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Coronavirus Disease 2019

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


Summary of Recent Changes

4/27/23

  • COVID-19 vaccination section is updated with code of federal regulation references as well as the new state requirement effective Jan 1, 2023, for all healthcare providers in California, including SNFs, to report all immunizations administered at the facility to CAIR2 including but not limited to COVID-19 immunization.
  • The LAC DPH Updated Health Officer Order on COVID-19 Vaccination Requirement for Health Care Workers was revised April 20, 2023 following FDA’s deauthorization of monovalent mRNA vaccines to require health care workers newly coming into coming into compliance with this order (i.e., new hires) to receive a single dose of the bivalent vaccine.
  • Updated the outpatient COVID-19 treatment section to add that symptomatic residents who are highly suspected to have a COVID-19 diagnosis despite initial negative viral testing should also be considered eligible for an oral antiviral treatment. Please note CDPH AFL 22-20 for outpatient COVID-19 treatments is still in effect.
  • Per federal requirements, SNFs now must ensure all staff, including frontline staff, undergo basic infection prevention and control training at hire and annually. Please see the “Infection Prevention and Control Guidance” section for more details.
  • Source control continues to be required for staff (surgical/procedure masks or higher) regardless of vaccination status as per the LAC DPH "Masking in Healthcare and Direct Care Settings” Health Officer Order, effective Apr 3, 2023. Please see source control under “Infection Prevention and Control Guidance” for more details on masking guidance for residents and table 2 for visitors.
  • New table 1 “Transmission Based Precautions, PPE, and Resident Placement for COVID-19” clarifies recommendations for isolation vs quarantine.
  • Table 2 “Infection Prevention & Control Measures for Visitation” has been updated to clarify recommendations on location of visitation and to include masking recommendations for visitors during high CDC COVID-19 community level or outbreak status.
  • New table 3 “Summary of Testing Guidance” consolidates testing guidance based on CMS QSO 20-38-NH-Revised and CDC guidance.
  • New table 4 consolidates isolation and infection control guidance for residents based on their COVID-19 status or risk status.
  • The separate LAC DPH “Inter-facility Transfer Rules During COVID-19 Pandemic” page has been retired. Relevant guidance is now included in the “Inter-facility Transfers” section.
  • COVID-19 “Reporting Requirements” is updated to differentiate the various reporting requirements for SNFs, including how to report an outbreak.
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.

The current CDC COVID-19 Community Level for Los Angeles County can be found here: http://publichealth.lacounty.gov/media/Coronavirus/data/response-plan.htm

Definitions

A case is defined as an individual with a positive viral test (e.g., PCR/NAAT or antigen test) regardless of symptoms unless a confirmatory PCR/NAAT test is negative for an asymptomatic individual with a positive antigen 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 includes those who have had a higher risk occupational exposure OR those who have had community-related exposures including 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 indoors when not in their rooms, and staff donning full PPE prior to providing care or entering rooms where there are infected persons (i.e., placing on transmission-based precautions). Please see “Isolation and Quarantine” 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 in SNFs, when required, involves restricting the resident to their room as much as possible, wearing well-fitting masks indoors when not in their rooms, and staff donning full PPE prior to providing care or entering rooms where there are exposed persons (i.e., placing on transmission-based precautions). Residents in quarantine should be managed in-place; avoid movement of residents to different rooms that could lead to new exposures. Please see “Isolation and Quarantine” section below for more details.

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

  • Individuals who recently had COVID-19 still need to stay up to date with their vaccines.
  • Proof of vaccination: Individuals must show acceptable proof of vaccination that confirms the above definition. Acceptable proof of vaccination is listed by CDPH in their “Vaccine Record Guidelines & Standards” document.

COVID-19 Vaccination Guidance

Staying up to date with COVID-19 vaccine doses is critical to protecting both residents and staff in SNFs. The latest COVID-19 vaccine clinical recommendations are located on CDC’s website: Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Approved or Authorized in the US. Below are key COVID-19 vaccine guidance and resources for SNFs in LA County.

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

Offer, Track, and Report COVID-19 Vaccination Doses

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

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

Outpatient COVID-19 Treatment

Antiviral Treatment

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

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

Facilities should not transfer residents to hospitals solely for treatment of mild or moderate COVID-19. Residents should be treated at their SNF.

To ensure facilities are compliant with CDPH AFL 22-20 and best practices, facilities should:

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

    * Includes physicians, advanced practice registered nurses (e.g., nurse practitioners), and physician assistants.

Residents with COVID-19 may also be assessed for and offered IV remdesivir. Given the emergence of variants resistant to monoclonal antibodies, providing remdesivir in the outpatient setting may be of particular importance for facilities with severely immunosuppressed patients or high-risk pediatric populations.

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

Pre-exposure Prophylaxis

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

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 https://www.cdc.gov/infectioncontrol/basics/index.html.

General Requirements

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

Source Control

Residents

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

Staff

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

Visitors

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

Hand Hygiene (HH)

  1. HH should preferentially be done with alcohol-based hand rub (ABHR) with at least 60% alcohol in most cases. HH can also be done with soap and water especially when hands are visibly soiled.
  2. All staff, residents, and visitors should perform HH frequently. Please see LAC DPH’s Hand Hygiene Poster, which goes beyond WHO’s 5 Moments of Hand Hygiene for the nursing home setting.

Transmission Based Precautions and Personal Protective Equipment (PPE)

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

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

Transmission Based Precautions, PPE, Resident Placement Recommended Signage
Isolation
Separation of people confirmed or suspected to be infected with a contagious disease from people who are not infected.
  • Resident is restricted to their room with door closed if safe and practical, except when it is medically necessary to leave their room.
  • Resident wears face mask indoors when not in their room
  • Staff dons and doffs for each resident encounter:
    • N95 respirator*
    • Gloves (with hand hygiene)
    • Gown
    • Eye protection (goggles, face shield)

*If working in dedicated COVID-19 isolation area (formerly “Red Zones”) where resident doors cannot be safely closed at all times or residents frequently leave their rooms, then it is recommended to treat the entire COVID-19 isolation area as a single resident care area where staff dons a new N95 prior to entry and doffs (discards) upon exit of the area. If followed, this should be explained in a risk assessment as a part of the facility’s written mitigation plan.

COVID-19 Transmission-Based Precautions
SNF Figure 2 Diagram
Quarantine
Separation of people who were exposed to a contagious disease to see if they become sick.		 For COVID-19, quarantine is not routinely recommended. Public Health may direct individual facilities on a case-by-case basis to quarantine residents in certain risk groups (see table 4 below) to help control transmission in an outbreak.

Regardless of whether quarantine is implemented:

  • Residents should wear well-fitting masks per the source control section.
  • Residents should not be moved to different rooms to avoid movement that could lead to new exposures; i.e., close contacts should stay in their original rooms and new admissions/re-admissions should not be moved to a different room after negative serial testing is complete.
Only if a resident is placed in quarantine, then infection control signage (e.g., COVID-19 transmission-based precautions) is indicated.

Avoid the use of “Yellow Zone” or “Green Zone” signs that may not accurately communicate COVID-19 risk levels and negatively affect adherence to basic infection prevention and control.

  1. General
    1. Standard precautions must always be followed regardless of the resident’s COVID-19 status for general prevention of all infectious diseases.
    2. Transmission based precautions are based on the COVID-19 status of the resident. Please see table 1 above.
    3. Facilities should regularly audit adherence (also called adherence monitoring) to appropriate PPE use and hand hygiene via “secret shoppers” in all shifts and including all staff types.
    4. Facilities should follow CDC’s strategies to optimize the supply of PPE and equipment to have at least a 2-week supply of PPE and other infection prevention and control supplies (https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html).
    5. If there are PPE shortages, the facility should make and document efforts to acquire more supply including contacting Public Health’s PPE Coordinator: DPHPPECoordinator@ph.lacounty.gov
  2. N95 respirators
    1. All staff must wear fit tested NIOSH-approved N95 respirators per transmission-based precautions for COVID-19 as described in table 1 above.
    2. Initial and annual N95 respiratory fit testing is required for all staff per California Division of Occupational Safety and Health (Cal-OSHA).
    3. N95 respirators are recommended for all aerosol generating procedures (suction, sputum induction, non-invasive ventilation like BiPAP or CPAP, CPR, nebulizer treatments, etc.) regardless of the resident’s COVID-19 status when the CDC COVID-19 Community Level is high for LA County.
    4. NIOSH-approved N95 respirators with an exhalation valve can be used as protection (i.e., as PPE) and source control when there is no anticipated high velocity body fluids as per CDC. If high velocity body fluids are possible, then the CDC recommends wearing a surgical N95 or, if a surgical N95 is not available, cover their respirator with an additional surgical/procedure face mask or a face shield. The additional face mask or face shield should be worn in a way that does not compromise the fit of the respirator.
    5. Cal-OSHA no longer allows for re-use (over multiple shifts) or extended use (with multiple residents in the same shift) of N95 respirators when used for respiratory protection for residents in isolation for suspected and confirmed cases. However, staff may wear N95 respirators in an extended fashion if used for source control.
    6. If there is a shortage of N95 respirators, facilities should make efforts to acquire more supply including documented communication with Public Health (DPHPPECoordinator@ph.lacounty.gov). If, despite these efforts, the facility is still experiencing a shortage, facilities could consider extended use of N95 respirators and must document their reasoning in a written risk assessment.
  3. Eye protection
    1. Eye protection, which can be goggles or face shields, may be considered at the facility’s discretion for staff providing care to residents not in isolation or quarantine when the CDC Community Level for LA County is high or when the facility is in an active outbreak. Public Health may direct facilities in active outbreaks to require eye protection for all areas of the facility on a case-by-case basis to mitigate transmission.
  4. Gown use
    1. As a part of transmission based precautions for COVID-19, gowns should be worn prior to providing direct care or entering rooms/care areas where residents are in isolation (designated COVID-19 isolation area or isolating in place). Care areas include but are not limited to resident rooms, shower rooms, rehab gyms, etc.
    2. Gowns should be doffed prior to exiting resident care areas and re-entering common areas, e.g., hallways. Gowns should also be changed (i.e., doff used gown and don new gown) for every resident encounter in multi-occupancy rooms.
    3. Re-use (over multiple days) and extended use (over multiple residents) of gowns are not allowed.

Ventilation, Filtration, and Air Quality: Effective ventilation is one of the most important ways to control small aerosol transmission. Nonetheless, ventilation and other indoor air quality improvements are additions to and not replacements for infection prevention and control including any applicable state or local directives. Please carefully review in full the following guidance from CDPH, Department of Health Care Access and Information (HCAI) formerly OSHPD, and Cal/OSHA: Interim Guidance for Ventilation, Filtration, and Air Quality in Indoor Environments.

Please note SNFs have a second opportunity to apply for Civil Money Penalty (CMP) Reinvestment funds to purchase portable fans and portable room air cleaners with high-efficiency particulate air (HEPA, H-13 or -14) filters to increase air exchange or improve air quality. Facilities should only use portable air cleaners with the involvement of professionals* and following the above state guidance. While portable air cleaners may help when used correctly, facilities should not rely on any single solution to effectively improve the ventilation and air quality of their buildings. Facilities should consult with professionals* to perform comprehensive evaluations of their HVAC (Heating, Ventilation, and Air Conditioning) systems and indoor air quality and obtain permits or approvals from any applicable regulatory bodies as necessary prior to implementing changes.

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

Environmental cleaning:

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

For a list of EPA-registered disinfectants that have qualified for use against SARS-CoV-2 (the COVID-19 pathogen) go to: https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2. Products should always be used according to manufacturer’s instructions; disinfectants may not have proper effectiveness against SARS-CoV-2 if manufacturer’s instructions are not followed.

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 2. “Infection Prevention & Control Measures for Visitation” summarizes safe entry policies for visitors.
    2. All staff should follow Infection Prevention Guidance for Healthcare Personnel which includes routine self-monitoring for symptoms of possible COVID-19 and exclusion from work when symptomatic or infected with COVID-19.
    3. Prior to entry, visitors of residents in isolation (dedicated COVID-19 isolation area or in-place) should be advised of their possible exposure risk. When there is an active outbreak at the facility, all visitors should be advised of their possible exposure risk.
    4. If a facility elects to conduct entry screening at their own discretion, Emergency Medical Service (EMS) workers, including ambulance transport personnel, should not be included in the entry screening process, regardless of the urgency of the situation. Like other healthcare workers, they follow infection prevention guidance that includes routine self-monitoring of symptoms and exclusion from work when sick or infected.
  2. Conduct symptom screening for all residents.
    1. All residents should be assessed for symptoms and have their vital signs, including temperature and oxygen saturation, checked at least every 24 hours, with more frequent monitoring recommended for residents who are close contacts or suspect cases, for example every shift, and especially for residents with confirmed COVID-19, for example every 4 hours.
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) as referenced in CMS QSO 20-39-NH-Revised. To mitigate risks to other, visitation, communal dining, and group activities should be conducted adhering to the “Core Principles of COVID-19 Infection Prevention” by following the guidance in this section and the rest of this guidance including but not limited to the “Infection Prevention and Control Guidance” section.

Communal Dining and Group Activities

Residents who are in isolation, whether suspect isolating in-place or confirmed isolation in the dedicated COVID-19 isolation area, should avoid communal dining and group activities regardless of community levels or the facility’s outbreak status. Residents who are close contacts may continue participating in group activities while wearing well-fitting masks with good filtration but should not participate in communal dining through day 10 since their last exposure (day 0 being day of exposure). These activities may take place indoors or outdoors regardless of the facility’s outbreak status and regardless of the resident’s vaccination status. Facilities should continue to follow all infection prevention and control measures to conduct communal dining and group activities safely including but not limited to the following:

  1. Residents are strongly encouraged to wear source control (well-fitting masks) indoors during communal dining and group activities when there is an outbreak in the facility or when the CDC COVID Community Level is high. Communal dining and group activities should be done in shifts with the same group of residents to minimize broad exposure as much as possible.
    1. Additionally, the same group of residents should be assigned to specific areas as much as possible to further minimize exposure.
    2. Use a sign-in sheet/roster of residents present during these activities to help with contact tracing should a resident later test positive for COVID-19.
  2. Outdoor settings should be prioritized for communal dining and activities whenever practical, and especially during an outbreak.
  3. For further guidance on communal dining and activities during the holidays, please refer to CMS QSO-20-39-NH-Revised, FAQs section, #2.
  4. If there is a COVID-19 outbreak in the facility, the facility should work with their assigned outbreak investigation team from Public Health to mitigate transmission, which may include temporarily pausing communal dining and activities for all residents regardless of COVID-19 status or vaccination status, both indoors and outdoors. The facility should have documentation of communication with their Public Health contact directing them to do so including an anticipated date to resume communal dining and activities.

Visitation

  1. Facilities should follow CMS QSO 20-39-NH-Revised to ensure they are supporting in-person visitation in a manner that is consistent with resident rights as protected by Title 42 CFR section 483.10(f)(4)(v) while minimizing infectious risk to other residents and staff.
  2. Health care workers including consultants, students, volunteers, and contractors who enter the facility to provide services to residents, even if they are not directly employed by the facility, are not considered visitors for the purposes of this guidance and should adhere to the same COVID-19 infection prevention requirements for staff (e.g., masking, donning and doffing required PPE for COVID transmission-based precautions).
  3. Public Health may be more protective and, on a case-by-case basis, can direct facilities with active outbreaks to temporarily cease visitation, both indoors and outdoors, to assist with outbreak investigation and/or management. This should be rare. The facility should have documentation of communication with their Public Health contact directing them to do so including an anticipated date to resume visitation. However, even when there is a temporary suspension of visitation, there must be a consideration of resident rights which means some visitation may still occur. This includes, but is not limited, to compassionate care visitation for residents in critical condition or end-of-life situations; essential support person visitation for residents who are experiencing weight loss, dehydration, failure to thrive, psychological distress, or functional decline or struggling with a change in environment; and essential support person visitation for residents with physical, intellectual, or developmental disability or cognitive impairment.
  4. Visitors who are unable to adhere to the core principles of COVID-19 infection prevention as outlined in CMS QSO 20-39-NH-Revised should not be permitted to visit or should be asked to leave.
  5. Table 2, below, is a summary of infection prevention and control measures for visitation based on CMS and CDC guidance:
Table 2. 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 4). 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 4). Criteria for the general public does not apply in this setting given the high-risk nature of these facilities and their residents.
Masks Based on CMS QSO-20-39-NH-Revised, visitors should wear well-fitting masks when indoors if: 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 should is 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

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

Table 3. Summary of Testing Guidance

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

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

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

 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 Quarantine” 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 (suspect case) should be immediately be isolated in place pending results of confirmatory PCR/NAAT testing. Please see “Isolation and Quarantine” 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 have the ability to ramp up testing in the event routine screening testing is required again 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 the CDC Community Level is high and a consideration at lower transmission.

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

If admission testing is performed, this does not necessarily mean quarantine is indicated. Please see “Isolation and Quarantine” 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 quarantine (close contact) or isolation (symptomatic) have been met.
  2. If outbreak testing has been triggered and an asymptomatic resident refuses testing, the facility should ensure the resident wears a mask indoors when not in their room, avoids communal dining, and practices effective hand hygiene until the outbreak has been closed.

Isolation and Quarantine

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

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

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 (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 PCAR/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)
Suspect COVID-19 Case:
  • Symptomatic pending test results
  • 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 (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.
  •  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, high community level, in addition to clinical presentation. 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 wear well-fitting masks indoors when they are not in their rooms through day 10 after last exposure.
  • Residents should avoid communal dining, but should be allowed to continue group activities.
  • Quarantine*** is not routinely recommended. Public Health may direct individual facilities on a case-by-case basis to quarantine close contacts to help control transmission in an outbreak.
    • When applicable, quarantine duration should be 7 days when all tests are negative or 10 days if testing was not complete.
  • 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.
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 the CDC COVID-19 Community Level is high for LA County.
  • Quarantine*** is not routinely recommended. Public Health may direct individual facilities on a case-by-case basis to quarantine these resident groups in-place to help control transmission in an outbreak.
    • When applicable, quarantine duration should be 7 days when all tests are negative or 10 days if testing was not complete.
  • 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 the CDC COVID-19 Community Level is high for LA County.
  • Avoid moving residents after negative serial testing is complete.
  • Quarantine*** is not routinely required. Public Health may direct individual facilities on a case-by-case basis to quarantine these resident groups in-place (do not move to different rooms once quarantine is complete) to help control transmission in an outbreak.
    • When applicable, then quarantine duration should be 7 days when all tests are negative or 10 days if testing was not 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.

***Quarantine involves 1) restricting the resident to their room as much as possible if safe and practical; 2) resident wearing well-fitting masks indoors when not in their rooms; and 2) staff wearing 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.). Residents in quarantine should be managed in-place; avoid movement of residents that could lead to new exposures.

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

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

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

Reporting Requirements

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

*NOTE: The current COVID-19 outbreak definition for SNFs in Los Angeles County is at least one PCR/NAAT laboratory confirmed case of COVID-19 (symptomatic or asymptomatic) OR at least one symptomatic case with a positive SARS-CoV-2 antigen result in a SNF resident who has been at the facility for at least 7 days.

For more details, please see the LAC DPH COVID-19 Case Reporting Protocol for SNFs or visit the LAC DPH COVID-19 Provider Reporting page.

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