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Coronavirus Disease 2019

Guidelines for Preventing & Managing
COVID-19 in Skilled Nursing Facilities


Important Changes

10/31/2024: There is a new website for the annual winter respiratory virus season Health Officer Order: http://ph.lacounty.gov/acd/respvirusseasonhoo.htm. Please go through it and familiarize your staff with the requirements for November 1, 2024-April 30, 2025. Specifically:

  • Staff must receive both the influenza vaccine and the COVID-19 vaccine for the 2024-2025 winter respiratory virus season, OR wear a well-fitting, high-quality mask with good filtration, or higher-level respirator, at all times when in contact with residents or when in resident care areas or areas of the facility in which residents may be present. Staff who decline one or both of the vaccines must present this declination to their employer in writing on a form provided by their employer.
  • Masking for all staff has been required since 07/15/2024. Staff that have received BOTH the influenza and the updated COVID-19 vaccine for 2024-2025 may continue to mask for their own protection but will not be required to mask from November 1, 2024- April 30, 2025, unless there is an outbreak in the facility. Communicate this when speaking to staff about receiving the COVID-19 and influenza vaccines, although masking regardless of vaccination status may continue to be required by your facility or, if warranted based on local respiratory virus transmission, by LAC DPH. The following requirement is still in place:
    • Before entry, all visitors must be offered self-testing with a COVID-19 antigen test and a well-fitting, high-quality mask with good filtration to wear during their visit. This is regardless of vaccination status.
      • If a visitor refuses the test and/or mask, they should not be barred from entry, but should be allowed to conduct their visit, as long as they avoid others in the facility and visit their loved one in a facility-designated space with good ventilation. Symptomatic visitors should especially be highly encouraged to return after they recover or wear a mask during their visit.
      • If a visitor tests positive for COVID-19, whether symptomatic or not, they should not be allowed to visit until after they recover.
      • To order more antigen tests from LAC DPH, please fill out this form: COVID-19 Antigen Test Request Form.
Introduction

These guidelines outline actions that Skilled Nursing Facilities (SNFs) should take to help prevent and manage COVID-19, based on the current status of and trends in community transmission in LA County.

Definitions

A case is defined as an individual with a positive COVID-19 test.

  • Confirmed: resident cases who are either symptomatic with a positive viral test (PCR/NAAT or antigen) or asymptomatic with a positive molecular (PCR/NAAT) test.
  • Suspect: resident cases who are symptomatic with pending/unknown test results or asymptomatic with a positive antigen test pending confirmatory PCR/NAAT testing.
  • Residents: a close contact is defined as sharing the same indoor airspace (e.g., resident room, rehab gym, communal dining room, communal activity/visitation area, shower room, hallway, nursing station, etc.) for a cumulative total of 15 minutes or more over a 24-hour period with a case during their infectious period regardless of source control.
  • Staff: an exposed staff member includes those who have had a higher risk occupational exposure OR those who have had close contact outside of work and close contact with another staff while working in non-resident care areas (administrative offices).
  • The infectious period is defined as 2 days prior to the date of symptom onset (or the positive specimen collection date, if asymptomatic) through day 10 after symptom onset or date of positive specimen collection.

The separation of persons with COVID-19 from persons without COVID-19. Isolation measures in SNFs include restricting the resident to their room, infected residents wearing well-fitting masks when not in their rooms, and staff donning full PPE prior to providing care or entering rooms where there are infected persons (i.e., those placed on transmission-based precautions). Please see “Isolation and Management of Close Contacts of Cases” section below for more details.

Quarantine keeps asymptomatic persons who might have been exposed to SARS-CoV-2 away from others to see if they become infected. Quarantine is no longer recommended in SNFs, and residents who are close contacts of cases are discussed below.

An individual is considered up to date with COVID-19 vaccines when they have received all doses recommended for them by the CDC.

COVID-19 Vaccination Guidance

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:

Outpatient COVID-19 Treatment

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.

Infection Prevention and Control Guidance

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

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:

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.

COVID-19 Prevention - General and Administrative Practices

  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.
Communal Dining, Group Activities, and Visitation

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

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:
Table 1. Infection Prevention & Control Measures for Visitation
Residents Not in Isolation Residents in Isolation (dedicated COVID-19 isolation area or in-place)
Safe Entry Policies
  • All visitors must be educated that they may not enter if they have any of the following: 1) recent positive viral test for SARS-CoV-2*, 2) COVID symptoms*, 3) close contact ≤14 days.
  • When there is an active outbreak at the facility, all visitors should be advised of their possible exposure risk prior to entry.

    • * Visitors should follow the same criteria used to discontinue isolation for SNF residents (please see table 3). Criteria for the general public does not apply in this setting given the high-risk nature of these facilities and their residents.
  • All visitors must be educated that they may not enter if they have any of the following: 1) recent positive viral test for SARS-CoV-2*, 2) COVID symptoms*, 3) close contact ≤14 days.
  • Prior to entry, visitors should be advised of their possible exposure risk and the other infection prevention practices in this table.

    • * Visitors should follow the same criteria used to discontinue isolation for SNF residents (please see table 3). Criteria for the general public does not apply in this setting given the high-risk nature of these facilities and their residents.
Masks Visitors are strongly recommended to wear well-fitting masks when indoors if:
  • Respiratory virus transmission is high in the community; OR
  • Facility is in an outbreak; OR
  • Visiting residents at high risk for severe illness (moderately to severely immunocompromised)
 All visitors should be offered an N95 respirator or higher and perform a seal check. Residents should also wear well-fitting masks if safe and practical.
Other Infection Prevention and Control
  • Visitors should frequently perform hand hygiene preferably with alcohol-based hand rubs.
  • Visitors should frequently perform hand hygiene preferably with alcohol-based hand rubs.
  • Facilities may offer visitors additional PPE (eye protection, gowns, gloves) for COVID-19 transmission based precautions.
Physical Distancing There is no recommendation to physically distance or avoid physical contact (e.g., hugs, holding hands) between a resident and their visitor(s), regardless of vaccination status. However, physical distancing should be followed during large indoor gatherings to avoid crowding especially in poorly ventilated areas.
Location of Visit
  • Outdoor visitation is preferred whenever practical and if the outdoor visitation area is easily accessible from the facility entrance.
  • Dedicated large indoor spaces with good ventilation are preferred if outdoor visitation is not practical (e.g., inclement weather, poor air quality, inability to move resident outside) or it is difficult to conduct in-room visitation without roommates present.
  • Per CMS, in-room visitation is ideal when the roommate is not present and is preferred during an outbreak. If that is not an option, then the number of visitors that are in the room at one time should be limited to avoid crowding and all visitors should wear a well-fitting mask while in the room and perform frequent hand hygiene.
  • During outbreaks, facilities should ensure visitors limit their movement inside the facility and go directly to the resident’s room or visitation area.
  • Visitation is preferably conducted in the resident’s room.
  • During outbreaks, facilities should ensure visitors limit their movement inside the facility and go directly to the resident’s room or visitation area.

COVID-19 Testing

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.

Testing Indication Residents Staff
Symptomatic
Individual with symptoms of COVID-19 including mild symptoms, regardless of vaccination status

NOTE: If a staff or resident develops new symptoms consistent with COVID-19 ≤ 90 days of a prior positive test and an alternative etiology cannot be identified, then retesting with an antigen test can be considered in consultation with the medical director, infectious disease, or infection control experts.

 One antigen test immediately and if negative, one PCR/NAAT test collected 48 hrs later for a total of at least 2 tests;

OR

One PCR/NAAT test immediately.

During the respiratory virus season, residents with acute respiratory symptoms should also be tested for influenza and other respiratory viruses as per LAC DPH's guidance on management of influenza in context of COVID-19 in SNFs.

 Test immediately. Please see LAC DPH’s COVID-19 Infection Prevention Guidance for Healthcare Personnel.
Contact Tracing Testing
One or more case(s) identified in a resident or staff AND contact tracing is feasible (i.e., exposure is known and limited and there are staffing resources to support rapid contact tracing). 		Serially test residents who are close contacts1 and exposed staff identified in contact tracing 3 times on days 1, 3, and 5 after the last exposure (day 0).

Antigen tests or PCR/NAAT tests (if TAT is <48 hrs) may be utilized.

If additional resident case(s) are identified during close contact testing, then the facility should immediately broaden their testing strategy to group-level or facility-level response testing serially every 3-7 days for PCR/NAAT tests (if TAT <48 hrs) or every 3 days for antigen tests until there are no new cases identified among residents or staff for 14 days.

Any asymptomatic residents with positive antigen test results (suspect case) must immediately be isolated in place pending results of confirmatory PCR/NAAT tests. Please see “Isolation and Management of Close Contacts” section.
Group-level testing2 involves all residents and staff in the same area (unit, wing, nursing station area, etc.), regardless of vaccination status, when ≥1 case is identified in a resident or staff. This is the recommended initial response testing strategy when the exposure is suspected to be limited to the same area of the facility.

Facility-wide testing2 involves all residents and staff in the facility, regardless of vaccination status, when ≥1 case is identified in a resident or staff. This is the recommended initial response testing strategy when widespread exposure is suspected, the exposure level is unknown, or contact tracing is unreliable or unable to be performed in a timely way.

For initial response testing strategy: serially test on days 1, 3, and 5 after exposure (day 0).

If the initial round of testing on days 1, 3, and 5 yields additional cases among residents, then response testing should be further broadened to facility-wide if not done so already.

Subsequent rounds of response testing should be every 3-7 days for PCR/NAAT tests (if TAT <48 hrs) or every 3 days for antigen tests until there are no new cases identified among residents or staff for 14 days.

Any asymptomatic residents with positive antigen test results (suspected case) should immediately be isolated in place pending results of confirmatory PCR/NAAT testing. Please see “Isolation and Management of Close Contacts” section.

Routine screening testing2: Individuals who are asymptomatic, not a new admission or re-admission, not a close contact, and when there is no facility-wide or group-level post-exposure or response testing. Generally not recommended, but may be performed at the discretion of the facility. If a facility chooses to conduct routine screening testing, it should not be based on vaccination status and resident rights should be respected (i.e., resident refusal should not result in quarantine or influence their rooming or placement).

NOTE: Facilities should maintain testing capacity and should have the ability to ramp up testing in the event routine screening testing is required at a future date.
New Admissions and Re-Admissions2 who are asymptomatic without a current diagnosis of COVID-19 at the time of admission and without known close contacts.

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

 Serially testing a total of 3 times on days 0, 3, and 5 after admission (day 0) is a strong recommendation when transmission of respiratory viruses (including SARS-CoV-2) is high in the community and a consideration when the level is low. Public Health may direct individual facilities on a case-by-case basis to test all admissions and re-admissions to help control an outbreak.

Antigen tests or PCR/NAAT tests (if TAT is <48 hrs) may be utilized.

If admission testing is performed, follow guidance in “Isolation and Management of Close Contacts” section.

 Not applicable.
Footnotes:
Retesting Previously Positive Staff/Residents
  1. Testing recommendations for asymptomatic residents who recently recovered from a COVID infection and who become a close contact are as follows. If their last positive test was:
    1. ≤30 days ago, then repeat testing is not recommended.
    2. 31-90 days ago, then point-of-care antigen testing may be considered at least 5 days after the most recent exposure.
  2. Staff or residents who previously tested positive within the last 90 days and are asymptomatic should not be included in routine screening (if applicable per facility’s discretion), facility-wide or group-level response testing, or new admission/re-admission testing.

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.

Isolation and Management of Close Contacts of Cases

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

Who Infection Control Measures
Confirmed COVID-19 Case
  • Isolate in a designated COVID-19 isolation area (formerly Red Zone)* as per CDPH AFL 23-12.
  • Place on COVID-19 transmission-based precautions
    • Resident is restricted to their room with door closed if safe and practical, except when it is medically necessary to leave their room.
    • Staff dons full PPE prior to entering care area or providing care.
  • Residents should wear well-fitting masks indoors when not in their room for the duration of their isolation period.
  • Typically, time-based strategy is recommended for determining the isolation duration:
    • Symptomatic residents: at least 10 days AND improvement in symptoms AND fever-free without use of medications for 24 hours (time-based strategy)
    • Asymptomatic residents: 10 days since collection date of positive PCR/NAAT test without the development of new symptoms. If they develop symptoms during their infection, the isolation period should be restarted from the onset of symptoms per the symptomatic resident criteria above.
  • Test-based strategies for determining isolation duration are recommended for the following situations and should be done under advisement of an infectious disease specialist:
    • Residents who had critical illness due to COVID-19: isolation duration could be extended up to 20 days
    • Residents with severely immunocompromising conditions**: isolation duration may be extended beyond 20 days since symptom onset or date of initial positive test (if asymptomatic)
Suspected COVID-19 Case:
  • Symptomatic pending test results
  • Symptomatic with a negative point-of-care antigen testing pending confirmatory laboratory-based molecular (PCR/NAAT) testing
  • Asymptomatic with positive point-of-care antigen test pending confirmatory laboratory-based molecular (PCR/NAAT) testing
  • Immediately isolate in place (avoid movement of residents that could lead to new exposures) and place on COVID-19 transmission based precautions (resident is restricted to their room except when it’s medically necessary to leave their room; staff dons full PPE prior to entering care area or providing care) while pending clinical evaluation and testing results.
    •  For residents awaiting testing results in multi-occupancy rooms, strategies to reduce exposures between residents should be implemented including but not limited to drawing curtains between resident beds. Staff should change gowns and gloves with frequent hand hygiene between each resident contact in the same room.
  • Residents should be restricted to their rooms as much as possible (avoid communal dining and group activities) and wear well-fitting masks indoors when not in their rooms.
  • If a point of care (POC) antigen test is used initially and is negative, then isolation should be maintained, and a confirmatory PCR/NAAT test should be collected 48 hours later.
  • During the respiratory virus season, residents with acute respiratory symptoms should also be tested for influenza and other respiratory viruses as per LAC DPH's guidance on management of influenza in context of COVID-19 in SNFs.
  • Isolation duration is dependent on the level of clinical suspicion for COVID-19 which should consider epidemiologic factors, e.g., ongoing outbreak, recent close contact, in addition to clinical presentation and alternate diagnosis. This decision should be made in consultation with a clinical/treating provider.
    • Low clinical suspicion: isolation can be discontinued when PCR/NAAT test is confirmed negative
    • Higher clinical suspicion and/or no clear alternate diagnosis: isolation can be discontinued when two (2) PCR/NAAT tests taken 24 hrs apart are confirmed negative
    • No testing: At least 10 days AND improvement in symptoms AND fever-free for 24 hrs without fever-reducing medications
  • Symptomatic residents who decline testing should not be isolated in a room with other residents with confirmed SARS-CoV-2 infection. However, certain staff dedicated to caring for confirmed cases (e.g., RN, LVN) may also provide care for these residents if infection prevention and control practices are strictly adhered to and shared staff visit their rooms after providing care to confirmed cases.
  • If SARS-CoV-2 infection is confirmed, then residents should be immediately moved into the designated COVID-19 isolation area to complete the remainder of their isolation.
Close contacts (asymptomatic)
  • Residents should avoid communal dining, but should be allowed to continue group activities.
  • Exposed residents must wear well-fitting masks indoors when not in their rooms for 7 days when all tests are negative or 10 days if testing was not complete.
  • Staff should wear full PPE per COVID transmission based precautions when providing care or entering a room where the resident is (resident room, shower room, rehab gym, etc.).
  • Exposed residents should be managed in-place; avoid movement of residents that could lead to new exposures.
  • Closely monitor for signs and symptoms of COVID-19 including temperature and oxygen saturation checks at least once per shift for 10 days after exposure. If symptoms develop, immediately isolate in place and test.
Residents undergoing group-level or facility-wide post-exposure and response testing who are asymptomatic and not part of the above categories
  • Residents are strongly recommended to wear well-fitting masks indoors when they are not in their rooms during an active outbreak or when transmission of COVID-19 is high.
  • Closely monitor for signs and symptoms of COVID-19 including temperature and oxygen saturation checks at least once per shift. If symptoms develop, immediately isolate-in place and test.
New admission, re-admissions, or returning after leaving the facility >24 hrs who are asymptomatic and not part of the above categories
  • Residents are strongly recommended to wear well-fitting masks indoors when they are not in their rooms during an active outbreak or when transmission of COVID-19 is high.
  • Avoid moving residents after negative serial testing is complete.
  • Monitor for signs and symptoms of COVID-19 including temperature and oxygen saturation checks at least once per shift. If symptoms develop, immediately isolate in place and test.
Footnotes:
* Special staffing considerations for the designated COVID-19 Isolation Area:
  • During outbreak investigations, Public Health may direct facility to assign staff to the designated COVID-19 isolation area. If this is the case, dedicated staff should not care for residents outside of the isolation area. If staff must care for other residents, e.g., due to critical staffing shortage, they should visit the isolation area last.
  • If a facility is experiencing critical staffing shortage and there is prior approval from Public Health, asymptomatic staff with confirmed COVID-19 infection may be allowed to work only in the designated COVID-19 isolation area while wearing an N95 respirator for source control at all times while in the facility until they are no longer considered infectious and meet routine return to work criteria. The approval should include the anticipated duration of work for each asymptomatic confirmed staff. The facility must also show they are actively working to secure more staffing. Asymptomatic confirmed staff will need to be able to keep separated from uninfected staff, which includes having separate breakrooms.

**The following are considered severely immunocompromising conditions as per CDC: actively receiving chemotherapy for cancer, hematologic malignancies, being within one year from receiving a hematopoietic stem cell or solid organ transplant, untreated HIV infection with CD4 count <200, combined primary immunodeficiency disorder, taking immunosuppressive medications (e.g., drugs to suppress rejection of transplanted organs or to treat rheumatologic conditions such as mycophenolate, rituximab, prednisone dose >20mg/day for more than 14 days), or other severely immunocompromised condition as determined by the resident’s primary/treating physician.

Healthcare Personnel Monitoring and Return to Work

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.
For return to work refer to the following sections:

Inter-facility Transfers

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.

In cases of hospital overload, this transfer guidance may be adjusted by LAC DPH.

Reporting Requirements

Per LAC DPH’s COVID-19 Reporting Requirements Health Officer Order and, the CDPH AFL 23-08, SNFs are required to report within 24 hours:

  • Any suspected COVID-19 outbreak* to both Public Health (LAC DPH) and Licensing & Certification. Report to LAC DPH using one of the following methods:
  • COVID-19 associated deaths:
    • Death certificates are now the primary means of tracking COVID-19 deaths at the local, state, and federal levels to accurately assess trends and inform public health response. If COVID-19 played a role in a patient’s death, it is important to report it accurately on the death certificate. For more information on certifying deaths due to COVID-19 for clinical providers (including SNF medical directors), please see the Los Angeles County Health Alert Network message dated July 3, 2023 and CDC’s guidance.
    • Additionally, COVID-19 associated deaths must be reported within 24 hours following the instructions here. Deaths should be considered COVID-19 associated if COVID-19:
      • Directly preceded death, or
      • Initiated the train of morbid events leading directly to death, or
      • Is a significant condition that contributed to the death.
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Public Health has made reasonable efforts to provide accurate translation. However, no computerized translation is perfect and is not intended to replace traditional translation methods. If questions arise concerning the accuracy of the information, please refer to the English edition of the website, which is the official version.

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