9-29-22: LAC DPH and CDPH are aware of and are reviewing the updated CDC guidance for healthcare personnel and healthcare settings. California regulations are currently more restrictive than CDC guidance and must continue to be followed. This includes masking indoors in healthcare settings and congregate care facilities.
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.
Getting vaccinated against COVID-19 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.
Definition of Up to Date:
An individual is up to date with COVID-19 vaccines when they have received all recommended doses in the primary series (i.e., are fully vaccinated) and any recommended booster dose(s).
In other words, individuals falling into the following categories are up to date:
Please note, as of Sep 2, 2022, there is a new booster recommendation that replaces all prior booster recommendations for individuals 12 years and older.
Visit the LAC DPH COVID-19 Vaccine Schedule website for color-coded vaccine schedules in English and Spanish.
Proof of vaccination: Staff and visitors can only be considered fully vaccinated or up to date if they show acceptable proof of vaccination that confirms the above definitions. Proof of vaccination for staff and visitors includes the following as per AFL 21-28 and AFL 22-07.
Track, Increase, and Maintain COVID-19 Vaccination & Booster Coverage
*Please read the full orders for description of who is included in “workers”.
Outpatient COVID-19 Treatment: Oral Antivirals
Oral COVID-19 antivirals, e.g., ritonavir-boosted nirmatrelvir (Paxlovid) and molnupiravir (Lagevrio), are highly effective in preventing severe outcomes, including hospitalizations and death, among high-risk individuals infected with COVID-19 including nursing home residents. Because they need to be started within five (5) days of symptom onset, it is crucial to initiate the process of assessing residents with confirmed COVID-19 as soon as they test positive. Per LAC DPH’s Order of the Health Officer on Prevention of COVID-19 Transmission in SNFs and CDPH AFL 20-22 (COVID-19 Treatment Resources for SNFs), all residents with a positive SARS-CoV-2 viral test must be immediately assessed by their healthcare provider for any symptoms of COVID-19. Outpatient COVID-19 treatment, specifically ritonavir-boosted nirmatrelvir or molnupiravir, should be initiated at the facility within 5 days of symptom onset if clinically appropriate, i.e., they have mild or moderate symptoms and there are no contraindications or drug-drug interactions. 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 meeting the requirements set forth in LAC DPH’s SNF Health Officer Order and CDPH AFL 20-22, facilities should:
Residents with confirmed COVID-19 may also be assessed for and offered other outpatient treatments for COVID-19 other than an oral antiviral, for example remdesivir or bebtelovimab. For more information please see LAC DPH’s COVID-19 Outpatient Therapeutics page and NIH’s Therapeutic Management of Nonhospitalized Adults with COVID-19.
Residents should also be evaluated by their healthcare providers for eligibility for pre-exposure prophylaxis. Residents are eligible if they have moderate to severe immune compromise and/or have not received any available COVID-19 vaccine due to a true medical contraindication (e.g., severe allergic reaction) AND they are neither currently infected nor recently exposed (e.g., Green Cohort). Currently, tixagevimab/cilgavimab (Evusheld) has emergency use authorization (EUA) for pre-exposure prophylaxis and can be administered via intramuscular injection. Please bookmark and refer to LAC DPH’s COVID-19 Outpatient Therapeutics page for the most up to date information.
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 1. 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).
The following recommendations for communal dining, group activities, and visitation are based upon the most recent CDPH All Facility Letter (AFL) and CMS Quality Safety & Oversight memo (QSO):
The purpose of these guidelines is to help each facility develop resident-centered visitation, communal dining, and group activity policies 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.
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 stated in CDPH AFL 22-07 and CMS QSO 20-39-NH-Revised. Residents have the right to make choices about aspects of his or her life in the facility that are significant to the resident as long as it does not impose on the rights of other residents. Furthermore, residents or their designated representative when the resident does not have capacity, should be involved, and have their preferences prioritized. 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. Failure to facilitate resident 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.
Communal Dining and Group Activities
Communal dining and group activities should be permitted for residents not in quarantine or isolation (Green Cohort). These activities may take place indoors and outdoors regardless of the facility’s outbreak status and regardless of the resident’s vaccination status. Facilities must continue to follow all infection prevention and control measures to conduct communal dining and group activities safely.
The facility should adhere to the following measures for all communal dining and activities:
If there is a COVID-19 outbreak in the facility, then the following applies:
Visitation should be supported by the facility in a manner that is consistent with resident rights in the federal regulation Title 42 CFR section 483.10(f)(4)(v).
|Table 1. Infection Prevention & Control Requirements for All Visitation (General and Essential)|
|Green Cohort||Yellow & Red Cohorts|
|Vaccination/Negative Test Verification||Facilities may consider checking for proof of one of the following for general visitors seeking indoor visitation: 1) up to date status with all COVID-19 vaccine and booster doses; OR 2) negative SARS-CoV-2 test within 2 days if lab-based PCR or within 1 day if point-of-care antigen; OR 3) recovered from COVID-19 ≤ 90 days. This is up to the individual facility’s internal policy as a part of their COVID-19 mitigation plans and should ensure that resident rights, as protected under federal regulation Title 42 CFR section 483.10(f)(4)(v), are not significantly impacted. Vaccination status and negative viral test verification should not be requested for essential visitors or outdoor visits.|
|Face Masks||All visitors must wear well-fitted mask with good filtration (N95, KF94, KN95, or surgical masks) throughout the visit whether indoors, in-room, or outdoors when not actively eating/drinking. Residents should also wear well-fitted face mask if safe and practical when not actively eating/drinking.||All visitors must wear N95 respirator or higher throughout the visit and perform a seal check. Residents should also wear well-fitted face masks if safe and practical.|
|PPE||Eye protection (goggles, face shields) may be considered for visitors for indoor visits when community transmission is moderate, substantial, or high.||Proper donning and doffing of eye protection (goggles, face shield), gowns, and gloves for visitors is required when indoors/in-room and recommended when outdoors.|
|Physical Distancing||If both resident and visitor(s) are up to date with COVID-19 vaccines, physical distancing is not required and may include physical contact (e.g., hugs, holding hands).||Residents and their visitors should maintain ≥6 ft physical distancing regardless of vaccination status of either resident or visitor and regardless of facility’s outbreak status. Exceptions can be made on case-by-case basis for compassionate care visitors including support persons and for end-of-life situations.|
|Location of Visit||
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 does 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 (this can be an extension of routine screening testing of residents once weekly in the section below). 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 Figure 3. Indication to Quarantine in Yellow Cohort and Table 2. Quarantine Guidance for the Yellow Cohort). Individuals who are asymptomatic, close contacts or exposed, and within 31-90 days of recent COVID-19 infection, then point-of-care antigen tests are preferred over molecular tests, e.g., RT-PCR. 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 LA County Health Officer Order as described below. Please note when there are differences in testing requirements, the most conservative testing guidance must be followed. 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.
Figure 2. Testing Schematic
Retesting Previously Positive Staff/Residents
Refusal of Testing
Facilities should have 3 separate cohorting areas as described below and shown in Figure 4.
Figure 3. Indication to Quarantine in Yellow Cohort
Table 2. Quarantine Guidance for the Yellow Cohort
|Indication to quarantine in Yellow Cohort||Room Placement||Duration of Quarantine||Testing|
New admissions, re-admissions, or left the facility >24 hrs AND
Not up to date with COVID-19 vaccines
Exception: asymptomatic residents who recently recovered from a prior COVID-19 infection within the last 90 days should be placed in the Green Cohort
New admission/re-admission: Do not mix this group w/ any other resident groups in the Yellow Cohort (e.g., do not room with exposed/ close contacts, or symptomatic residents).
Left facility >24 hours: Place with other new admissions/re-admissions (preferable). Otherwise, quarantine in place, avoid movement of residents that could lead to new exposures.
|At least 7 days from date of admission. Second PCR test collected on day 5-7 should result negative before moving to Green Cohort.||PCR testing total of two times; immediately on admission (<72 hrs) AND on day 5-7 after admission.|
Prioritize for single occupancy rooms.
At least 10 days AND at least 24 hrs since last fever without fever-reducing medication AND improvement in symptoms
One PCR test performed immediately
|Atypical symptoms of possible COVID-19 (e.g., delirium/confusion, change in functional status, change in oral intake, and new or worsening falls)||Quarantine in place, avoid movement of residents that could lead to new exposures.||No minimum duration||One PCR test performed immediately|
|Asymptomatic with indeterminate test results (excluding new admissions, re-admissions, close contacts, or exposed residents)||Prioritize for single occupancy rooms||At least 2 days have passed since collection of confirmatory negative test without development of new symptoms||Collect confirmatory PCR test within 48 hours of the initial indeterminate test|
|Close contacts and those exposed to a confirmed case in the same unit/wing regardless of whether the close contact occurred inside or outside the facility, e.g., while “out on pass”
Exception: asymptomatic residents who recently recovered from a prior COVID-19 infection within the last 30 days should remain in the Green Cohort. If the prior COVID-19 infection was 31-90 days ago, then point-of-care antigen testing is recommended and quarantine in the Yellow Cohort may be considered.
|If quarantine is indicated as per Figure 2: Quarantine in place. All exposed residents should remain in their current rooms to avoid movement of residents that could lead to new exposures.||
If quarantine is indicated as per Figure 2: At least 7 days following the last exposure (day 0). PCR test* collected on day 5-7 should result negative before moving to Green Cohort.
* If the prior COVID-19 infection was 31-90 days ago, then point-of-care antigen testing is preferred.
|Regardless of indication to quarantine: PCR testing* total of 2 times on day 2 AND day 5-7 after the last exposure (day 0).
* If the prior COVID-19 infection was 31-90 days ago, then point-of-care antigen testing is preferred.
|Moderately to severely immunocompromised who are newly admitted/readmitted, frequently leave the facility (e.g., for chemotherapy), or leave the facility >24 hours||Consider applying same guidance as for residents not up to date with COVID-19 vaccines who are new admissions/re-admissions, or leave the facility >24 hrs.|
Figure 4. Cohorting
Special Staffing Considerations in Cohort Areas
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. For return to work for HCP refer to the following sections:
Facilities are required to follow transfer and home discharge rules as listed on the LAC DPH website (http://publichealth.lacounty.gov/acd/NCorona2019/InterfacilityTransferRules.htm).
Facilities are required to report all positive test results from point-of-care SARS-CoV-2 antigen tests, any suspected COVID-19 outbreak*, and all fatalities associated with COVID-19 within 24 hours including out of facility/hospital deaths of presumed cases and all deaths that occurred during an active COVID-19 outbreak, regardless of testing.
*Please note that the current COVID-19 outbreak definition in SNFs in Los Angeles County is at least one PCR laboratory confirmed case (symptomatic or asymptomatic) of COVID-19 in a SNF resident who has resided in the facility for at least 7 days.
For more details, please see the LAC DPH COVID-19 Case Reporting Protocol for SNFs flowchart.
Reliable sources of information about COVID-19 infection prevention/control and vaccination in SNFs: