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.
COVID-19 Vaccination Guidance:
Definition of Fully Vaccinated:
A person is considered fully vaccinated ≥2 weeks following the receipt* of either:
* This guidance can also be applied to COVID-19 vaccines that have been listed for emergency use by the World Health Organization (e.g. AstraZeneca/Oxford and Sinopharm). COVID-19 vaccines that receive WHO’s Emergency Use Listing (EUL) have met international standards for safety, efficacy and manufacturing and are deemed suitable for use during a public health emergency.
NOTE: Staff and visitors can only be considered fully vaccinated if they show acceptable proof of vaccination that confirms the above definition.
Track, Increase, and Maintain COVID-19 Vaccination Coverage
This will a) help facilities anticipate when individuals are due for a booster, if and when approved by the FDA and CDC, or an additional dose as recommended by the CDC, b) help facilities’ ability to efficiently implement guidance in this document that depends on vaccination status, and c) allow for easier reporting on vaccination surveys from Public Health and CDPH.
The purpose of these visitation guidelines is to help each facility develop a resident-centered visitation policy that balances the need to protect staff and residents from COVID-19 transmission with the need to provide timely care that optimizes residents’ physical and psychological health in alignment with state and federal requirements.
The following recommendations for communal dining, group activities, and visitation are based upon the most recent CDPH All Facility Letter (AFL) CMS Quality Safety & Oversight memo (QSO):
Criteria for Communal Dining, Group Activities, and General Visitation
For facilities to allow any gathering, facilities must meet these baseline CMS criteria:
1Per CMS Guidance, contingency PPE capacity strategy is allowable, such as CDC’s guidance Optimizing Supply of PPE and Other Equipment during Shortages. However, facilities’ crisis capacity PPE strategy does not constitute adequate access to PPE.
Communal Dining and Group Activities
Communal dining and group activities are permitted only for residents in the Green Cohort and certain Yellow Cohort residents* provided the facility meets the baseline criteria. Group activities are permitted outdoors and may be permitted indoors depending on the resident’s vaccination status, the resident’s COVID-19 status, and the facility’s outbreak status.
* If there is no outbreak in the facility, the following residents of the Yellow Cohort may follow the Green Cohort permissions for communal dining and group activities (as long as they are asymptomatic and are not close contacts/considered exposed to a case):
See Table 1 Communal dining & group activities
Facility should adhere to the following measures for all communal dining and group activities:
If there is a COVID-19 outbreak in the facility, then the following applies:
General visitation should be supported by the facility provided the facility meets the baseline criteria above.
Resident Rights: Facilities may not restrict visitation 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 stated in CDPH AFL 20-22.8 and CMS QSO 20-39-NH-Revised. Furthermore, residents or their designated representative when the resident does not have capacity, should be involved, and have their preferences prioritized in the determination of essential visitors (e.g. caregivers/essential support persons, compassionate care visitors). Failure to facilitate residents’ visitation rights, without adequate reason related to clinical necessity or resident safety, would constitute a potential violation of this federal regulation, and the facility would be subject to citation and enforcement actions.
If the visit is conducted outdoors between a fully vaccinated resident of the Green Cohort and their fully vaccinated visitor, then they do not have to wear a face mask nor physically distance and can include physical contact.
Below are recommendations for testing and cohorting in SNFs based upon California Department of Public Health (CDPH) requirements outlined in recent CDPH AFLs:
NOTE: Interpretation of COVID-19 viral test results do not change after an individual has received COVID-19 vaccination.
Testing of Symptomatic Residents or Staff.
Response Testing. If a single positive COVID-19 case is identified among either staff or residents, the SNF must conduct comprehensive testing of all residents and staff regardless of vaccination status to identify potential asymptomatic infections. All residents and staff should be tested once every 3-7 days. If testing capacity is limited, testing may be prioritized for the residents and staff in the same area (e.g., nursing station, floor, etc.) as the COVID-19 positive individual. Any close contact and exposed residents of confirmed COVID-19 cases will need to be quarantined accordingly in the Yellow Cohort (see below). All residents and staff who test negative will need to be included in response testing until there are at least 2 weeks with no additional infections identified. After 2 weeks of negative testing for residents, the facility could restart routine testing for residents as outlined below, in consultation with local Public Health.
Routine Screening Testing
Routine screening testing must be conducted according to the latest CDPH AFL 20-53 and AFL 12-28 as described below. If any resident or staff tests positive, the SNF must report the positive case to LAC DPH and proceed with response testing as described above. Routine screening testing is resumed when no new cases are identified from two sequential weeks of response testing. If COVID-19 point of care antigen tests are used as an alternative to PCR tests, then they should be administered at least twice per week and confirmatory PCR testing should follow LA County's SNF antigen testing guidelines; otherwise, the following guidance still applies.
Retesting Previously Positive Staff/Residents
Figure 1. Testing Schematic
Refusal of Testing
Facilities should have 3 separate cohorting areas as described below and shown in Figure 2.
Figure 2. Cohorting
Special Staffing Considerations in Cohort Areas
Below are general and COVID-19 specific recommendations. For more information on infection control recommendations, visit https://www.cdc.gov/infectioncontrol/basics/index.html.
Universal Source Control
Hand Hygiene (HH)
Respiratory Hygiene/Cough Etiquette:
Transmission Based Precautions and Personal Protective Equipment (PPE)
HCP should follow transmission- based precautions for each cohort including standard precautions and wearing of appropriate PPE while providing resident care as detailed below.
Figure 3. PPE in Each Cohort
In addition to CDC guidelines, the recommendations below are referenced from the California Department of Public Health AFL for Environmental Infection Control for the Coronavirus Disease 2019 (COVID-19).
All HCP should routinely self-monitor for symptoms of possible COVID-19 and the facility should screen all HCP for symptoms of COVID-19 prior to the start of shifts as per the LAC DPH COVID-19 Infection Prevention Guidance for Healthcare Personnel. Please also refer to this guidance for more detailed information regarding the management of close contacts to confirmed cases including household exposures outside of work. For staffing shortages, refer to Facilities Experiencing Staffing Shortages.
Return to Work for Symptomatic HCP and for HCP with Confirmed COVID-19
Facilities are required to follow relevant sections in the LAC DPH Guidance for Monitoring Health Care Personnel.
Facilities are required to follow transfer rules as listed on the LAC DPH website (http://publichealth.lacounty.gov/acd/NCorona2019/InterfacilityTransferRules.htm).
Los Angeles County Department of Public Health
Other reliable sources of information about COVID-19 infection prevention/control and vaccination in SNFs: