having the potential to have been within 6 ft for 15 minutes or longer while working in the facility during the 7 days prior to the onset of symptoms; for example, worked on the same unit during the same shift, and no more likely sources of exposure identified outside the facility. Determining epi-linkages requires judgment and may include weighing evidence whether or not transmission took place in the facility, accounting for likely sources of exposure outside the facility.

Epidemiologic Data for Outbreaks

  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.
  3. Create a line list and contact information following the COVID-19 template above.
  4. Maintain surveillance for new cases until no new cases for at least 7 days.
  5. Create an epi-curve, by date of onset (see CDC Quick Learn Lesson: Create an Epi Curve for guidance). Only include cases (HCP and patients) that meet the case definition on the epi-curve. (Optional)



Case: A case is defined as an individual with a positive viral test (e.g., PCR/NAAT or antigen test) regardless of symptoms unless a confirmatory PCR/NAAT test is negative for an asymptomatic individual with a positive antigen test.

  • The infectious period is defined as 2 days prior to the date of symptom onset (or the positive specimen collection date, if asymptomatic) through day 10 after symptom onset or date of positive specimen collection.
  • Confirmed: cases who are either symptomatic with a positive viral test (PCR/NAAT or antigen) or asymptomatic with a positive molecular (PCR/NAAT) test.
  • Suspect: cases who are symptomatic with pending/unknown test results or asymptomatic with a positive antigen test pending confirmatory PCR/NAAT testing.

Every staff member or resident with any signs or symptoms of COVID-19 should be tested with a SARS-CoV-2 viral test (PCR/NAAT or antigen) as soon as possible, regardless of vaccination status and regardless of time since prior COVID-19 infection.


Immediately isolate and initiate standard, contact, droplet precautions, plus N95 respiratory use and eye protection for all suspect or confirmed patients with signs or symptoms of COVID-19. A patient with COVID-19 is considered to be infectious from 2 days before their symptoms started until their isolation period ends. Asymptomatic patients with a positive SARS-CoV-2 viral test are considered to be infectious from 2 days before their test was taken until their isolation period ends.

Healthcare Personnel (HCP):

Refer to Guidance on Quarantine and Isolation for Health Care Personnel (HCP) Exposed to SARS-CoV-2 and Return to Work for HCP with COVID-19 (CDPH AFL 21-08.9) for return to work protocol for infected HCP.


A close contact refers to anyone who shared the same indoor airspace with someone with COVID-19 for a cumulative total of 15 minutes or more over a 24-hour period while they were infectious.

Although the general public is not required to quarantine, psychiatric patients have risk factors such as unknown CoV-19 vaccination, unable to verbally express symptoms, non-compliance to wearing masks, unable to properly wear a mask, frequent inpatient admissions and discharges, contact with other high-risk individuals. Monitor close contacts for symptoms every shift.


Identify any close contacts or exposures to the COVID-19 positive case. Public Health may direct facilities to quarantine contacts for 10 days, regardless of vaccination status, to mitigate transmission. If the contacts do not have symptoms, quarantine can end after Day 10.

Note: Quarantine can end after Day 5 only if the contact is asymptomatic, a COVID-19 viral test collected on or after Day 5 is negative and is able to properly wear a mask through Day 10.

How to count quarantine days: Day 0 is the day of your last contact (exposure) with the infected person. Day 1 is the first full day after the last exposure.

If the contacts are discharged home prior to completion of quarantine, provide them instructions for close contacts (available at ph.lacounty.gov/covidcontacts).

Healthcare Personnel (HCP):

Identify all close contact HCP (includes clinical and ancillary staff), and determine risk status using the guide outlined in Infection Prevention and Guidance for Healthcare Personnel. Refer to Guidance on Quarantine and Isolation for Health Care Personnel (HCP) Exposed to SARS-CoV-2 and Return to Work for HCP with COVID-19 (CDPH AFL 21-08.9) for management of exposed HCP.


Healthcare providers are to contact any visitors that may have been exposed to a suspected or confirmed case and provide them instructions (available at ph.lacounty.gov/covidcontacts).

Public Health may restrict visitation during an outbreak.



For current COVID-19 testing guidance please visit CDC Overview of Testing for SARS-CoV-2 and CDPH COVID-19 Testing Guidance.


Close Contact Testing

Test patients who are close contacts and staff with higher-risk exposures identified in contact tracing after exposure. This approach should only be utilized when exposure is known to be limited and contact tracing can be done immediately.

  1. If additional cases are identified among one or more patient, then the facility should immediately broaden their testing strategy to response testing serially every 3-7 days until there are no new cases identified among patients or staff for 7 days. This decision is made in consultation with public health officials.
  2. Either antigen tests or PCR/NAAT tests (if turn-around time (TAT) is <48 hours) may be utilized. Any asymptomatic patients with positive antigen test results must immediately be isolated in place on COVID-19 precautions pending results of confirmatory PCR/NAAT tests.

Tracking of COVID-19 test results for patients and staff needs to be available to California Department of Public Health (CDPH) and Los Angeles County Department of Public Health (LAC DPH) upon request.

 Refusal of Testing

  1. Staff: The following restrictions only apply to staff directly employed by the facility:
    • 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.
    • 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. Patients:
    • Patient (or patient representatives) may exercise their right to decline COVID-19 testing. In discussing testing with patients, staff should use person-centered approaches when explaining the importance of testing for COVID-19. Facilities must have procedures in place to address patients who refuse testing.
    • Patients who refuse testing AND who have signs/symptoms of COVID-19 must be placed on COVID-19 transmission based precautions (preferably in a single room if symptomatic), until the time-based criteria for discontinuing isolation (symptomatic) have been met.
    • If outbreak testing has been triggered and an asymptomatic patient was identified as a close contact and refuses testing, ensure that the patient maintains > 6 feet distance from other patients, wears a mask, and practices effective hand hygiene until the outbreak has been closed.

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 frequently touched surfaces such as light switches, bed rails, bedside tables, devices and equipment in resident rooms (e.g., walkers), etc.
  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 patient 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)


Visitation may be restricted during an outbreak as directed by public health officials.

Communal Activities and Dining

Communal dining and group activities should be permitted for all patients except those who are in isolation, Red Cohort. Asymptomatic patients who are close contacts may participate in group activities while wearing well-fitting face masks through day 10 since their last exposure. Asymptomatic patients who are close contacts should not participate in communal dining through day 10 since their last exposure. Day 0 is the day of the last contact (exposure) with the infected person..

Interfacility Transfer

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).

Reporting Requirements

Refer to Provider and Laboratory Reporting Guidelines for COVID-19 at http://publichealth.lacounty.gov/acd/ncorona2019/reporting.htm.

Admission and Readmissions

  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.
  2. The decision to close admissions, in collaboration with HFID, should be recommended based upon a number of factors.  Consider closing the facility to admissions for the following concerns:
    • Immediate jeopardy for infection prevention and control concerns by licensing
    • Concerning rates of adverse outcomes including hospitalizations and deaths
    • Evidence of concerning viral transmission based on response testing of residents
    • Inability to cohort residents per protocol, inability to effectively dedicate COVID-19 and non-COVID-19 areas in the facility
    • Lack of effective infection control practices as evidence by a virtual or on-site infection control visit
    • Inadequate supply of PPE
    • Staffing shortages reported

Closure Criteria

The outbreak can be closed once closure criteria is met:

1. Two consecutive weeks of response testing in a staff and patients have been negative;


2. Upon the discretion of the AMD or MD designee.

Prior to closure, all of the following documents must be completed:

  • PHN uploads all documents into IRIS and completes all required documents in IRIS per protocol
  • PHNS reviews and forwards to AMD
  • PHN or PHNS can close COVID-19 outbreak in IRIS after approval by AMD or AMD delegated physician.  Closure letter will be signed by AMD or AMD delegate and placed in IRIS under the filing cabinet.

Ventilation, Filtration, and Air Quality

Effective ventilation is one of the most important ways to control small aerosol transmission. Facilities should consult with professionals (facilities engineers, mechanical engineers, indoor air quality or industrial hygiene consultants, etc.) to perform comprehensive evaluations of their HVAC (Heating, Ventilation, and Air Conditioning) systems and indoor air quality and obtain permits or approvals from any applicable regulatory bodies as necessary prior to implementing changes. Facilities should not rely on any single solution to effectively improve the ventilation and air quality of their buildings. Importantly, ventilation and other indoor air quality improvements are additions to and not replacements for infection prevention and control including any applicable state or local directives. Please carefully review in full the following guidance from CDPH, Department of Health Care Access and Information (HCAI) formerly OSHPD, and Cal/OSHA: Interim Guidance for Ventilation, Filtration, and Air Quality in Indoor Environments.

Infection Prevention and Control Guidance

Information on infection control basics and the difference between standard and transmission-based precautions can be found at https://www.cdc.gov/infectioncontrol/basics/index.html.

Due to security and behavioral concerns in behavioral health settings, some infection control guidance may need to be tailored for the safety of the patients.

  • Patients 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, facemasks (preferably with short ear-loops rather than longer ties) should be encouraged as much as possible. Ensure that HCP interacting with patients who cannot wear a facemask are wearing eye protection and a facemask (or a respirator if the patient is suspected or confirmed to have COVID-19).
  • Encourage frequent hand washing with soap and water for patients and HCP. Consider providing personal pocket-sized alcohol-based hand sanitizer (ABHS) dispensers for HCP.
  • Limit the number of patients/residents allowed to access smoking spaces at the same time.

Universal Source Control

View CDC recommendations for universal source control.

Recommend COVID-19 PCR testing upon admission for unvaccinated patients, patients whose vaccination status is unknown, patients who are symptomatic, and patients with known exposure as these results can inform the type of infection control precautions used (e.g., room assignment/cohorting, or personal protective equipment used). Recommend antigen or COVID-19 PCR testing upon admission for fully vaccinated patients who are asymptomatic and without known exposure. Continue to monitor all patients for the development of COVID-19 symptoms, and promptly test any newly symptomatic patients and patients who are exposed to a suspected or confirmed case during their hospital stay, regardless of their vaccination status.

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

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