Skilled Nursing Facilities

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

Definition of Outbreak:

1. At least one molecular* laboratory confirmed case of COVID-19 (symptomatic or asymptomatic) OR at least one symptomatic case with a positive SARS-CoV-2 antigen** result in a resident who has resided in the skilled nursing facility (SNF) for at least 7 days. 

*Laboratory-based molecular tests are also known as nucleic acid amplification tests (NAATs) and include RT-PCR tests.

**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.

1. When opening a COVID-19 outbreak based on a positive antigen test, only the following symptoms are considered: new onset or worsening cough or shortness of breath, new loss of taste or smell, fever, chills, sore throat, congestion, or runny nose.
   • If a symptomatic resident has discordant viral test results within 48 hours of each other (e.g., positive antigen test and negative molecular test), please immediately contact LTC_NCoV19@ph.lacounty.gov for guidance. In these situations, an outbreak opening may not be warranted yet, but the resident must stay in isolation pending further evaluation and the facility should immediately conduct post-exposure and response testing. Please note that in general, positive antigen test results in symptomatic individuals do not need confirmatory molecular (PCR/NAAT) testing as false positives is very rare.
2. If newly admitted or re-admitted residents (at the facility < 7 days) test positive via a molecular or antigen SARS-CoV-2 this is not considered an outbreak at this time as residents could have been exposed outside the SNF, but post-exposure and response testing should still be initiated.
3. Facilities should test all individuals with symptoms of possible COVID-19 immediately.

1. Following the COVID-19 line list template, Create and maintain a line list including information on all cases and contacts among staff and residents even if a case may not be considered part of the outbreak (see parts e. and f. below for more details). Contacts should include all residents who are close contacts and all staff who have higher-risk exposures to confirmed cases.
2. Confirm etiology of outbreak using testing data and thorough contact tracing.
3. Maintain surveillance for new cases until no new cases for at least 2 weeks.
4. 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.
5. Resident cases should be associated with an outbreak if the resident’s symptom onset or positive specimen collection date (if asymptomatic) was after their 7th day of residency at the facility*. Additionally, the following resident cases are not considered outbreak-associated:
   • They were admitted as a known case.
   • Their specimen collection date was within 90 days of a prior COVID-19 infection.
   • Their symptom onset or specimen collection date was 3 or more days after being discharged from the facility.
   • Their only positive test is an unsupervised antigen test, i.e., self-performed test. *Symptom onset or positive specimen collection date is considered day 0.  
6. Staff cases should be associated with an outbreak if the staff worked any time starting 4 days prior to symptom onset or positive specimen collection date (if asymptomatic) and through day 10 after their symptom onset or positive specimen collection date*. Additionally, the following staff cases are not considered outbreak-associated:
   • Their positive specimen collection date was within 90 days of a prior COVID-19 infection.
   • Their positive specimen collection date or symptom onset date occurred prior to the first resident case or after the outbreak was considered closed per the outbreak closure criteria below.
   • Their only positive test is an unsupervised antigen test, i.e., self-performed test. *Symptom onset or positive specimen collection date is considered day 0.

Staying up to date with COVID-19 vaccines including recommended boosters 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.

One updated (bivalent) booster is recommended for everyone ages 6 months and older when eligible. This bivalent booster should be given at least 2 months after the last COVID-19 vaccine dose [after either the final primary series dose or the last original (monovalent) booster dose]. This updated booster is recommended regardless of how many original (monovalent) booster doses or which type of vaccine(s) were received in the past. This bivalent booster has been updated to target both the original strain as well as the Omicron BA.4 and BA.5 subvariants of the COVID-19 virus. Keeping everyone up to date by getting recommended boosters when eligible is the single most effective evidence-based measure to protect SNF residents and staff from severe outcomes like hospitalizations and deaths related to COVID-19.

Visit the LAC DPH COVID-19 Vaccine Schedule website for more information including color-coded vaccine schedules in English and Spanish. Additional vaccine resources from are located on the DPH vaccine resources page.

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

1. All facilities should increase and maintain vaccination coverage, including recommended booster doses, for both staff and residents.
   1. Regardless of staff vaccination requirements from state or county Health Officer Orders, facilities must offer recommended additional/booster doses as soon as recommendations are released by the CDC and doses are made available to the facility, especially for residents.
   2. Facilities should utilize Best Practices for Improving Vaccination in SNFs including but not limited to re-offering the vaccine/booster doses, providing education, hosting listening sessions including to persons who have previously declined, etc.
   3. 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.
2. 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 - please see sample vaccination tracker templates for residents and staff) for all current residents in a single file and all current staff in a single file:
      1) vaccination status;
      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 Los Angeles County Department of Public Health (LAC DPH), California Department of Public Health (CDPH), and/or National Healthcare Safety Network (NHSN).

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. All recommended COVID-19 doses, primary series and booster(s), should be offered and administered to residents and staff per the CDC COVID-19 vaccination schedule as soon as official clinical recommendations are released and doses made available to facilities.
   3. If the LTC pharmacy is not able to provide vaccines 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 single booster dose. Workers not yet eligible for boosters must be in compliance no later than 15 days after the recommended timeframe in the orders. 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.
2. Staff that have satisfied the healthcare worker booster requirement with a monovalent booster (i.e., their booster was prior to Sept 2022) should be strongly encouraged to receive their updated (bivalent) booster to stay up to date with COVID-19 vaccines. Staff who are not vaccinated and/or boosted against COVID-19 due to qualified medical reasons or religious exemptions have additional PPE recommendations. Please see Infection Prevention and Control Guidance 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”.

Outpatient COVID-19 Treatment: Oral Antivirals

Oral COVID-19 antivirals, e.g., ritonavir-boosted nirmatrelvir (Paxlovid) and molnupiravir (Lagevrio), are highly effective in preventing severe outcomes, including hospitalizations and death, among high-risk individuals infected with COVID-19 including nursing home residents. Because they need to be started within five (5) days of symptom onset, it is crucial to initiate the process of assessing residents with confirmed COVID-19 as soon as they test positive. Per LAC DPH’s Order of the Health Officer on Prevention of COVID-19 Transmission in SNFs and CDPH AFL 20-22 (COVID-19 Treatment Resources for SNFs), all residents with a positive SARS-CoV-2 viral test must be immediately assessed by their healthcare provider for any symptoms of COVID-19. Outpatient COVID-19 treatment, specifically ritonavir-boosted nirmatrelvir or molnupiravir, should be initiated at the facility within 5 days of symptom onset if clinically appropriate, i.e., they have mild or moderate symptoms and there are no contraindications or drug-drug interactions. Facilities should not transfer residents to hospitals solely for treatment of mild or moderate COVID-19. Residents should be treated at their SNF.

To ensure facilities are meeting the requirements set forth in LAC DPH’s SNF Health Officer Order and CDPH AFL 20-22, facilities should:

1. Carefully review and implement LAC DPH’s SNF Protocol for Oral COVID-19 Antivirals Assessment and Prescription (checklist) within 24 hours of any resident testing positive for SARS-CoV-2 by laboratory-based PCR or point of care antigen in a symptomatic individual AND any new COVID-19 admission/re-admission.
   • During a COVID-19 outbreak at the facility, all residents testing positive for SARS-CoV-2 should be assessed daily following this protocol, including asymptomatic residents who are not initially eligible.
2. In advance of COVID-19 diagnoses and/or COVID-19 outbreaks, facilities should evaluate all residents for any oral COVID-19 treatment drug-drug interaction risk, renal and hepatic impairment and indicate such information in resident charts to facilitate timely access to treatment when a COVID-19 diagnosis is made.
3. Provide information on outpatient COVID-19 treatments to residents, medical decision makers, families, and caregivers before they are needed. Consider posting flyers around the facility, sending out flyers, and handing out flyers, which can be accessed on LAC DPH’s webpages: Medicine to Treat and Prevent COVID-19, COVID-19 Medications Flyers.
4. Prescribing providers* should contact medical decision-makers ahead of time and discuss outpatient COVID-19 treatment (specifically the oral antivirals Paxlovid and molnupiravir). Providers should obtain written advanced consent for treatment whenever possible to expedite the process and ensure this high-risk patient population can start treatment in time.
   
   * Includes physicians, advanced practice registered nurses (e.g., nurse practitioners), and physician assistants.

Residents with confirmed COVID-19 may also be assessed for and offered other outpatient treatments for COVID-19 other than an oral antiviral, for example remdesivir or bebtelovimab. For more information please see LAC DPH’s COVID-19 Outpatient Therapeutics page and NIH’s Therapeutic Management of Nonhospitalized Adults with COVID-19.

Pre-exposure Prophylaxis

Residents should also be evaluated by their healthcare providers for eligibility for pre-exposure prophylaxis. Residents are eligible if they have moderate to severe immune compromise and/or have not received any available COVID-19 vaccine due to a true medical contraindication (e.g., severe allergic reaction) AND they are neither currently infected nor recently exposed (e.g., Green Cohort). Currently, tixagevimab/cilgavimab (Evusheld) has emergency use authorization (EUA) for pre-exposure prophylaxis and can be administered via intramuscular injection. Please bookmark and refer to LAC DPH’s COVID-19 Outpatient Therapeutics page for the most up to date information.

Below are general and COVID-19 specific recommendations. For more information on infection control basics and the difference between standard and transmission-based precautions, visit https://www.cdc.gov/infectioncontrol/basics/index.html.

General Requirements

1. CDPH guidance (https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/AFL-20-52.aspx) requires that facilities employ a full-time, on-site infection preventionist (IP) who will implement an infection prevention and control program. Facilities deemed by Los Angeles County Public Health to have insufficient IPs to meet these requirements will be directed to attain additional IPs as per LAC DPH’s “Order of the Health Officer for Control of COVID-19: Prevention of COVID-19 Transmission in Skilled Nursing Facilities.”
2. All staff in the facility should undergo basic infection prevention and control training at hire and annually. Recommended trainings are listed here: http://publichealth.lacounty.gov/acd/ICPTrainingforSNFs.htm.
3. 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.

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 suspected or confirmed to have COVID-19. Masks are also required for 10 days for close contacts, new admissions, re-admissions, and those who left the facility >24 hrs.
   1. 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.
   2. 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.
   3. Face shields with a drape may be offered to residents who are not able to wear masks.
3. All other residents are strongly recommended to wear masks when not in their rooms.

Staff

1. All staff, regardless of vaccination status, must wear a medical-grade surgical/procedure mask or N95 respirator for universal source control at all times while they are in the facility.
2. In low and medium periods of COVID transmission when N95 respirators are optional, staff who are not up to date with COVID-19 vaccines are strongly encouraged to wear N95 respirators whenever indoors regardless of the COVID-19 status of residents for which they are caring.
3. Please see Cohort-Specific Transmission Based Precautions and PPE section for appropriate mask use for each cohort.

Visitors

1. 1. All visitors, regardless of vaccination status, must wear a well-fitting face mask with good filtration for the duration of their visit while indoors, unless actively eating or drinking.

Hand Hygiene (HH)

1. Healthcare personnel (HCP) and all other staff members should perform HH before and after all resident encounters, regardless of a resident’s COVID-19 status. They should follow the instructions in the LAC DPH’s Hand Hygiene Poster, which goes beyond WHO’s 5 Moments of Hand Hygiene for the nursing home setting.
2. HH should preferentially be done with alcohol-based hand rub (ABHR) with at least 60% alcohol in most cases. HH can also be done with soap and water especially when hands are visibly soiled.
3. Facilities should have a process for regularly auditing (also called adherence monitoring) HH adherence using “secret shoppers” and providing on the spot feedback for all staff types in all shifts. Facilities can use CDPH’s HH adherence monitoring tool.
4. 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. Please see LAC DPH’s Hand Hygiene Poster.
5. 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 residents in isolation including standard precautions as summarized in figure 1 and detailed below.

Figure 1. PPE for COVID-19

1. General
   1. Standard precautions must always be followed regardless of the resident’s COVID-19 status for general prevention of all infectious diseases.
   2. Transmission based precautions are based on the COVID-19 status of the resident. Facilities should post and follow the signage for residents in isolation (Red Cohort or in-place).
   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 must regularly audit their HCP’s adherence to appropriate PPE use.
   5. 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).
   6. 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. N95 respirators
1. All staff must wear fit tested NIOSH-approved N95 respirators in any indoor space where there are residents who are in isolation (Red Cohort or isolating in place).
2. N95 respirators must be worn for all aerosol generating procedures (suction, sputum induction, ventilation, CPR, nebulizer treatments, etc.) regardless of the resident’s COVID-19 status.
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. If high velocity body fluids are possible, then the CDC recommends wearing a surgical N95 or, if a surgical N95 is not available, cover their respirator with an additional surgical/procedure face mask or a face shield. The additional face mask or face shield should be worn in a way that does not compromise 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) or extended use (with multiple residents in the same shift) of N95 respirators when used for respiratory protection for residents in isolation for suspected and confirmed cases. 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 use of N95 respirators and must document their reasoning in a written risk assessment.
3. Eye protection
   1. Eye protection, which can be goggles or face shields, may be considered at the facility’s discretion for staff providing care to residents not in isolation or quarantine when the CDC Community Level for LA County is high or when the facility is in an active outbreak. Public Health may direct facilities in active outbreaks to require eye protection for all areas of the facility on a case-by-case basis to mitigate transmission.
   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.
4. Gown use
   1. As a part of transmission based precautions for COVID-19, gowns should be worn prior to providing direct care or entering rooms/care areas where residents are in isolation (Red Cohort or isolating in place). Care areas include but are not limited to resident rooms, shower rooms, rehab gyms, etc.
   2. Gowns should be doffed prior to exiting resident care areas and re-entering common areas, e.g., hallways. Gowns should also be changed (i.e., doff used gown and don new gown) for every resident encounter in multi-occupancy rooms.
   3. Re-use (over multiple days) and extended use (over multiple residents) of gowns are not allowed.
   4. The same gowns should never be worn for care of both COVID-19 positive and negative patients.
   5. If there is a shortage of gowns, facilities should contact Public Health (LTC_NCoV19@ph.lacounty.gov) immediately for guidance.

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.

Please note SNFs have a second opportunity to apply for Civil Money Penalty (CMP) Reinvestment funds to purchase portable fans and portable room air cleaners with high-efficiency particulate air (HEPA, H-13 or -14) filters to increase air exchange or improve air quality. Facilities should only use portable air cleaners with the involvement of professionals and following the Interim Guidance for Ventilation, Filtration, and Air Quality in Indoor Environments. Placement of portable air cleaners must be carefully considered to avoid blowing air from one person to another especially in multi-occupancy rooms and communal areas and should not be placed in corners of rooms or beneath tables where they will not effectively clean the air. Do not create tripping hazards with these devices or associated electrical cords that increase fall risk for SNF residents. Finally, please note LAC DPH does not necessarily endorse the usage of portable air cleaners as the most effective or only strategy to improve ventilation and indoor air quality in SNFs, but recommend SNFs to consult with professionals on a comprehensive evaluation and plan.

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 resident 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. Conduct entry screening.
   1. All persons, regardless of vaccination status, should be screened for a recent diagnosis of COVID-19, symptoms of COVID-19 infection, AND close contact exposure (visitors) or higher-risk exposure (staff). This includes facility staff and visitors.
      1. All staff should follow Healthcare Personnel Monitoring and Return to Work on guidance for self-monitoring, entry screening, and return to work guidance for staff who are symptomatic, exposed and asymptomatic, or infected.
      2. Any visitor with a recent diagnosis of COVID-19 (a positive viral test for SARS-CoV-2) are prohibited from entry until they have met the same criteria for discontinuing isolation as for residents*.
      3. Any visitor with symptoms of possible COVID-19 infection is prohibited from entry. They should reschedule their visit after they have met the same criteria for discontinuing isolation-in-place as for residents*. Symptoms include but are not limited to the following: fever, chills, new onset cough or 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.
      4. Any visitor who reports a close contact exposure must be prohibited from entering for 14 days from their last exposure with the infected person.
      5. v. Options to conduct entry screening include, but are not limited to, in-person screening on arrival at the facility or via an electronic monitoring system in which individuals self-report any of the above before entering the facility. Temperature-taking is recommended but not required. The facility must ensure there is a process in place that educates visitors the screening process and make them aware of next steps should they screen positive (i.e., reschedule their visit).
         
         * Please see table 3 (Summary of Testing and Infection Control Guidance for Residents) and Quarantine and Isolation guidance section isolation durations for residents.
   2. Prior to entry, visitors of residents in isolation (Red Cohort or in-place) should be advised of their possible exposure risk. When there is an active outbreak at the facility, all visitors should be advised of their possible exposure risk.
   3. 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 screening for all residents.
   1. 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 residents who are suspect cases, for example every shift, and especially for residents with confirmed COVID-19 (Red Cohort), for example every 4 hours.
   2. 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.

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

The purpose of these guidelines is to help each facility develop resident-centered visitation, communal dining, and group activity policies 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.

Resident Rights

Facilities may not restrict visitation or suspend communal dining and group activities 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. Residents have the right to make choices about aspects of his or her life in the facility that are significant to the resident as long as it does not impose on the rights of other residents. Furthermore, residents or their designated representative when the resident does not have capacity, should be involved, and have their preferences prioritized. To mitigate risks to other, visitation, communal dining, and group activities should be conducted adhering to the “Core Principles of COVID-19 Infection Prevention” by following the guidance in this section and the rest of this guidance including but not limited to the “Infection Prevention and Control Guidance” section. Failure to facilitate resident 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.

Communal Dining and Group Activities

Communal dining and group activities should be permitted for all residents except those who are in isolation, whether suspect isolating in-place or confirmed isolation in the Red Cohort. Residents who are close contacts may participate in group activities while wearing well-fitting face masks but should not participate in communal dining through day 10 since their last exposure (day 0 being day of exposure). These activities may take place indoors or outdoors regardless of the facility’s outbreak status and regardless of the resident’s vaccination status. Facilities must continue to follow all infection prevention and control measures to conduct communal dining and group activities safely.

The facility should adhere to the following measures for all communal dining and activities:

1. Source control (well-fitting face masks) for residents permitted to participate in communal dining and group activities depend on the facility’s outbreak status and the CDC Community Level for LA County:
   
   

   Table 1. Resident Masking Requirements During Communal Dining and Group Activities

   	Active outbreak or within 14 days of outbreak closure	No outbreak for 14 days or more
   CDC Community Level: Low	Well-fitting face masks are required* when not actively eating or drinking, regardless of vaccination status	Well-fitting face masks are optional^ but recommended when not actively eating or drinking, regardless of vaccination status
   CDC Community Level: Medium to High	Well-fitting face masks are required* when not actively eating or drinking, regardless of vaccination status	Well-fitting face masks are required* when not actively eating or drinking, regardless of vaccination status

   *When safe and practical. Please see contraindications under source control for residents.
   ^Exception: Residents who are new admissions, re-admissions, or have returned after leaving the facility more than 24 hrs must wear face masks for 10 days. Residents who are close contacts must wear face masks for 10 days when participating in group activities.

2. Communal dining and group activities should be done in shifts with the same group of residents 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. All communal, high-touch surfaces should be cleaned and disinfected after residents or staff vacate an area. Please see “Infection Prevention and Control Guidance” section for more details.
4. Outdoor settings should be prioritized for communal dining and activities whenever practical, and especially during an outbreak.
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 are strongly preferred, where practical, for residents in non-COVID areas. Otherwise, indoor communal dining and group activities may also occur.
2. Residents should wear well-fitting face masks when not actively drinking or eating.
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 COVID-19 status and vaccination status, both indoors and outdoors, to assist with outbreak investigation and/or management. The facility should have documentation of communication with their Public Health contact directing them to do so including an anticipated date to resume communal dining and activities.

Visitation

Visitation should be supported by the facility in a manner that is consistent with resident rights in the federal regulation Title 42 CFR section 483.10(f)(4)(v).

1. Healthcare personnel (HCP) are facility staff directly employed by the facility and are exceptions to visitation restrictions.
2. Facilities must support visitation for all residents regardless of 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 visitation, both indoors and outdoors, to assist with outbreak investigation and/or management. The facility should have documentation of communication with their Public Health contact directing them to do so including an anticipated date to resume visitation. However, even when there is a temporary suspension of visitation, there must be a consideration of resident rights which means some visitation may still occur. This includes but is not limited to compassionate care visitation for residents in critical condition or end-of-life situations; essential support person visitation for residents who are experiencing weight loss, dehydration, failure to thrive, psychological distress, or functional decline or struggling with a change in environment; and essential support person visitation for residents with physical, intellectual, or developmental disability or cognitive impairment.
3. Visitor Requirements:
• Visitors must follow the same criteria used to discontinue isolation for SNF residents. Criteria for the general public does not apply in this setting given the high-risk nature of these facilities and their residents. Please see table 3 (Summary of Testing and Infection Control Guidance for Residents) and “Quarantine and Isolation” guidance section for isolation durations for residents.
• All visitors 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.
• In addition to AFL 22-07, the following apply to all visitors of SNFs in Los Angeles County:
  1. Visitors should document, e.g., in a visitor log, 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 7 days of visiting the facility. Facilities should promptly conduct contact tracing and perform post-exposure testing where indicated by the contact tracing.
4. Facilities should do as much as possible to support safe in-person visitation:
   • 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 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 symptoms, infection control precautions including hand hygiene and universal masking, specified entries/exits and routes to designated visitation areas, etc.
5. 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.
6. The following infection prevention and control measures must be followed for all visitation:

Below are recommendations for testing 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 22-13 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 molecular (PCR/NAAT) testing with a turn-around time (TAT) of 48 hours or less for COVID-19. Refer to the state's COVID-19 Testing Taskforce Laboratory List to find a lab providing COVID-19 PCR/NAAT 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. If COVID-19 antigen testing is used, facilities should confirm with PCR/NAAT testing when an asymptomatic individual tests positive via antigen or a symptomatic individual tests negative via antigen.
3. Outside test results are acceptable for staff and visitors if documentation of test date and test result can be provided. Results from self-tests are acceptable if 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.
4. Establish testing plan as part of CDPH-required COVID-19 mitigation plan.
5. Thorough documentation to demonstrate compliance with testing regulations in accordance with CDPH AFL 22-13.

Testing of Symptomatic Residents or Staff.

1. Every staff member or resident with 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*. 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.
   1. * NOTE: If a staff or resident develops new symptoms of COVID-19 ≤ 90 days of the prior positive test and an alternative etiology cannot be identified, then retesting can be considered in consultation with the medical director, infectious disease, or infection control experts. In this situation, a point-of-care antigen testing is preferred.
   2. If point of care (POC) antigen testing is used initially and is negative, then testing should be repeated in 48 hours with a molecular (PCR/NAAT) test for a total of at least two tests.
2. All symptomatic residents should be presumed infectious pending test results and should isolate in place in their current rooms on transmission-based precautions for COVID-19.
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. All symptomatic staff must be immediately restricted from working (see LAC DPH’s COVID-19 Infection Prevention Guidance for Healthcare Personnel).
5. Any staff or resident testing positive for COVID-19 should prompt post-exposure and response testing (see below). Staff testing positive must isolate at home and be excluded from work. Symptomatic residents testing positive must isolate in the Red Cohort.

Post-exposure and Response Testing. If a single positive COVID-19 case is identified among either staff or residents, the SNF must immediately conduct contact tracing to identify all residents who may have had close contact with the case(s) and all staff who may have had higher-risk exposures with case(s). Post-exposure and response testing should occur depending on the level of the exposure or ability to contact trace as described in figure 2 and detailed below.

Figure 2. Post-exposure and Response Testing

1. Close contact testing: This testing approach involves testing only the residents who are close contacts and staff with higher-risk exposures identified in contact tracing on days 1, 3, and 5 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 resident, then the facility should immediately broaden their testing strategy to group-level or facility-level response testing serially every 3-7 days. For example, if one additional resident case is identified in the same unit, floor, nursing station, or other specific area, then group-level response testing should be immediately initiated. However, if multiple resident cases are identified regardless of location or at least one resident case is identified in a different unit, floor, nursing station, or other specific area of the facility, then facility-wide response testing of all residents and staff should immediately begin.
   2. If post-exposure and response testing is expanded to either group-level or facility-wide testing, then testing should continue at least every 3-7 days until there are no new cases identified among residents or staff for 14 days.
   3. Either antigen tests or PCR/NAAT tests (if TAT is <48 hrs) may be utilized. Any asymptomatic residents with positive antigen test results must immediately be isolated in place on COVID-19 precautions pending results of confirmatory PCR/NAAT tests.
2. Group-level and facility-wide testing: When the initial case has potential for only moderate exposure (see figure 2 for example), then group-level testing should be initiated (e.g., testing all residents in the same unit, floor, nursing station, or other specific area of the facility). Facility-wide testing should be performed when there is widespread exposure or when the exposure is unknown (see figure 2 for example). Facility-wide testing should also be implemented when it is difficult to perform contact tracing in a complete and timely way.
   1. Initial group-level and facility-wide testing should occur on days 1, 3, and 5 after potential exposure (day 0). If the initial round of testing on days 1, 3, and 5 yields additional cases among residents, then response testing must be further broadened to facility-wide if not done so already, and all residents and staff who test negative should be included in response testing every 3-7 days until there are at least 14 days with no additional infections identified. After 14 consecutive days of negative testing for residents, the facility could stop response testing and resume routine testing for residents (if applicable) as outlined below, in consultation with their outbreak investigation team at Public Health.
   2. Either antigen tests or PCR/NAAT tests (if TAT is <48 hours) may be utilized. Antigen testing, if used for subsequent rounds of serial testing, should occur at least twice per week or every 3 days at the minimum. Any asymptomatic residents with positive antigen test results must immediately be isolated in place on COVID-19 precautions pending results of confirmatory PCR/NAAT tests.

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. Routine screening testing is resumed when no new cases are identified from two sequential weeks of response testing.

1. Staff including regular visitors: Routine screening testing (i.e., testing individuals who are asymptomatic, do not have higher-risk exposures, and when there is no outbreak) is currently not required regardless of their vaccination status as per CMS QSO 20-38-NH-Revised. Facilities should maintain testing capacity and have the ability to ramp up testing in the event routine screening testing is required again at a future date.
   1. When the CDC Community Level for LA County is Medium to High, facilities are encouraged to consider conducting routine screening testing of all staff, regardless of vaccination status, once or twice per week. Routine screening testing could be prioritized for staff who provide care or work in areas where there are residents with moderate-severely immunocompromising conditions, residents who are dependent on mechanical ventilation (e.g., subacute units), or residents who are otherwise at higher risk for severe COVID-19 outcomes.
2. Residents: Routine screening testing of residents is generally not required or recommended regardless of vaccination status. Please see below for an exception.
   1. Once weekly screening testing of residents who frequently leave the facility is recommended, regardless of vaccination status, when the CDC Community Level for LA County is Medium to High. These residents should not be quarantined nor should refusal of testing influence decisions on their rooming or placement.
3. Antigen tests: If COVID-19 point of care antigen tests are used for routine screening testing, then they should be administered at least twice per week and confirmatory PCR/NAAT testing should immediately be performed for any positive antigen test results in asymptomatic individuals. While the confirmatory PCR/NAAT test results are pending, residents should be isolated in place on COVID-19 transmission-based precautions and staff should be restricted from work. Only when a PCR/NAAT test confirms a positive result should an asymptomatic resident be moved to the Red Cohort to finish their isolation as per the “Quarantine and Isolation” section.

New Admission and Re-admission Testing. Residents who are asymptomatic and newly admitted or re-admitted to a facility should undergo serial testing on days 0, 3, and 5 after admission (day 0). New admissions and re-admissions do not need to quarantine. New admissions and re-admissions who are asymptomatic, not close contacts, and within 90 days of a prior COVID-19 infection do not need to undergo testing. If a new admission or re-admission tests positive by a PCR/NAAT test, then they should be immediately isolated following guidance in the “Isolation and Quarantine” section. If a new admission or re-admission who is asymptomatic tests positive by antigen testing, then they should be isolated in place pending confirmatory PCR/NAAT test results. The results of the PCR/NAAT test will determine whether the resident should be isolated in the Red Cohort or if isolation can be discontinued.

Residents who have returned after leaving the facility for 24 hours or longer should be managed as an admission.

Figure 3. Testing Schematic

Retesting Previously Positive Staff/Residents

1. Staff or residents who previously tested positive within the last 90 days and are asymptomatic should not be included in routine screening, facility-wide or group-level response testing, or new admission/re-admission testing requirements.
2. Testing recommendations for asymptomatic residents who recently recovered from a COVID infection and who become a close contact are as follows. If their last positive test was:
   1. ≤30 days ago, then repeat testing is not recommended.
   2. 31-90 days ago, then point-of-care antigen testing may be considered at least 5 days after the most recent exposure.
3. 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. In this situation, a point-of-care antigen testing is preferred.

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. Residents:
• 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.
• If a resident (or resident representative) refuses routine screening testing (i.e., the resident is asymptomatic, not a close contact, and there is no active outbreak in the facility), while all efforts should be made to educate the resident/resident representative to undergo testing, the resident should not be quarantined or be restricted to their rooms. They should be permitted to continue with their usual activities including any permitted group activities, communal dining, and visitation as per guidelines above.
• Residents who refuse testing AND who have signs/symptoms of COVID-19 or who are close contacts must be placed on COVID-19 transmission based precautions (preferably in a single room if symptomatic), until the time-based criteria for discontinuing quarantine (close contact) or isolation (symptomatic) 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.

Isolation Area (Red Cohort): This designated, physically separate area is only for residents who have confirmed COVID-19 with or without symptoms.

1. The COVID-19 isolation area should include ventilation measures to prevent transmission to other residents outside the isolation area as per CDPH AFL 22-13. Please see “Infection Prevention and Control Guidance” section for guidance on ventilation.
2. Residents may be transferred out 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 without re-testing to end isolation (time-based strategy).
     • NOTE: Residents who had critical illness due to COVID-19 could have their isolation duration extended up to 20 days since symptom onset. Residents with severely immunocompromising conditions could have their isolation duration extended beyond 20 days since symptom onset (please see below for a list of severely immunocompromising conditions). For both these groups of residents, use of a test-based strategy in consultation with an infectious disease specialist, if available, is recommended to inform when isolation can be discontinued.
   • For asymptomatic residents with PCR/NAAT confirmed COVID-19:
   • 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 without re-testing to end isolation (time-based strategy).
     • NOTE: Residents with severely immunocompromising conditions could have their isolation duration extended beyond 20 days since date of first positive COVID-19 diagnostic test. Please see below for a list of severely immunocompromising conditions. Use of test-based strategy in consultation with an infectious disease specialist, if available, is recommended to inform when isolation can be discontinued.
   • If they develop symptoms during their infection, 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. Special Staffing Considerations:
   • Staff assigned to the Red Cohort should not care for residents outside of the cohort/isolation area. If staff must care for other residents, they should visit the Red Cohort last.
   • If a facility is experiencing critical staffing shortage and there is prior approval from Public Health, asymptomatic staff with lab-confirmed COVID-19 infection may be allowed to work in the Red Cohort. The approval should include the anticipated duration of work for each asymptomatic confirmed staff. The facility must also show they are actively working to secure more staffing. Asymptomatic confirmed staff will need to be able to keep separated from uninfected staff, which includes having dedicated breakrooms and bathrooms until they are no longer considered infectious.

Isolation in place of suspect cases: Residents with COVID-19 signs or symptoms who are pending test results or who refuse to test should isolate in place. Additionally, asymptomatic residents with a positive test pending confirmatory PCR/NAAT testing results should also isolate in place. If SARS-CoV-2 infection is confirmed, then residents should be moved into the Red Cohort to complete the remainder of their isolation.

1. Isolation in place requires staff entering the resident room or providing direct care in another room (shower room, rehab gym, etc.) to wear full PPE per transmission based precautions for COVID-19.
2. Residents should be restricted to their rooms as much as possible and wear well-fitting face masks when not in their rooms.
3. If a point of care (POC) antigen test is used initially and is negative, then isolation should be maintained, and a confirmatory PCR/NAAT test should be collected 48 hours later.
4. For residents awaiting testing results in multi-occupancy rooms, strategies to reduce exposures between residents should be implemented including but not limited to drawing curtains between resident beds. Staff should change gowns and gloves with frequent hand hygiene between each resident contact in the same room.
5. Symptomatic residents who decline testing should be isolated in place and should not be placed in a room with other residents with confirmed SARS-CoV-2 infection. Certain Red Cohort staff (e.g., RN, LVN) may provide care for them if infection prevention and control practices are strictly adhered and visit their rooms after providing care in the Red Cohort as much as possible.
6. Isolation in place duration:
   • Low clinical suspicion: isolation-in-place can be discontinued after PCR/NAAT test is confirmed negative
   • Higher clinical suspicion and/or no clear alternate diagnosis: isolation can be discontinued after two (2) PCR/NAAT tests taken 24 hrs apart are confirmed negative
   • No testing (e.g., resident refuses testing): At least 10 days AND improvement in symptoms AND fever-free for 24 hrs without fever-reducing medications

The determination for ending isolation in place for residents with symptoms and negative COVID-19 viral test(s) should be based on the level of clinical suspicion for COVID-19. The determination should consider epidemiologic factors (e.g., ongoing outbreak, recent close contact, high community transmission) in addition to clinical presentation. This decision should be made in consultation with their clinical/treating provider.

Quarantine: Quarantine is no longer required for asymptomatic residents who have known or possible exposures to COVID-19. However, in an outbreak, Public Health may direct facilities to quarantine the following resident groups in order to mitigate transmission: asymptomatic residents who are close contacts, included in group-level or facility-wide post-exposure and response testing, new admissions, re-admissions, or returning after leaving the facility >24 hours.

Regardless of decision to quarantine, residents in these above groups should:

1. Wear source control (well-fitting face mask) when not in their rooms for 10 days after admission or last exposure.
2. Be closely monitored for signs and symptoms of COVID-19 including temperature and oxygen saturation checks at least once per shift. If symptoms develop, immediately isolate in place and test.

If quarantine is required:

1. Residents should be restricted to their rooms as much as possible if safe to do so.
2. Residents should be managed in-place; avoid movement of residents to other rooms that could lead to new exposures.
3. Duration should be 7 days when all tests are negative or 10 days if testing was not performed.

Table 3. Summary of Testing and Infection Control Guidance for Residents

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
• 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).

Once an outbreak has been identified, facilities should immediately implement the following measures.

1. Immediately initiate Novel Respiratory Precautions for all suspect and confirmed residents while continuing Standard Precautions. Residents who have confirmed COVID-19 infection should be transferred to the Red Cohort for isolation. Residents who are suspect for COVID-19 infection (symptomatic with pending/unknown test results or asymptomatic with positive antigen test pending confirmatory PCR/NAAT test) should isolate in-place in their current room with the same roommates unless there are sufficient rooms for isolation in a single-occupancy room. Please see “Isolation and Quarantine” section for full details.
2. Post-exposure and Response testing should be immediately initiated as described in the ‘COVID-19 Testing’ section above.
   1. Lab testing of residents and staff should be done through a commercial lab, if possible.
   2. Antigen tests can also be utilized where appropriate following the ‘COVID-19 Testing’ section and Table 3. Summary of Testing and Infection Control Guidance for Residents.
3. Immediately implement a line listing of all HCP and residents who are cases (suspected and confirmed) and contacts regardless of symptom status and regardless of whether they are associated with the outbreak. Contacts should include all residents who are close contacts and all staff with higher-risk exposures. The outbreak line list must be updated and shared with the District Public Health Nurse (DPHN)/Outbreak Investigator (OI) on a regular basis and as requested pursuant to the LAC DPH Health Officer Order “Prevention of COVID-19 Transmission in Skilled Nursing Facilities".
4. Instruct the facility to notify DPHN/OI assigned to the facility immediately if any resident or staff report COVID-19 symptoms including fever and if any resident or staff test positive for COVID-19 regardless of symptom status or vaccination status.
5. Immediately set up vaccination clinics to increase up to date vaccination coverage among residents and staff. Keeping up to date with COVID-19 vaccinations (getting the latest booster or dose recommended depending on the age group or health status) continues to be the most effective prevention against severe COVID-19 especially among the high risk nursing home population. Facilities should continue and increase their vaccination efforts during outbreaks. For COVID-19 vaccine access, SNFs should preferentially use their long-term care pharmacies and may also use LAC DPH’s mobile vaccine service as back up when needed.
6. All residents with a positive SARS-CoV-2 viral test must be immediately assessed by their healthcare provider for eligibility for outpatient COVID-19 treatment, specifically the oral antivirals ritonavir-boosted nirmatrelvir (Paxlovid) or molnupiravir (Lagevrio) as per LAC DPH’s Order of the Health Officer on Prevention of COVID-19 Transmission in SNFs and CDPH AFL 20-22 (COVID-19 Treatment Resources for SNFs. Residents with confirmed COVID-19 infection are eligible if they have mild to moderate symptoms and there are no contraindications or drug-drug interactions that cannot be managed. Because they need to be started within five (5) days of symptom onset, it is crucial for all residents testing positive for SARS-CoV-2 to be assessed daily following LAC DPH’s SNF Protocol for Oral COVID-19 Antivirals Assessment and Prescription (checklist), including asymptomatic residents who are not initially eligible.
7. Symptomatic residents should also be tested for influenza during the flu season, which is typically October through March every year, as per the LAC DPH guidance on Testing & Isolation/Quarantine for Influenza in the Context of COVID-19 in SNFs.
8. Proactively monitor all residents for fever (>100.0° F), new or worsening respiratory symptoms (i.e. cough, sore throat, shortness of breath), and oxygen saturation at least every 24 hours; with more frequent monitoring for residents who are suspect cases, e.g., every shift; and even more frequent for residents with confirmed COVID-19 (Red Cohort), e.g., every 4 hours. Records should be kept of resident symptom and temperature checks.
9. Continue to screen all HCPs, regardless of vaccination status, for fever (>100.0° F) and respiratory symptoms (cough, sore throat, shortness of breath) at least at the beginning of each shift.
   1. Temperature checks for HCP prior to work is helpful in ensuring a healthy workforce but is of unclear benefit in the setting of a highly vaccinated workforce and is not required.
   2. Facilities should have screening systems in place that cause the least amount of delay and disruption as possible. Please see the “Symptom Monitoring” section of the LAC DPH COVID-19 Infection Prevention Guidance for Healthcare Personnel.
   3. Symptomatic HCP with no clear alternate diagnosis should isolate at home and be restricted from work pending clinical evaluation and testing results, regardless of vaccination status. Please see the “Return to Work for Symptomatic HCP” section of the LAC DPH COVID-19 Infection Prevention Guidance for Healthcare Personnel.
10. All HCPs, regardless of vaccination status, who had higher-risk occupational exposure to a confirmed infectious COVID-19 case should be managed per ‘Management of Exposed Asymptomatic HCP’ section of the LAC DPH COVID-19 Infection Prevention Guidance for HCP. This includes serial testing on days 1, 3, and 5 (day 0 is day of exposure) regardless of staffing shortage. All HCP with exposures should wear an N95 respirator at all times while in the facility until they have a negative test result on Day 5.
11. HCPs with confirmed infection of COVID-19 should be excluded from work and follow Table 2. Work Restrictions for HCP with SARS-CoV-2 Infection (Isolation) from the LAC DPH COVID-19 Infection Prevention Guidance for HCP.
12. Implement the following changes to infection prevention and control practices:
    1. Reinforce source control requirements for staff and visitors. Additionally, reinforce source control for residents when not in their rooms who are close contacts, new admissions, readmissions, returning after leaving the facility >24 hrs through day 10 after last exposure or day of admission, even if quarantine is not instituted.
    2. Increase auditing of HCP adherence to relevant infection prevention and control practices including source control, hand hygiene, and isolation precautions. Ensure that all shifts including evening, overnight, and weekend shifts are covered.
    3. Assess the facility’s HVAC (heating, ventilation, and air conditioning) systems and indoor air quality in consultation with professionals (facilities engineers, mechanical engineers, indoor air quality, or industrial hygiene consultants, etc.) following the CDPH, HCAI, and Cal/OSHA Interim Guidance for Ventilation, Filtration, and Air Quality in Indoor Environments. Please note that there are no single solutions to effectively and permanently improve a building’s ventilation and indoor air quality. Additionally, ventilation and other indoor air quality improvements are additions to and not replacements for infection prevention and control basics including any applicable state and local directives.
       • Review with facilities their plan to continue making improvements upon the closure of their outbreaks.
    4. Facilities should consider substituting metered dose inhalers for nebulizers to reduce the risk of aerosolization especially for residents with roommates, regardless of vaccination or COVID status.
    5. Eye protection (goggles, face shields) is a consideration as part of PPE even for staff caring for residents not in isolation or quarantine when the facility is in an active outbreak. Public Health outbreak investigation teams may direct facilities, on a case-by-case basis, in active outbreak to require eye protection for staff caring for all residents regardless of COVID status to mitigate transmission.
    6. Increase environmental cleaning & disinfection throughout the facility with emphasis on high touch surfaces particularly in unit(s) where resident cases were identified and where confirmed cases reside (Red Cohort). If not done so already, facilities should ensure they are using an approved disinfecting agent: List N: Disinfectants for Use Against SARS-CoV-2.
13. While quarantine is no longer routinely required for asymptomatic residents, Public Health outbreak investigation teams may direct facilities to quarantine the one or more of the following resident groups in order to mitigate transmission: asymptomatic residents who are close contacts, included in group-level or facility wide post-exposure and response testing, new admissions, re-admissions, or returning after leaving the facility >24 hours. If quarantine is required:
    1. Residents should be managed in-place; avoid movement of residents to other rooms with new roommates that could lead to new exposures.
    2. Residents should be restricted to their rooms as much as possible if safe to do so.
    3. Duration of quarantine should be 7 days when all tests are negative or 10 days if testing was not performed.
14. For any transfers out of the building, notify EMS and the receiving facility of possible exposures. In general, other than discharge back into the community, transfers out should only be to higher level of care (hospitals) when clinically appropriate. SNFs experiencing COVID-19 outbreaks should not laterally transfer residents to another SNF unless first cleared by their LAC DPH contact managing the outbreak. Please see Interfacility Transfer Rules for the most up to date guidance.
15. In general, SNFs should continue to accept patients transferring from hospitals when they’re clinically indicated even during an outbreak, and receiving SNFs may not require a negative test result for COVID-19 as a criteria for admission or readmission as stated in CDPH AFL 22-31. On a case-by-case basis, the Public Health outbreak investigation team may decide to temporarily hold only new admissions of residents without COVID-19 to units where ongoing transmission of COVID may be occurring following the ‘Restricting Admissions to SNFs During an Outbreak’ section. Facilities should continue to re-admit returning residents regardless of COVID-19 status. Please refer to Interfacility Transfer Rules for most up to date guidance.
16. Group activities and communal dining should be managed as per the 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.
    1. Outdoor settings should be prioritized for communal dining and activities whenever practical, and especially during an outbreak. Otherwise, indoor communal dining and group activities may also occur.
    2. As per Table 1, residents participating in group activities and communal dining must wear well-fitting face masks when not actively eating or drinking for the duration of the outbreak and through 14 days after the outbreak has been closed, regardless of resident vaccination status and regardless of LA County’s CDC Community Level.
    3. On a case-by-case basis, Public Health may direct a facility to temporarily suspend all communal dining and activities for all residents regardless of COVID status, vaccination status, both indoors and outdoors, to assist with outbreak investigation/management. This should be very rare. The facility must have documented communication with their Public Health contact with this recommendation including an anticipated date to resume communal dining and activities.
17. Allow visitors and manage in-person visitation as per Visitation section.
    1. On a case-by-case basis, Public Health may direct a facility to temporarily suspend visitation to assist with outbreak investigation/management. This should be very rare. The facility must have documented communication with their Public Health contact with this recommendation including an anticipated date to resume visitation.
    2. However, even when there is a temporary suspension of visitation, there must be a consideration of resident rights which means some visitation may still occur. This includes but is not limited to compassionate care visitation for residents in critical condition or end-of-life situations; essential support person visitation for residents who are experiencing weight loss, dehydration, failure to thrive, psychological distress, or functional decline or struggling with a change in environment; and essential support person visitation for residents with physical, intellectual, or developmental disability or cognitive impairment.

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.

Facilities are required to report all positive test results from point-of-care SARS-CoV-2 antigen tests, any suspected COVID-19 outbreak*, and all fatalities associated with COVID-19 within 24 hours including out of facility/hospital deaths of presumed cases and all deaths that occurred during an active COVID-19 outbreak, regardless of testing.

*Please note that the current COVID-19 outbreak definition in SNFs in Los Angeles County is 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.

For more details, please see the LAC DPH COVID-19 Case Reporting Protocol for SNFs flowchart.