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Coronavirus Disease 2019

Developing COVID-19 Dedicated Skilled Nursing Facilities

Developing COVID-19 Dedicated Skilled Nursing Facilities

Updated 10-19-20


Vulnerable patients housed in skilled nursing facilities (SNFs) have been impacted heavily by COVID-19. In order to try to decrease the risk of outbreaks in SNFs, public health authorities have recommended strict rules for transfer of patients with COVID-19 from acute care hospitals to SNFs. While this measure has protected patients in SNFs, it has also caused bottlenecks in hospital discharges when patients no longer require hospital-level care, but they do not meet the transfer criteria to SNFs. Designating specific buildings, units or floors of SNFs to care for COVID-19 fills this valuable niche to both keep SNFs safer and at the same time open needed hospital capacity.

Facilities that are interested in having specific units, floors, or buildings dedicated to COVID-19 patients must meet specific baseline requirements and should be prepared to operate within a specified infection prevention structure. This document will help identify some of the principles that should be considered by SNFs as they begin to move down this path. Contact Acute Communicable Disease Control if your facility is interested is receiving this designation by emailing Covid-facility@ph.lacounty.gov.

Baseline Requirements

I. Getting Started

  1. Basic infection prevention requirements should be met by the facility in line with published guidance (http://ph.lacounty.gov/acd/ncorona2019/snf.htm).
  2. Requirements for designation.
    1. Facilities with high level regulatory findings (i.e.. immediate jeopardy, etc.) in previous 24-month period will not be eligible for consideration.
    2. Facilities with evidence of ongoing COVID-19 transmission (onset of newly symptomatic cases of COVID-19 within the previous 14 days) must wait to be designated until cases have resolved.
  3. Develop a written plan which addresses all of the areas of this document. This document should address the facility approach to the following specific areas of emphasis:
    1. Staffing of the unit
    2. Physical cohorting plan for the unit. The plan should include a floorplan of the unit with clear markings of physical barriers separating areas with COVID-19 patients.
    3. Shared equipment cleaning
    4. Personal protective equipment (PPE) plan for the facility including plans for optimization of PPE.
    5. Admissions requirements
    6. Discharge/Transfer requirements
  4. If SNF designates a specified unit or floor that is part of a larger facility, this site will have additional requirements.
    1. Staff for the COVID-19 unit should be kept separate at all times.
    2. The unit should be separated from the remainder of the facility through a separate entrance if possible.
    3. Equipment should be dedicated to the COVID-19 unit and should not be moved between COVID-19 and non-COVID-19 areas.
  5. Facilities should develop a plan for transportation of COVID-19 positive patients.
  6. All proposed COVID-designated units, floors or buildings will be assessed by a LAC DPH infection prevention specialist prior to receiving patients, to ensure the area is appropriate for COVID-19 care.
  7. Ongoing monitoring of COVID-19 receiving facilities
    1. Facilities will continue to be monitored daily by Health Facilities Inspection Division (HFID)
    2. Facilities will be required to do weekly check-in calls with nurses from the Acute Communicable Disease Control (ACDC) Program that oversees COVID-19 facilities.
    3. Facilities will be required to complete a data spreadsheet for COVID-19 unit patients weekly. This spreadsheet will be given to each facility to complete.
    4. If facilities are unable to maintain requirements of designation, they may be removed from LAC DPH designation list.

II. Staffing

  1. Facilities should designate specific staff to the COVID-19 facility.
    1. Consider preferentially staffing the facility with healthcare personnel who have recovered from COVID-19.
    2. All staff that provide care to COVID-19 patients are not to work or enter into any non-COVID-19 area or facility.
    3. If feasible, any non-clinical staff that work or go into the COVID-19 facility or unit are dedicated to COVID-only facilities or areas.
    4. Staff designated to care for COVID-19 patients should have dedicated respite areas if possible or should adhere to social distancing, enhanced environmental cleaning and universal source control in common areas.
    5. COVID-19 unit PPE donning and doffing areas should be located at least 6 feet away from other staff and resident areas. Doffing area may be inside the COVID-19 dedicated unit, but staff should keep respiratory protection on until after leaving the unit.
    6. Designated staff should minimize their interaction with staff from other COVID-19-naïve units or facilities.
    7. Receiving centers should have ready access to respiratory therapy as many patients recovering from COVID-19 will have significant respiratory problems.
  2. Personal protective equipment (PPE)
    1. Facility should have adequate PPE to manage a fully occupied COVID-19 facility for at least 4 weeks.
    2. Calculate PPE burn rate (https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/burn-calculator.html).
    3. SNFs should have plans for PPE conservation in place to maximize their PPE supply (https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html).
    4. Staff should have PPE donning and doffing competencies be performed prior to work in the unit.
    5. Ensure adequate supplies of hand sanitizer and EPA-approved healthcare disinfectant on the unit.
    6. Covid-19 unit should have alcohol hand hygiene dispensers available in donning and doffing areas and at entrance and exit areas of the COVID-19 unit.

III. Procedures

  1. Transfer in
    1. SNFs should admit COVID-19 confirmed patients once they are deemed medically stable. Patients recovering from COVID-19 can initially appear stable but can decompensate rapidly. Receiving centers should staff in order to anticipate higher acuity patients than normal.
    2. Patients who are early in their COVID-19 infection should be monitored closely for clinical worsening and should develop plans for transport to acute care hospitals rapidly.
    3. Transportation from acute care hospitals should be coordinated with acute care hospitals directly. LAC DPH does not have access to additional transport options for COVID-19 positive patients.
  2. Transfer out
    1. Viral shedding is still not clearly defined for COVID-19 for all patient groups, therefore the recommended duration of cohorting may be vary between different public health authorities. Because patients in SNFs are at particular risk for poor outcomes, these guidelines are more stringent than for the general population or for home-dwelling individuals.
    2. Residents who test positive for COVID are considered non-infectious in the following situations and removed from COVID-19 designated cohort area:
      1. If COVID+ status was identified as part of asymptomatic testing: 14 days from testing date if they remain asymptomatic. If residents develop symptoms, the 14-day isolation period should restart from the date of symptom onset.
      2. If patients required hospitalization: 14 days from date of hospitalization and no fever for 72 hours, whichever is longer.
      3. If symptomatic, but not requiring hospitalization: 14 days from symptom onset or 72 hours after last fever, whichever is longer.
      4. The CDC test-based strategy may be used as an alternative to time-based strategy: Residents who are clinically improving may be removed from isolation after testing negative twice using PCR testing at least 24 hours apart and at least 72 hours after last fever.
  3. Transferring patients from the COVID-19 unit for medical care (medical appointments, dialysis, etc.)
    1. All residents of the COVID-19 dedicated unit should don a surgical mask, clean clothes and perform hand hygiene prior to travel off the unit.
    2. Transportation for COVID-19 patients will need to be arranged by the SNF and any EMS or other transport company should be notified of COVID-19 status.
    3. Receiving facilities should be notified of COVID-19 status of patient prior to transport.

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