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 vaccine doses 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.

Visit CDPH vaccine schedules in English and Spanish. Additional vaccine resources from are located on the DPH vaccine resources page.

Offer, Track, and Report COVID-19 Vaccination Doses

1. Per 42 CFR 483.80(d)(3), SNFs must educate and offer recommended vaccine doses as soon as recommendations are released by the CDC and doses are made available to the facility, for both residents and staff. This must be well documented. Please review the linked federal regulations for full details. Facilities should increase and maintain their up to date COVID-19 vaccine coverage as high as possible, especially for residents.
1. Residents
1. 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.
2. For residents coming from a hospital, including stays in the emergency department or observation, please request the hospital to offer COVID-19 vaccine to the resident prior to transfer as per the CDC’s “Vaccinating Patients upon Discharge from Hospitals, Emergency Departments & Urgent Care Facilities” guidance.
3. If the resident is unvaccinated, it is strongly recommended to get them vaccinated within a week of admission.
4. Residents recently had a COVID-19 infection who are not up to date may consider delaying their next recommended dose by up to 3 months given that reinfection is less likely in the weeks to months after infection. However, there are reasons for SNF residents to get their next recommended dose sooner than 3 months including their personal risk of severe disease, local COVID-19 community level, or the facility’s outbreak status.
2. Staff
1. Per 42 CFR 483.80(i) and CMS QSO-23-02-ALL Revised Guidance for Staff Vaccination Requirements (page 6), facilities must ensure all of their staff have completed a primary series unless exempted. Please review the linked federal regulatory documents.
2. Per LAC DPH’s Updated Health Officer Order on COVID-19 Vaccination Requirement for Health Care Workers, revised April 20, 2023, workers who are newly coming into compliance with this order (i.e., new hires) must receive a single dose of the bivalent vaccine (or the Novavax monovalent booster for those who cannot receive the bivalent vaccine).
3. There must be acceptable proof of vaccination that confirms they are meeting the above requirements. Please see CDPH’s “Vaccine Record Guidelines & Standards” document.
4. Staff that have satisfied the healthcare worker vaccination requirement should be strongly encouraged to stay up to date with COVID-19 vaccines.
3. Accessing COVID-19 vaccines: Facilities should work with their facility’s contracted long-term care (LTC) pharmacy to schedule an appointment or obtain a delivery of vaccine. Of note, single-dose vials are now available for certain COVID-19 vaccines; please ask your LTC pharmacy for availability. 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.
4. LAC DPH developed a one-pager on Best Practices for Improving Vaccination in SNFs based on feedback from LA County SNFs. In particular, it is key for facility leadership to prioritize and fully support COVID-19 vaccine efforts, engage clinical providers including medical directors, rely on evidence from trusted sources, focus on the positives (e.g., promoting positive testimonials), and persist by continually evaluating and re-adjusting the facility’s vaccine strategies for better outcomes.
2. To help facilities comply with federal regulations, all facilities should track all vaccine 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 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 OR date the person declined. This will a) help facilities anticipate when individuals are due for their next recommended dose, and b) 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).
   2. The above can be accomplished with password protected spreadsheets like these vaccination tracker templates for SNF residents and staff developed by LAC DPH.
3. As of Jan 1, 2023, all healthcare providers including SNFs must report all immunizations administered at the facility to the CAIR2 as per California regulation Health and Safety Code 120440 which was recently amended by Assembly Bill 1797. For COVID-19 vaccine doses, dose administration must be documented in the facility’s medical record system within 24 hours and reported to CAIR2 no later than 72 hours of administration.

Resources for enrolling and reporting in CAIR2 as a front-end user:

• How to Enroll in CAIR2: https://www.cdph.ca.gov/Programs/CID/DCDC/CAIR/Pages/CAIR-Join-Enroll.aspx
• California COVID-19 Vaccination Program’s Reporting Requirements main page: https://eziz.org/covid/reporting/
• Reporting COVID-19 Vaccine Doses Administered job aid: https://eziz.org/assets/docs/COVID19/IMM-1425.pdf#page=28
• CAIR2 Help Desk: https://www.cdph.ca.gov/Programs/CID/DCDC/CAIR/Pages/CAIR-users-help-desk.aspx

Antiviral Treatment

There are highly effective outpatient COVID-19 antiviral treatments to prevent severe outcomes, including hospitalizations and death among high-risk individuals infected with COVID-19 including nursing home residents. The preferred outpatient treatment is ritonavir-boosted nirmatrelvir (Paxlovid), an oral antiviral, or intravenous remdesivir. Molnupiravir (Lagevrio) is an alternative if these preferred treatments are not appropriate, feasible to use, or clinically appropriate. See NIH COVID-19 Treatment Guidelines Antiviral Agents Summary Recommendations.

Per CDPH AFL 22-20 (COVID-19 Treatment Resources for SNFs), all SNF residents with a diagnosis of mild to-moderate COVID-19 are eligible for outpatient antiviral treatment and should be evaluated by a prescribing clinician to start treatment. Because the oral antiviral therapies need to be started within five (5) days of symptom onset (remdesivir is within 7 days of symptom onset), it is crucial for prescribing clinicians to assess residents for COVID-19 as soon as they become symptomatic. Patients that are unable to receive Paxlovid should be treated with either remdesivir or molnupiravir if eligible. See LAC DPH’s COVID-19 Outpatient Therapeutics page for more detailed information.

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 compliant with CDPH AFL 22-20 and best practices, 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/NAAT 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.
   • NOTE: Symptomatic residents who are highly suspected to have a COVID-19 diagnosis despite initial negative viral testing (e.g., also close contacts and/or there is an active outbreak in the facility), then they should be considered eligible for an oral antiviral treatment.
2. In advance of COVID-19 diagnoses and/or COVID-19 outbreaks, facilities should evaluate all residents for any 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 (at a minimum, the first line therapy Paxlovid). 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 COVID-19 may also be assessed for and offered IV remdesivir. Given the emergence of variants resistant to monoclonal antibodies, providing remdesivir in the outpatient setting may be of particular importance for facilities with severely immunosuppressed patients or high-risk pediatric populations.

For more information please see LAC DPH’s COVID-19 Outpatient Therapeutics page and NIH’s Therapeutic Management of Nonhospitalized Adults with COVID-19 for the most up to date information.

Pre-exposure Prophylaxis

Currently, there are no products authorized or approved for use as pre-exposure prophylaxis for COVID-19.

The following general and COVID-19 specific recommendations based on the following:

• Los Angeles County’s “Masking in Healthcare and Direct Care Settings” Health Officer Order, effective April 3, 2023
• CMS QSO 20-39-NH-Revised “Nursing Home Visitation – COVID-19 (Revised)”, last updated Sep 23, 2022
• CDPH AFL 23-12 “COVID-19 Recommendations for PPE, Resident Placement/Movement, and Staffing in Skilled Nursing Facilities” released Jan 24, 2023
• CDC “Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the COVID-19 Pandemic”
• CDC “Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2”.

For more information on infection prevention and control (IPC) basics and the difference between standard and transmission-based precautions, visit https://www.cdc.gov/infectioncontrol/basics/index.html.

General Requirements

1. CDPH guidance (AFLs 20-84 and 21-51) and California Assembly Bill 2644 require that facilities employ a full-time, on-site trained infection preventionist (IP) who will implement an infection prevention and control program. LAC DPH’s recommended training courses are listed here: http://publichealth.lacounty.gov/acd/ICPTrainingforSNFs.htm (table 1)
2. All staff in the facility are permanently required to undergo basic infection prevention and control training at hire and annually per federal requirement F945 to meet the requirements of an infection prevention and control (IPCP) as delineated in 42 CFR §483.80(a). LAC DPH’s recommended trainings are listed here: http://publichealth.lacounty.gov/acd/ICPTrainingforSNFs.htm (table 2).
3. SNFs should include COVID-19 infection prevention and control, including their plan for outbreaks or during time of high community levels, in their facility mitigation plans and integrate them into their emergency preparedness plans. These plans will need to be revised as guidance changes.

Source Control

Residents

1. All residents should have access to clean well-fitting masks with good filtration.
2. Well-fitting masks should by worn by any resident that is suspected or confirmed to have COVID-19 when not in their rooms.
3. Well-fitting masks should be worn by close contacts indoors when not in their rooms for 10 days post-exposure.
4. When the CDC COVID-19 Community Level for LA County is high or when there is an outbreak at the facility, well-fitting masks are strongly recommended for everyone indoors including residents when they are not in their rooms. This includes masking during communal dining and group activities, when not actively eating or drinking.
5. All other residents are encouraged to wear masks indoors when not in their rooms. Individuals at high risk for severe illness (e.g., moderately to severely immunocompromised) are encouraged to wear the most protective mask for personal protection.

Staff

1. As per the LAC DPH “Masking in Healthcare and Direct Care Settings” Health Officer Order, all staff must wear a surgical/procedure mask or higher (e.g., N95 respirator) for source control when they are providing resident care, working with a resident in-person, or in resident care areas in the facility when a resident is present.
   1. Since it is difficult to safely restrict residents to their rooms at all times in SNFs, common areas like the hallways, nursing stations, communal activity areas, etc. should be considered a part of this masking requirement.
2. Please see Table 1. Transmission Based Precautions, PPE, and Resident Placement for COVID-19 for appropriate mask use depending on the COVID-19 status of the resident.

Visitors

1. Per CMS QSO 20-39-NH-Revised, all visitors should wear a well-fitting mask with good filtration for the duration of their visit while indoors, when the CDC COVID-19 Community Level for LA County is high or when the facility is in an outbreak. Please also see Table 2.
2. Otherwise, visitors are strongly recommended to wear well-fitting masks especially when visiting residents at high risk for severe illness (e.g., moderately to severely immunocompromised).

Hand Hygiene (HH)

1. 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.
2. All staff, residents, and visitors should perform HH frequently. Please see LAC DPH’s Hand Hygiene Poster, which goes beyond WHO’s 5 Moments of Hand Hygiene for the nursing home setting.

Transmission Based Precautions and Personal Protective Equipment (PPE)

HCP should follow transmission-based precautions for residents in isolation including standard precautions as summarized in table 1 and detailed below.

Table 1. Transmission Based Precautions, PPE, and Resident Placement for COVID-19

	Transmission Based Precautions, PPE, Resident Placement	Recommended Signage
Isolation Separation of people confirmed or suspected to be infected with a contagious disease from people who are not infected.	Resident is restricted to their room with door closed if safe and practical, except when it is medically necessary to leave their room. Resident wears face mask indoors when not in their room Staff dons and doffs for each resident encounter: N95 respirator* Gloves (with hand hygiene) Gown Eye protection (goggles, face shield) *If working in dedicated COVID-19 isolation area (formerly “Red Zones”) where resident doors cannot be safely closed at all times or residents frequently leave their rooms, then it is recommended to treat the entire COVID-19 isolation area as a single resident care area where staff dons a new N95 prior to entry and doffs (discards) upon exit of the area. If followed, this should be explained in a risk assessment as a part of the facility’s written mitigation plan.	COVID-19 Transmission-Based Precautions
Quarantine Separation of people who were exposed to a contagious disease to see if they become sick.	For COVID-19, quarantine is not routinely recommended. Public Health may direct individual facilities on a case-by-case basis to quarantine residents in certain risk groups (see table 4 below) to help control transmission in an outbreak. Regardless of whether quarantine is implemented: Residents should wear well-fitting masks per the source control section. Residents should not be moved to different rooms to avoid movement that could lead to new exposures; i.e., close contacts should stay in their original rooms and new admissions/re-admissions should not be moved to a different room after negative serial testing is complete.	Only if a resident is placed in quarantine, then infection control signage (e.g., COVID-19 transmission-based precautions) is indicated. Avoid the use of “Yellow Zone” or “Green Zone” signs that may not accurately communicate COVID-19 risk levels and negatively affect adherence to basic infection prevention and control.

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. Please see table 1 above.
   3. Facilities should regularly audit adherence (also called adherence monitoring) to appropriate PPE use and hand hygiene via “secret shoppers” in all shifts and including all staff types.
   4. Facilities should follow CDC’s strategies to optimize the supply of PPE and equipment to have at least a 2-week supply of PPE and other infection prevention and control supplies (https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html).
   5. If there are PPE shortages, the facility should make and document efforts to acquire more supply including contacting Public Health’s PPE Coordinator: DPHPPECoordinator@ph.lacounty.gov
2. N95 respirators
1. All staff must wear fit tested NIOSH-approved N95 respirators per transmission-based precautions for COVID-19 as described in table 1 above.
2. Initial and annual N95 respiratory fit testing is required for all staff per California Division of Occupational Safety and Health (Cal-OSHA).
3. N95 respirators are recommended for all aerosol generating procedures (suction, sputum induction, non-invasive ventilation like BiPAP or CPAP, CPR, nebulizer treatments, etc.) regardless of the resident’s COVID-19 status when the CDC COVID-19 Community Level is high for LA County.
4. 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.
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 used for source control.
6. If there is a shortage of N95 respirators, facilities should make efforts to acquire more supply including documented communication with Public Health (DPHPPECoordinator@ph.lacounty.gov). 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.
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 (designated COVID-19 isolation area 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.

Ventilation, Filtration, and Air Quality: Effective ventilation is one of the most important ways to control small aerosol transmission. Nonetheless, 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 above state guidance. While portable air cleaners may help when used correctly, facilities should not rely on any single solution to effectively improve the ventilation and air quality of their buildings. Facilities should consult with professionals* 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.

*Professionals: facilities engineers, mechanical engineers, indoor air quality or industrial hygiene consultants, etc.

Environmental cleaning:

Please refer to CDC guidelines on environmental infection control: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#anchor_1604360721943.

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. Products should always be used according to manufacturer’s instructions; disinfectants may not have proper effectiveness against SARS-CoV-2 if manufacturer’s instructions are not followed.

1. Communicate safe entry policies to visitors and staff
   1. Facilities should follow the guidance laid out by the CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic under the section “Establish a Process to Identify and Manage Individuals with Suspected or Confirmed SARS-CoV-2 Infection” to ensure safe entry.
      1. Table 2. “Infection Prevention & Control Measures for Visitation” summarizes safe entry policies for visitors.
   2. All staff should follow Infection Prevention Guidance for Healthcare Personnel which includes routine self-monitoring for symptoms of possible COVID-19 and exclusion from work when symptomatic or infected with COVID-19.
   3. Prior to entry, visitors of residents in isolation (dedicated COVID-19 isolation area 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.
   4. If a facility elects to conduct entry screening at their own discretion, Emergency Medical Service (EMS) workers, including ambulance transport personnel, should not be included in the entry screening process, regardless of the urgency of the situation. Like other healthcare workers, they follow infection prevention guidance that includes routine self-monitoring of symptoms and exclusion from work when sick or infected.
2. Conduct symptom screening for all residents.
   1. All 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 close contacts or suspect cases, for example every shift, and especially for residents with confirmed COVID-19, for example every 4 hours.

The following recommendations for communal dining, group activities, and visitation are based upon the following:

• CDC “Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the COVID-19 Pandemic”
• CMS QSO 20-39-NH-revised: Nursing Home Visitation - COVID-19

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 referenced in CMS QSO 20-39-NH-Revised. 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.

Communal Dining and Group Activities

Residents who are in isolation, whether suspect isolating in-place or confirmed isolation in the dedicated COVID-19 isolation area, should avoid communal dining and group activities regardless of community levels or the facility’s outbreak status. Residents who are close contacts may continue participating in group activities while wearing well-fitting masks with good filtration 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 should continue to follow all infection prevention and control measures to conduct communal dining and group activities safely including but not limited to the following:

1. Residents are strongly encouraged to wear source control (well-fitting masks) indoors during communal dining and group activities when there is an outbreak in the facility or when the CDC COVID Community Level is high. 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.
2. Outdoor settings should be prioritized for communal dining and activities whenever practical, and especially during an outbreak.
3. For further guidance on communal dining and activities during the holidays, please refer to CMS QSO-20-39-NH-Revised, FAQs section, #2.
4. If there is a COVID-19 outbreak in the facility, the facility should work with their assigned outbreak investigation team from Public Health to mitigate transmission, which may include temporarily pausing communal dining and activities for all residents regardless of COVID-19 status or vaccination status, both indoors and outdoors. 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

1. Facilities should follow CMS QSO 20-39-NH-Revised to ensure they are supporting in-person visitation in a manner that is consistent with resident rights as protected by Title 42 CFR section 483.10(f)(4)(v) while minimizing infectious risk to other residents and staff.
2. Health care workers including consultants, students, volunteers, and contractors who enter the facility to provide services to residents, even if they are not directly employed by the facility, are not considered visitors for the purposes of this guidance and should adhere to the same COVID-19 infection prevention requirements for staff (e.g., masking, donning and doffing required PPE for COVID transmission-based precautions).
3. 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. This should be rare. 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.
4. Visitors who are unable to adhere to the core principles of COVID-19 infection prevention as outlined in CMS QSO 20-39-NH-Revised should not be permitted to visit or should be asked to leave.
5. Table 2, below, is a summary of infection prevention and control measures for visitation based on CMS and CDC guidance:

Surveillance. Active symptom screening of residents and staff are the basis of infectious disease surveillance. Prompt identification and management of symptomatic individuals (testing and isolation), including those with mild symptoms, can help mitigate transmission.

Testing Methods

1. While point of care (POC) antigen testing or laboratory-based molecular (PCR/NAAT) testing are acceptable for meeting CMS requirements for COVID-19 testing, it is recommended for SNFs to maintain 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.
2. If a SNF is running low on POC antigen testing supplies or the 48-hour TAT for laboratory testing cannot be consistently met, then the facility should document its efforts to remedy this as soon as possible including communication with the local health department (LTC_NCoV19@ph.lacounty.gov).
   1. Refer to the state's COVID-19 Testing Taskforce Laboratory List to find a lab providing COVID-19 PCR/NAAT testing.
   2. LA County SNFs can request additional COVID-19 POC antigen test kits via this link: https://www.surveymonkey.com/r/YJTH9S9. For urgent requests (e.g., outbreak), please also contact nCovid-tlt@ph.lacounty.gov.
3. Usage of POC antigen tests
   1. If POC antigen tests are used for routine screening testing (if applicable per facility’s discretion) or for serial response testing, then they should be administered at least twice per week or every 3 days.
   2. Antigen tests are preferred over PCR/NAAT testing for individuals who are within 90 days of prior infection because some individuals may remain positive by PCR/NAAT but not be infectious during this period.
   3. Facilities should confirm with a follow-up PCR/NAAT test when an asymptomatic individual tests positive via antigen or a symptomatic individual tests negative via antigen.
      1. Exception: Confirmation with PCR/NAAT testing is not indicated for individuals who are within 90 days of their prior infection.

Table 3. Summary of Testing Guidance

The table below contains recommendations for COVID-19 testing in SNFs based upon CMS QSO 20-38-NH-Revised and the CDC “Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the COVID-19 Pandemic” guidance. Please note when there are differences in testing requirements, the most conservative testing guidance should be followed.

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

Refusal of Testing

Please refer to CMS QSO 20-38-NH-Revised. The following are some clarifications for resident refusal of testing:

1. Residents who refuse testing AND who have signs/symptoms of COVID-19 or who are close contacts should 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.
2. If outbreak testing has been triggered and an asymptomatic resident refuses testing, the facility should ensure the resident wears a mask indoors when not in their room, avoids communal dining, and practices effective hand hygiene until the outbreak has been closed.

The following summary of isolation, quarantine, and related infection control guidance is based on CDPH AFL 23-12, CMS QSO 20-38-NH-Revised, and the CDC guidance “Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic.”

Table 4. Summary of Isolation and Infection Control Guidance for Residents

Facilities should follow the LAC DPH COVID-19 Infection Prevention Guidance for Healthcare Personnel.

Symptom monitoring

• Facilities need to communicate that HCP with symptoms of COVID-19 and/or a positive COVID-19 test must not enter the premises.
• All HCP should routinely self-monitor for symptoms of possible COVID-19.
• HCP with symptoms of COVID-19 should be restricted from the workplace pending SARS-CoV-2 diagnostic testing. See section: Evaluating HCP with Symptoms of COVID-19.

Return to work
For return to work refer to the following sections:

• Management of Asymptomatic Exposed HCP
• HCP with Confirmed COVID-19

Facilities should communicate COVID-19 status (suspect or confirmed infection) to the receiving facility (hospital, outpatient clinic, dialysis center, dental clinics) before transfer as per CDC. Healthcare facilities are strongly encouraged to use the LAC DPH Infectious Organism Transfer Form.

During outbreaks, facilities should communicate with their Public Health outbreak investigation team prior to any lateral transfer to another SNF. On a case-by-case basis, Public Health may restrict lateral transfers to other SNFs during outbreaks, especially of residents who are suspect or confirmed COVID-19 cases.

Receiving SNFs should not require a negative test result for COVID-19 as criteria for admission or readmission. Instead, SNFs and hospitals should proactively communicate and collaborate to facilitate the safe, timely, and appropriate placement of SNF residents. SNFs should be prepared to provide care safely without putting existing residents at risk, including maintaining the ability to quickly re-establish a designated COVID-19 isolation area (formerly known as a “Red Zone”) as per CDPH AFL 23-12. Please reach out to LAC DPH at LTC_NCoV19@ph.lacounty.gov for questions and/or help with transfers related to COVID-19 infection control.

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.