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

Definition of Outbreak (please take into account all of the footnotes below):

1. ≥2 cases of confirmed* COVID-19 among residents admitted for a non-COVID condition who have resided in the facility for at least 7 days, with epi-linkage**

OR

2. ≥2 cases of confirmed* COVID-19 among HCP AND ≥1 case of confirmed* COVID-19 among residents admitted for a non-COVID condition who have resided in the facility for at least 7 days, with epi-linkage**, AND no other more likely sources of exposure for at least 1 of the cases.***

*Laboratory-based molecular tests are also known as nucleic acid amplification tests (NAATs) and can include RT-PCR tests OR Antigen tests. PCR or supervised in-facility Ag, or testing done at another facility, are acceptable. HCP who are already excluded from work due to symptoms/positivity on home test should not report back to facility to be tested, but should continue exclusion from work per guidance and can be counted towards the outbreak case count if they fit the epi-linkage parameters. If opening an outbreak based on positive antigen test results, the positive individuals must be symptomatic.

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 individual has discordant viral test results within 48 hours of each other (e.g., positive antigen test and negative molecular test), please immediately contact LACSNF@ph.lacounty.gov for guidance. In these situations, an outbreak opening may not be warranted yet, but the individual must follow isolation protocols 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 are 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 facility, but post-exposure and response testing should still be initiated.
3. For residents who have been at the facility ≥ 7 days and who have left the facility in the past 7 days for medical appointments (outpatient clinic, dialysis, urgent care, ER stays) or going “out on pass,” and who test positive should be counted towards an outbreak and meet criteria for opening an outbreak. This is because it cannot be ruled out that the infection was not acquired at the facility.
4. Facilities should test all individuals with symptoms of possible COVID-19 immediately.

Please see CDC’s Overview of Testing for SARS-CoV-2 in the healthcare setting for more details on both molecular and antigen tests.

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

***This second criterion including HCP AND resident cases does not apply to ICFs and CLHFs.

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 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. 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 facilities in LA County.

You can also see the CDPH vaccine schedules in English and Spanish. Additional vaccine resources from LAC DPH 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.
1. Residents
1. Facilities should routinely utilize the California Immunization Registry (CAIR2) to help verify vaccination status for residents, including on admission.
2. If the resident is unvaccinated, it is strongly recommended to get them vaccinated within a week of admission.
3. 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 CDPH AFL 23-33 (Nov 13, 2023).
4. While the CDC says individuals with recent COVID-19 infection who are not up to date “may consider” delaying their next recommended dose by up to 3 months, this consideration is based on limited data that did not include the high-risk nursing home population. SNF residents are recommended to not delay getting up to date, and should get their next recommended dose as soon as they have met criteria for ending isolation and have recovered from their acute illness.
5. During active COVID-19 outbreaks, vaccination efforts should be prioritized for individuals who are not yet up to date.
6. Residents who are immunocompromised should follow clinical recommendations specific to their health status, which could include more frequent vaccination in consultation with their clinical provider: https://www.cdc.gov/vaccines/covid-19/clinical-considerations/interim-considerations-us.html#immunocompromised 
2. Staff
1. All staff are required to should stay up to date with COVID-19 vaccines. This includes all paid and unpaid employees, indirectly employed contractors or consultants, students, trainees, and volunteers who may work on-site regardless of whether they directly care for residents.
3. Accessing COVID-19 vaccines: Facilities should work with a pharmacy to obtain vaccine supplies. If the long term care (LTC) or other pharmacy is not able to provide vaccines in a timely manner, please notify Public Health at LACSNF@ph.lacounty.gov for additional resources. Of note, all COVID-19 vaccines now must be purchased by their healthcare providers for insured individuals since the federal government is no longer paying for COVID-19 vaccines after the end of the federal Public Health Emergency. COVID-19 vaccination, along with influenza and pneumococcal vaccines, should be reimbursed through Medicare or the individual’s health plan.
4. Increase uptake and build vaccine confidence: LAC DPH developed a one-pager on Best Practices for Improving Vaccination in SNFs based on feedback from LA County SNFs. These best practices also work for ICFs and CLHFs. 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 NHSN reporting and federal regulations, track vaccine doses for all staff and residents including verifying vaccination status of new staff hires and new admissions. Please remember that facilities should utilize the California Immunization Registry (CAIR2) to help verify vaccination status for residents and staff.
   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) Individual’s name and date of birth
      2) Vaccination status: up-to-date or not up-to-date depending on the dates of the current NHSN definition
      3) Date of the current year’s dose OR date the person declined,
      4) Manufacturer of the current COVID-19 vaccine dose received. This will help facilities anticipate when individuals are due for their next recommended dose and 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).
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 after 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, such as hospitalizations and death, among high-risk individuals infected with COVID-19, particularly 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 (available for download until August 16, 2024).

Per CDPH AFL 23-29 (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. This should also be considered in ICFs and CLHFs. 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. Residents 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, unless they are not staffed to care appropriately for positive residents. If a facility or pharmacy supplying therapeutics to a facility is having difficulty obtaining sufficient doses in a timely way, especially during an outbreak, please contact LAC DPH as soon as possible at LACSNF@ph.lacounty.gov or DPH-Therapeutics@ph.lacounty.gov.

To ensure SNFs are compliant with CDPH AFL 23-29 and best practices, they 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., are close contacts and/or there is an active outbreak in the facility) 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 and sending or 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, CDPH’s COVID-19 Treatment Resources for Providers, or NIH’s Therapeutic Management of Nonhospitalized Adults with COVID-19 for the most up to date information.

Pre-exposure Prophylaxis

Pemivibart is available as an intravenous infusion for some people who are moderately or severely immunocompromised. Please see the CDC’s Clinical Considerations for COVID-19 Treatment and Pre-exposure Prophylaxis in Outpatients website.

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

• CMS QSO 20-39-NH-Revised “Nursing Home Visitation – COVID-19 (Revised)”, last updated May 8, 2023
• 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 the CDC’s Infection Control Basics website.

General Requirements

1. CDPH guidance (AFLs 20-84 and 21-51) and California Assembly Bill 2644 require that SNFs 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 SNFs 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 COVID-19 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. Masks should by worn by any resident that is suspected or confirmed to have COVID-19 when not in their rooms for 10 days after their positive test or symptom onset.
3. Masks should be worn by close contacts indoors when not in their rooms for 10 days post-exposure.
4. When warranted based on local respiratory virus conditions in the community or when there is an outbreak at the facility, masks are strongly recommended for 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. When warranted based on local respiratory virus conditions in the community, when required by a Health Officer Order (see above sections), or when there is an outbreak, all staff regardless of vaccination status are to 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.
2. 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 masking practices.
3.  When there is no outbreak at the facility, there is no Health Officer Order requiring masking, or the local respiratory virus conditions in the community do not warrant masking, it is still a strong recommendation for all staff to wear a surgical/procedure mask or higher given the high-risk nature of this setting.
4. When the hospital admission level is low and when there is no outbreak at the facility, it is still a strong recommendation for all staff to wear a surgical/procedure mask or higher, if not required to do so by the facility, local, state, or federal authority, given the high risk nature of this setting.
5. Staff must wear a fit-tested NIOSH approved N95 respirator when entering the care area or providing care for residents suspected or confirmed to have COVID-19. Please see Table 3. Summary of Isolation and Infection Control Guidance for Residents.

Visitors

1.  If not required to do so by the facility, local, state, or federal authority, visitors are strongly recommended, based on CMS QSO 20-39-NH-Revised, to wear well-fitting mask with good filtration for the duration of an indoor visit when:
   1. The facility is in an outbreak; OR
   2. Visiting residents at high risk for severe illness (e.g., moderately to severely immunocompromised).
2. Masks may be required for visitors based on local respiratory virus conditions in the community.

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)

As detailed below, HCP should follow standard precautions and COVID-19 transmission-based precautions for residents suspected or confirmed to have COVID-19, or who are asymptomatic (close contacts).

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 3.
   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.
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 warranted based on local respiratory virus transmission.
4. NIOSH-approved N95 respirators with an exhalation valve can be used as protection (i.e., as PPE) and source control when there are no anticipated high velocity body fluids 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 who are close contacts when the CDC COVID-19 Hospital Admission Level for LA County is medium to 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, however, 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 documents:

• Best Practices for Ventilation of Isolation Areas to Reduce COVID-19 Transmission Risk in Skilled Nursing Facilities, Long-Term Care Facilities, Hospices, Drug Treatment Facilities, and Homeless Shelters from CDPH based on consensus recommendations from American Society of Heating, Refrigeration, and Air Conditioning Engineers (ASHRAE), American Society for Healthcare Engineering (ASHE), and Cal/OSHA’s Aerosol Transmissible Diseases (ATD) Standard.
• Improving Ventilation Practices to Reduce COVID-19 Transmission Risk in Skilled Nursing Facilities from CDPH Occupational Health Branch
• Interim Guidance for Ventilation, Filtration, and Air Quality in Indoor Environments jointly written by CDPH, Department of Health Care Access and Information (HCAI) formerly OSHPD, and Cal/OSHA

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 state guidance above. 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#r2.

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 1. “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). To mitigate risks to others, visitation, communal dining, and group activities should be conducted in adherence to the “Core Principles of COVID-19 Infection Prevention” section of CMS QSO 20-39-NH-Revised, and the “Infection Prevention and Control Guidance” section (above) of this guidance.

Communal Dining and Group Activities

Residents who are in isolation, whether suspected and in isolating in-place or confirmed isolation in the dedicated COVID-19 isolation area, should avoid communal dining and group activities regardless of local COVID-19 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 there is an outbreak in the facility or when respiratory virus transmission is high in the community. 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 1, 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: Laboratory-based PCR vs Point-of-care Antigen Testing

1. While either 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 strongly 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. During an outbreak, facilities should not rely on POC antigen testing as their only testing strategy and should also use laboratory-based PCR/NAAT testing especially for symptomatic individuals. This is because antigen tests have lower sensitivity than molecular (PCR/NAAT) tests and a negative antigen test result in a symptomatic person does not exclude COVID-19 infection.
3. 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 (LACSNF@ph.lacounty.gov).
   1. Use the CDPH Laboratory Field Services’ Clinical and Public Health Laboratories Licensing Search page to find a laboratory with an active license in LA County.
   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.
4. 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 48 hours later 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 2. Summary of Testing Guidance

The table below contains recommendations for COVID-19 testing in SNFs based upon new federal regulations under Title 42 CFR § 483.80(h) as described in CMS QSO 20-38-NH-Revised as well as 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 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, management of close contacts, 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 3. 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

• Staff with SARS-CoV-2 infection who are permitted to return to work must wear a well-fitting mask at all times while at work around others, including non-patients, through at least Day 10.

• 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, SNFs 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 suspected 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 suspected and confirmed residents while continuing Standard Precautions. Residents who have confirmed COVID-19 infection should be isolated. 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.
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 dose recommended depending on the age group or health status) continues to be the most effective prevention against severe COVID-19 especially among high-risk populations. 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 are recommended to be immediately assessed by a prescribing clinician for eligibility for outpatient COVID-19 treatment, specifically the oral antivirals ritonavir-boosted nirmatrelvir (Paxlovid) or molnupiravir (Lagevrio). More information can be found in AFL 23-29. 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. 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 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, facilities should continue to accept patients transferring from hospitals when they’re clinically indicated even during an outbreak, and receiving facilities 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 in SNFs 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 Hospital Admission 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 criteria for opening an outbreak is met in residents OR residents/HCP (see first section with outbreak definition who have not tested positive in the past 90 days 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 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.