Coronavirus Disease 2019

Table of Contents:

• Summary of Recent Changes
• Introduction
• COVID-19 Prevention - General and Administrative Practices
• Communal Dining, Group Activities, and Visitation
• COVID-19 Testing
• Cohorting
• Infection Prevention and Control Considerations
• Healthcare Personnel Monitoring and Return to Work
• Inter-facility Transfers
• Resources

11-24-20

• Changed recommendation for staff testing to increase to twice weekly testing for both routine and response testing, effective starting 11/30/20.
• Updated guidance on communal dining, group activities, and visitation to align with CDPH AFL 20-22.5
  • Restricted indoor general visitation; general visitation may continue to take place outdoors
  • Included reference to CDPH AFL 20-86 for infection control recommendations regarding group activities and communal dining for holiday celebrations at facilities
  • Revised the definition of essential visitors to include healthcare personnel (HCP) not directly employed by the facility, protection & advocacy representatives, and individuals authorized by federal disability rights laws
  • Replaced the term non-essential visitation with general visitation
• Added residents who leave facilities for non-medical reasons as a consideration for quarantining in Yellow Cohort upon their return including residents returning to facilities from non-facility holiday celebrations per CDPH AFL 20-86.
• Clarified testing recommendations for HCP and visitors
• Clarified guidance on staff refusal of testing
• Updated cohorting recommendations for symptomatic residents in consideration of the influenza season
• Added new guidance for the management of nursing home residents who may present with atypical symptoms of COVID-19
• Revised recommendation to specify that medical-grade surgical/procedure masks or respirators should be used instead of cloth face coverings for universal source control of HCP
• Updated the close contact definition per CDC

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.

We ask that you continue to ensure that your staff is trained, equipped, and capable of practices needed to:

• Prevent the spread of respiratory viruses, including COVID-19, within your facility.
• Promptly identify and isolate patients with possible COVID-19 and inform the correct facility staff and public health authorities.
• Care for patients with known or suspected COVID-19 as part of routine operations and with the appropriate infection prevention practices.
• Care for a larger number of patients in the context of an escalating outbreak.
• Monitor and manage any healthcare personnel that might be exposed to COVID-19.
• Communicate effectively within the facility and plan for appropriate external communication with patient family members related to COVID-19.

1. Conduct entry screening
   1. All persons should be screened for signs and symptoms of COVID-19 infection, including a temperature check. Persons requiring screening includes facility staff, essential visitors, and general visitors. Symptoms include but are not limited to the following: fever, chills, cough, shortness of breath, new loss of taste or smell, muscle or body aches, headache, sore throat, congestion or runny nose, nausea or vomiting, diarrhea, or not feeling well.
      1. Anyone with fever or signs or symptoms of COVID-19 infection is prohibited from entry.
   2. All visitors (general and essential) must be screened prior to entry for any history of close contact to a COVID-19 case within the past 14 days. See SNF Visitation Guidance for definitions of essential visitors and general visitors. Close contact is defined as being within 6 feet of a person with COVID-19 for a cumulative total of ≥15 minutes within a 24 hour period or having unprotected direct contact with infectious secretions or excretions of the person with COVID-19 (e.g., being coughed or sneezed on, sharing utensils or saliva, or providing care without wearing appropriate protective equipment).
      1. Anyone reporting recent close contact exposure is prohibited from entry.
   3. An exception to entry screening: Emergency Medical Service (EMS) workers responding to an urgent medical need. They do not have to be screened, as they are typically screened separately.
2. Conduct symptom and temperature screening for all staff and patients/residents
1. All staff should be checked for symptoms and fever twice daily, once prior to coming to work and the second at the end of the shifts (see Healthcare Personnel Monitoring section below.)
2. Patients/residents should be assessed for symptoms and have their temperature checked at least every 12 hours.
3. Records should be kept of these staff and resident symptom and temperature checks.
3. Reinforce physical distancing, hand hygiene, and universal source control.
1. Residents should remain in their room as much as possible and should be encouraged to wear a face covering if they leave. Remind residents to practice physical distancing and perform frequent hand hygiene. Residents who have underlying cognitive conditions should not be forcibly kept in their rooms nor forced to wear a face covering.
4. Support good workforce health.
1. Non-punitive sick leave policies to support staff to stay home when sick or when caring for sick household members. Make sure staff are aware of the non-punitive sick leave policy.
5. Enhanced environmental disinfection with EPA-approved healthcare disinfectants should be performed on high touch surfaces (e.g., bed rails, doorknobs, handrails, etc.).
6. Facilities must demonstrate that they have contracted with suppliers to order a 2-week supply of PPE and other infection prevention and control supplies
1. PPE and other infection prevention and control supplies (e.g., surgical masks, respirators, gowns, gloves, goggles, hand hygiene supplies) that would be used for both HCP protection and source control for infected patients (e.g., facemask on the patient) should be readily accessible for use.
2. Follow CDC’s Guidance on Strategies to Optimize the Supply of PPE and Equipment in the setting of shortages at cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html.

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) and CMS Quality Safety & Oversight memo (QSO):

• CDPH AFL 20-22.5: Guidance for Limiting the Transmission of COVID-19 in Long-Term Care Facilities
• CMS QSO 20-39-NH: Nursing Home Visitation – COVID-19

Criteria for Limited Communal Dining, Group Activities, and General Visitation for Select Cohorts
Currently, these activities are only allowed for residents in the Green Cohort and those residents in the Yellow Cohort who frequently leave the facility (e.g. residents receiving dialysis) and are not symptomatic, close contacts, or exposed. For facilities to allow limited gathering for these select cohorts facilities must meet these baseline CMS criteria:

• Adequate staffing: The facility must not be experiencing staff shortages; AND
• Supply of 14 days of Personal Protective Equipment (PPE) and disinfection supplies on hand: The facility must have adequate supplies of PPE¹for staff, such that all staff wear all appropriate PPE when indicated, and must have adequate essential cleaning and disinfection supplies; AND
• Access to adequate testing: The facility must maintain access to COVID-19 testing for all residents and staff by an established commercial laboratory; AND
• Approved COVID-19 Mitigation Plan: The facility must maintain regulatory compliance with CDPH guidance; AND
• Case status in the facility: The facility must have no new facility-onset COVID-19 cases among their residents for at least 14 days. Newly transferred residents with either known COVID-19 or who become positive during quarantine do not count as having acquired COVID-19 in the facility.

• NOTE: This last criterion does not apply to outdoor visitation; outdoor visitation is permitted regardless of facility case status.

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. Staff wear cloth face covering if facemask is not indicated, such as administrative staff.

Case status in the community: In addition to the above facility criteria, case status in the community as determined by local public health is a CMS criteria for the relaxation of gathering restrictions. In LA County, Public Health considers multiple metrics including but not limited to county test positivity rate, hospitalization rates, trends in cases and deaths in nursing homes and/or the community, and trend in new nursing home outbreaks. Public Health will notify all facilities about any changes in visitation and gathering guidance.

Communal Dining and Group Activities

Limited communal dining and group activities are permitted for select cohorts in facilities that meet the above criteria. They are permitted for residents in the Green Cohort and those residents in the Yellow Cohort who leave the facility frequently for outside appointments (e.g. residents receiving dialysis) who are not symptomatic, close contacts, or exposed. These permitted activities must not allow mixing of the Cohorts.

Facility should adhere to the following measures:

1. Facility adheres to universal source control
   1. All staff wearing appropriate face coverings at all times
   2. Residents wearing non-medical face coverings as described below
2. Facility adheres to physical distancing
   1. Groups of no more than 10 residents are allowed.
   2. All residents must keep at least 6 feet apart during all activities.
   3. All staff must keep 6 feet apart in break rooms and, as much as possible, during work activities.
   4. Activities should be done in shifts to allow better physical distancing.
      1. These shifts of residents should be kept together (i.e., same group of residents dine together consistently) and individual residents should be assigned to specific areas as much as possible to attempt to minimize exposure should a resident later test positive for COVID-19.
      2. Use a sign-in sheet/roster of residents present during these activities will help with contact tracing should a resident later test positive for COVID-19.
3. Enhanced environmental disinfection.
   1. All communal, high touch surfaces should be disinfected after residents or staff vacate an area.
4. The facility should prioritize outdoor settings for communal dining and group activities, if practical.
5. Please refer to CDPH AFL 20-86 (COVID-19 Infection Control Recommendations during Holiday Celebrations) for further guidance on group activities and communal dining during the holidays.

If a new facility-onset case is identified among residents, then the following applies:

1. Resident communal dining and group activities for any cohort, indoors and outdoors, must cease for at least 14 days.
2. The facility should review their infection control and prevention practices to prevent future new infections.
3. After there have been no new resident cases in the facility for 14 days and the Self-Assessment and Attestation have been submitted, resident communal dining and activities may resume.

Visitation

HCP and essential visitors are exempted from visitation restrictions. General visitors are limited to residents in the Green Cohort and certain residents of Yellow Cohort and are subject to restrictions based on CMS criteria. See definitions and guidance below.

1. Healthcare personnel (HCP) are facility staff directly employed by the facility and are exceptions to visitation restrictions.
2. Essential visitors are exceptions to visitation restrictions and should be permitted visitation regardless of facility’s outbreak status or COVID-19 status of the resident receiving the visitation. Based on CDPH AFL 20-22.5, essential visitors are defined as:
1. HCP not directly employed by the facility including consultants, contractors, trainees in the facility’s nurse aide training programs or from affiliated academic institutions, and local county public health staff.
2. Surveyors
3. Compassionate care visitors including visitors for:
   • End-of-life situations
   • Residents experiencing weight loss, dehydration, failure to thrive, psychological distress, functional decline, or struggling with a change in environment. The determination of who may benefit from in-person visitation should be made by an interdisciplinary team that includes the resident and/or designated representative.
4. Caregivers or essential support persons for patients with physical, intellectual, and/or developmental disabilities and patients with cognitive impairments; CDPH recommends that one essential support person be allowed to be present with the patient. The determination of who is the caregiver/essential support person should involve the resident and/or designated representative.
5. Ombudsman representatives
6. Protection & advocacy representatives
7. Visitors for legal matters that cannot be postponed including, but not limited to, estate planning, advance health care directives, Power of Attorney, and transfer of property title
8. Individuals authorized by federal disability rights laws including qualified interpreters when assistance is not available by onsite staff or video remote interpretation.
3. General visitors: General visitors are defined as visitors who do not fall under the definition of HCP or Essential Visitors. This was previously known as “Non-essential visitors.”
   1. General visitation is only permitted for Green Cohort residents and those residents in the Yellow Cohort who frequently leave the facility (e.g. residents receiving dialysis) and are not symptomatic, close contacts, or exposed.
   2. General visitation is permitted outdoors regardless of a facility’s outbreak status.
   3. Indoor and in-room general visitation is subject to case status in the community. Currently, indoor and in-room general visitation are not permitted in LA County due to significant community transmission.
   4. General visits should be scheduled in advance.
4. 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 20-22.5 and CMS QSO 20-39-NH. 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.
5. Place of Visitation
   1. Outdoor visitation is preferred for essential visitation whenever practical due to lower risk of transmission from increased space and airflow. General visitation should only be conducted outdoors.
   2. Large indoor spaces that allow for ≥ 6 ft physical distancing with good ventilation can be offered as an alternative for essential visits when outdoor visitation is not possible (e.g. inclement weather, poor air quality, inability to move resident outside). Essential visitation may be conducted in large indoor spaces even during an outbreak.
   3. In-room visitation
1. Essential visits may be conducted in-room when visitation outdoors and in large indoor spaces are not practical.
2. Per CMS, for essential visitation where there is a roommate and the health status of the resident prevents leaving the room, facilities should attempt to conduct in-room visitation with the roommate(s) not present in the room when possible. In addition, any in-room visitation must adhere to core principles of infection prevention and control.
3. General visits are only allowed to be conducted in-room when Los Angeles County is in Tier 2 (Red), 3 (Orange), or 4 (Yellow) as per Blueprint for a Safer Economy in addition to meeting the above criteria for indoor gatherings.
6. All visitors, essential and general, must adhere to the following measures or the facility may remove them from facility premises and/or restrict their entry.
   1. Visitors should be screened on entry as described above. If a visitor screens positive for COVID-19 symptoms and/or close contact to COVID-19, their visit must be postponed until after appropriate isolation or quarantine periods are completed.
   2. Visitors should document in a visitor log their name, contact information, and locations within the facility premises they are visiting in order to assist with contact tracing if needed.
   3. Visitors must wear face masks appropriate for the cohort of the resident they are visiting regardless of indoor or outdoor setting (surgical mask or higher). Residents should also be encouraged to wear facial coverings if possible.
   4. Visitors should don and doff appropriate PPE according to instruction by facility staff.
   5. Visitors should perform hand hygiene before and after the visit at minimum.
   6. Visitors should maintain physical distancing of 6 feet or more. If 6 feet of distance is not possible, a clear plastic divider may be used.
   7. Direct physical contact between an essential visitor and the resident can be considered on a case by case basis (e.g. compassionate care visitation) with a pre-determined plan that involves adequate infection prevention and control practices, e.g. wearing full PPE, minimizing total cumulative time of direct physical contact. Visitors must avoid direct physical contact with staff and other residents they are not visiting.
   8. Staff should monitor the visit to make sure infection control guidelines are followed (e.g., safe distancing, face coverings, no physical contact) to assure a safe visitation for both residents and loved ones.
   9. All visitors should be instructed to notify the facility if they develop COVID-19 signs and symptoms and/or have a positive test within 14 days of visiting the facility. Facilities should take all necessary actions including infection control precautions based on findings.
7. Facilities should establish the following to support in-person visitation:
   1. Facilities should limit the number of visitors per resident at one time and limit the total number of visitors in the facility at one time based on the size of the building, size and physical configuration of visitation areas, and individual resident needs (e.g. end-of-life situations).
   2. Facilities should consider scheduling visits for a specified length of time to help ensure all residents are able to receive visitors; facilities can consider shorter indoor visits and longer outdoor visits.
   3. Facilities should limit movement of visitors within the facility to encourage visitors to go directly to and from the resident’s room or designated visitation area.
   4. Facilities should disinfect rooms and designated visiting areas after each resident-visitor meeting.
   5. Facilities are encouraged to consider implementation of physical barriers, e.g. clear plastic dividers, in visitation areas to further reduce risk of transmission
   6. Facilities are encouraged to regularly communicate visitation guidelines and expectations with residents, family, caregivers, designated decision makers, etc. Facilities are also recommended to provide visitation instructions to visitors prior to their scheduled visits and/or on entry to facility.
   7. Facilities should place clear signage for visitors in relevant languages throughout the facility regarding education on COVID-19 signs and symptoms, infection control precautions including hand hygiene and universal masking, specified entries/exits and routes to designated areas, etc.
   8. Facilities could consider providing infection prevention and control education for visitors who are regularly visiting (more than one in-person visit every 7 days).
8. Facilities should continue to support other visitation options.
   1. Continue to offer alternative means of communication for people who would otherwise visit, such as virtual communications (phone, video-communication, etc.).
   2. Create a communication outlet (email listserv, website, call-in number with recording, etc.) to provide updated communication with families.
   3. Assign staff as primary contact to families for inbound calls and conduct regular outbound calls to keep families up to date.

Below are recommendations for testing and cohorting in SNFs based upon California Department of Public Health (CDPH) requirements outlined in recent CDPH AFLs:

• AFL 20-52 Coronavirus Disease 2019 (COVID-19) Mitigation Plan Implementation and Submission Requirements for Skilled Nursing Facilities (SNF) and Infection Control Guidance for Health Care Personnel (HCP) AFL
• AFL 20-53.3 Coronavirus Disease 2019 (COVID-19) Mitigation Plan Recommendations for Testing of Health Care Personnel (HCP) and Residents at Skilled Nursing Facilities (SNF) AFL

General requirements

1. Establish a relationship with a commercial lab to do rapid PCR testing with a turn-around time (TAT) of 48 hours or less for COVID-19. Refer to LAC DPH's Laboratory Information to find a lab providing COVID-19 PCR testing. If the 48-hour TAT cannot be met, then the facility should document its efforts to obtain quick turnaround testing results including communication with the local and state health departments.
2. COVID Point of Care Antigen testing may be used to complement PCR testing per LA County Antigen Testing Guidance.
3. Establish cohorting plan as part of CDPH-required COVID-19 mitigation plan.
4. Report weekly to Public Health the number of staff and residents tested each week for COVID-19, the number who are asymptomatic and test positive, and the number who are symptomatic and test positive, as per the May 26, 2020 Board of Supervisors Motion.
5. Thorough documentation to demonstrate compliance with testing regulations in accordance with CDPH AFL 20-53.3.

Testing of all admissions and readmissions. All newly admitted residents or readmissions should be tested upon admission. These patients should follow the transfer rules per LAC DPH. Lack of testing at discharge/transfer is not a reason to deny admissions of patients.

1. All newly admitted and readmitted patients who test negative should be placed in quarantine (Yellow Cohort) for at least 14 days, monitored for symptoms and signs of COVID-19, and retested at the end of quarantine. A negative post-quarantine result permits their transfer to the Green Cohort.
2. A positive PCR test should initiate isolation in the Red Cohort. Please see Cohorting section on appropriate isolation periods depending on the resident's clinical status.

Testing of symptomatic residents or staff.

1. Every staff member or resident with symptoms of COVID-19 should be tested as soon as possible. Be aware that older adults may have atypical symptoms of COVID-19 infection including but not limited to delirium (or confusion), change in functional status, change in oral intake, and new or worsening falls with or without fever or more typical symptoms.
2. All symptomatic residents should be presumed infectious pending test results and should be in quarantine in a private room in the Yellow Cohort, if possible, with priority given to residents with typical COVID-19 symptoms (acute respiratory symptoms). However, if a private room is unavailable, then the symptomatic resident and their roommates should remain in their current rooms with appropriate transmission-based precautions as appropriate for the Yellow Cohort.
3. 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.
4. Any staff or resident testing positive for COVID-19 should then prompt response testing (see below).
5. All symptomatic staff must be immediately restricted from working (see Healthcare Personnel Monitoring and Return to Work sections below).

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 to identify potential asymptomatic infections. All residents should be tested once weekly and all staff should be tested at the same frequency as routine staff testing. 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 contacts 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 testing of staff and residents. Routine testing is initiated when either no cases were identified at baseline testing OR after no new cases are identified from two sequential weeks of response testing. If any resident or staff tests positive, the SNF must report the positive case to LAC DPH and proceed with outbreak/response testing as described above.

1. All staff directly employed by the facility must be routinely tested at least twice per week. Further guidance on when facilities can reduce to once per week testing of staff will be communicated to facilities, and Public Health will base that decision on a combination of metrics related to case status in the community.
2. In addition, all regular visitors (essential and general) who visit the facility at least once a week or more, should be tested at the same frequency as facility staff. All other infection prevention and control requirements, including entry screening must be followed, regardless of negative test results.
   1. The absence of test results should not prevent essential visitation.
   2. Outside test results are acceptable if documentation of test date and test result can be provided.
   3. Same day on site point of care antigen testing of visitors is an additional safety measure that facilities may consider implementing prior to visiting the resident but is not required for entry. Please see local SNF antigen testing guidelines and follow Use of POC Ag tests for Screening-Only for Asymptomatic Staff.
3. Residents:
   
   1. SNFs must test a random sample of 10% of all residents weekly

Retesting Previously Positive Staff/Residents

1. Staff or residents who previously tested positive and are asymptomatic should not be retested for 90 days since the date of symptom onset or date of the first positive test.
   1. Exception: A staff or resident who develops new symptoms ≤ 90 days of the initial positive test should be retested.
2. Staff or residents who previously tested positive and are asymptomatic will be back in the routine testing pool after 90 days of the date of previously positive test or date of symptom onset.
3. Staff or residents who previously tested positive who re-test positive 90 days or more AFTER the first infection should be managed as a new infection; the person should be isolated and would be exempt from testing for another 90 days.

Figure 1. Testing Schematic

Refusal of Testing

1. Staff: The following restrictions only apply to staff directly employed by the facility.
   1. Staff who have signs or symptoms of COVID-19 and refuse testing are prohibited from entering the facility until return to work criteria are met.
   2. If outbreak testing has been triggered and a staff member refuses testing, the staff member should be restricted from entering the facility until the outbreak has been closed.
   3. For asymptomatic staff during routine testing, the facility should establish policies and procedures to address refusal in this situation.
2. Residents:
1. Residents (or resident representatives) may exercise their right to decline COVID-19 testing in accordance with the requirements under 42 CFR § 483.10(c)(6). In discussing testing with residents, staff should use person-centered approaches when explaining the importance of testing for COVID-19. Facilities must have procedures in place to address residents who refuse testing.
2. Residents who have signs or symptoms of COVID-19 and refuse testing must be placed in the Yellow quarantine cohort, preferably in a single room, until the criteria for discontinuing transmission-based precautions have been met.
3. If outbreak testing has been triggered and an asymptomatic resident refuses testing, the facility should ensure the resident maintains appropriate > 6 feet distance from other residents, wears a face covering, and practices effective hand hygiene until the outbreak has been closed.

Facilities should have 3 separate cohorting areas as described below and shown in Figure 2.

1. Red Cohort (Isolation Area). This area is only for patients who have laboratory-confirmed COVID-19 with or without symptoms. Patients may be transferred to the Green Cohort once they have completed the appropriate isolation period as follows:
   1. For symptomatic residents:
      • At least 20 days have passed since symptoms first appeared; and,
      • At least 24 hours have passed since last fever without the use of antipyretic medications and
      • Improvement in symptoms (e.g., cough, shortness of breath).
   2. For asymptomatic residents without severe immunosuppressing conditions with laboratory-confirmed COVID-19:
      • At least 14 days have passed since the date of first positive COVID-19 diagnostic test without the development of symptoms of COVID-19.
      • If they develop symptoms during this 14-day period, the isolation period should be restarted from the onset of symptoms per the symptomatic resident criteria outlined above.
   3. For asymptomatic residents with severely immunosuppressing conditions:
      • At least 20 days from the date of first positive COVID-19 diagnostic test without the development of symptoms of COVID-19.
      • If they develop symptoms during this 20-day period, the isolation period should be restarted from the onset of symptoms per the symptomatic resident criteria outlined above.
      • The following are considered severely immunosuppressing conditions: actively receiving chemotherapy for cancer, HIV with CD4 count <200, immunodeficiency disorder, prednisone dose >20mg/day for more than 14 days, receipt of immunosuppressive medications (biologics, etc.) for treatment of autoimmune disease, or other form of immunosuppression as determined by the patient’s primary physician.
2. Yellow Cohort(Mixed quarantine & symptomatic cohort)
   1. This cohort is for the following residents:
      • Close contacts to a known COVID-19 case. A close contact is anyone who has been within 6 feet of a person with confirmed COVID-19 for a cumulative total of ≥ 15 minutes within a 24 hour period (e.g. roommate) OR who had unprotected direct contact with infectious secretions or excretions of the person with COVID-19 (e.g. being coughed on or sneezed on or sharing utensils or saliva).
      • Newly admitted or re-admitted residents
      • Residents who frequently leave the facility for medical appointments (e.g. dialysis residents) should be grouped together in the Yellow Cohort.
      • Residents who have symptoms of COVID-19 pending test results including atypical symptoms.
      • Residents with indeterminate test results
      • All residents on the unit or wing where a case was identified in a resident or HCP should be considered exposed and placed in quarantine. All exposed residents should remain in their current rooms unless sufficient private rooms are available. Signage indicating appropriate precautions should be placed outside of these residents’ rooms.
      • Residents who leave the facility for a non-medical reason should be placed in the Yellow Cohort upon return to the facility; exceptions can be made on a case-by-case basis. Please see CDPH AFL 20-86 for further guidance on “COVID-19 Infection Control Recommendations during Holiday Celebrations,” including factors to consider in determining the risk of exposure to COVID-19.
   2. Private rooms should be prioritized for residents with typical COVID-19 symptoms (acute respiratory symptoms), close contacts, and those with indeterminate test results as they have a higher probability of infection. However, if private rooms are limited or unavailable, then symptomatic residents, especially residents with atypical symptoms, and their roommates should remain in their current rooms with appropriate transmission-based precautions as appropriate for the Yellow Cohort.
   3. For multi-occupancy rooms, strategies to reduce exposures between residents should be implemented: Residents with similar risk profiles should be placed in the same room (e.g., group low risk admissions in the same room). Curtains should be placed between resident beds. Staff should change gowns and gloves with appropriate hand hygiene between each patient contact in the same room.
      
      Residents may leave the Yellow Cohort under these circumstances:
   4. If their test result is positive for COVID-19, they should be moved into the Red Cohort.
   5. Newly admitted and readmitted patients must stay in quarantine in the Yellow Cohort for 14 days. They must be tested on admission and again at the end of quarantine. A negative post quarantine result permits the residents to be transferred to the Green Cohort.
   6. Close contacts and exposed residents to confirmed cases must stay in quarantine in the Yellow Cohort for 14 days. They should be tested on admission and again at the end of quarantine. Negative post-quarantine result permits the residents to be transferred to the Green Cohort.
   7. Residents with COVID-19 symptoms should remain in the Yellow Cohort until either:
      • One negative PCR test AND at least 10 days have passed AND at least 24 hours since last fever without fever-reducing medication AND improvement in symptoms (preferred).
        or
      • Two negative PCR tests at least 24 hours apart AND improvement in symptoms AND at least 24 hours since last fever without fever-reducing medication.
   8. Residents with atypical symptoms of possible COVID-19 (e.g. delirium/confusion, change in functional status, change in oral intake, and new or worsening falls) can be returned to Green Cohort status if there is at least one negative PCR test.
   9. Symptomatic residents who are not tested (e.g. resident refusal) should remain in the Yellow Cohort preferably in a single-occupancy room for at least 20 days since symptom onset AND at least 24 hours since last fever without fever-reducing medication AND improvement of symptoms.
   10. Asymptomatic residents with indeterminate test results should remain in the Yellow Cohort until they either have a positive PCR test or they have 2 negative PCR tests at least 24 hours apart. This does not apply to new admissions, readmissions, close contacts, or exposed residents.
3. Green Cohort: This cohort is reserved for residents who do not have COVID-19. To be in this cohort, residents must have either completed quarantine, cleared isolation, or have tested negative and remained asymptomatic after last negative testing.

Figure 2. Cohorting

Special staffing considerations in cohort areas

1. Staff assigned to the Red Cohort should not care for patients in other cohorts if possible. If staff must care for residents in multiple cohorts, they should visit the Red Cohort last and should doff PPE and perform hand hygiene prior to moving between cohorts.
2. With prior approval from Public Health, asymptomatic staff with lab-confirmed COVID-19 infection may be allowed to work in the Red Cohort. They will need to be able to keep separated from uninfected staff. This includes having dedicated breakrooms and bathrooms until they are no longer considered infectious (10 days after the date of collection of their initial positive test).
3. All staff in the facility should adhere to physical distancing of at least 6 feet while in break rooms and should wear masks while in the facility.

Below are general and COVID-19 specific recommendations. For more information on infection control recommendations, visit https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html.

General Considerations

1. California Department of Public Health (https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/AFL-20-52.aspx) guidance requires that facilities employ a full-time, on-site infection preventionist who will monitor compliance with infection control guidance.
2. CDPH also requires SNFs to have a CDPH-approved COVID-19-specific mitigation plan and to provide infection prevention and control training and updated infection control guidance to its HCP.

Universal Source Control

 Patients/Residents

1. All patients/residents must be provided a clean non-medical face covering daily.
2. Surgical masks are required for any resident that is COVID-19-positive or assumed to be COVID-19-positive.
3. All residents must wear the cloth face covering/mask when outside their room, unless they have a contraindication. This includes patients who must regularly leave the facility for care (e.g. hemodialysis patients).
4. Residents who due to underlying cognitive or medical conditions cannot wear face coverings should not be forcibly required to wear face coverings (and should not be forcibly kept in their rooms). However, face coverings should be encouraged as much as possible.
5. A cloth face cover should not be placed on anyone who has trouble breathing, or is unconscious, incapacitated, or otherwise unable to remove it without assistance.
6. Face shields with a drape may be offered to residents who are not able to wear face coverings.

Staff

1. All HCP should wear a medical-grade surgical/procedure mask or respirator for universal source control at all times while they are in the facility.
2. Please see Cohort-Specific Transmission Based Precautions and PPE section for appropriate mask use for each cohort.

Hand Hygiene (HH)

1. Healthcare personnel (HCP) and other staff members should perform HH before and after ALL patient encounters and should also use HH at the beginning of their shifts, before and after eating, after using the restroom, and at other times throughout the day.
2. Make sure HH supplies, such as soap and water or alcohol-based hand sanitizer, are readily accessible in all patient care areas, including areas where HCP remove PPE.
3. Sinks need to be well-stocked with soap and paper towels. Hand sanitizers should be replaced as needed.
4. Facilities should have a process for auditing adherence to recommended HH practices by the HCP.
5. Ensure that there are alcohol-based hand sanitizer dispensers at the PPE donning and doffing areas.

Respiratory Hygiene/Cough Etiquette:

1. Support hand and respiratory hygiene, as well as cough etiquette by residents and staff.
2. Place hand sanitizers at facility entrances and encourage all residents and staff to use every time they enter your facility.

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 patient care as detailed below.

Figure 3. PPE in Each Cohort

1. General
   1. Facilities must regularly audit their HCP’s adherence to appropriate PPE use.
   2. Post appropriate Transmission-Based Precautions signage outside of each resident room: https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html#anchor_1564058318
   3. Post signage on the appropriate steps for donning and doffing PPE in donning and doffing areas: lacounty.gov/acd/docs/CoVPPEPoster.pdf
   4. Facilities should follow CDC’s strategies to optimize the supply of PPE and equipment (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 and can consider contacting Public Health’s PPE Coordinator by email for inquiries about PPE supplies: DPHPPECoordinator@ph.lacounty.gov
2. Standard Precautions for All Patient Care
1. Gloves should be changed between every patient encounter.
2. Hand hygiene should be performed before donning and after doffing gloves. Please see above section on Hand Hygiene (HH) for more details.
3. Respiratory hygiene/cough etiquette must be followed at all times including during patient care.
4. Environmental cleaning recommendations should be followed where applicable before and after patient care. This includes properly disinfecting shared equipment, e.g., blood pressure cuffs and pulse oximeters before and after vital checks.
3. Droplet Precautions
   1. In the Green Cohort, surgical masks alone may be worn for duration of the shift in place of N95 respirators.
   2. In the Yellow and Red Cohorts, N95 respirators should be worn. Please see N95 respirators section below.
   3. In Yellow and Green Cohorts, eye protection, which is defined as a face shield or goggles, is recommended for close contact with patients (within 6ft), especially if the patient cannot reliably wear a face covering.
   4. In the Red Cohort, eye protection is recommended to be worn for duration of shift.
4. Contact Precautions
   1. Gowns should be changed between patients in all cohorts if adequate supplies are available, even in multi-occupancy rooms.
   2. If there is a shortage of gowns, the same gown may be worn with multiple residents (extended use) in the Red Cohort as long as there are no other contact pathogens (difficile, CRE, Candida auris, etc.) that require changing between residents. 
   3. If there is a shortage of gowns, gowns may be prioritized for patient care that may result in exposure to body fluids and/or high contact activity in the Yellow Cohort.
   4. The same gowns should never be worn for care of both COVID-19 positive and negative patients.
   5. Re-use (over multiple days) of gowns is not allowed.
5. N95 respirators
   1. In the Red Cohort, N95 respirator use should be worn for duration of the shift.
   2. In the Yellow Cohort, N95 respirator should be worn when providing for patient care (within 6 ft).
   3. N95 respirators should be worn for all aerosol generating procedures (suction, ventilation, CPR, nebulizer treatments, etc.) for all cohorts including the Green Cohort if the facility has an active outbreak.
   4. N95 respirators with an exhaust valve do not provide source control and should not be used in healthcare settings.
   5. Initial and annual N95 respiratory fit testing is required for all staff per California Division of Occupational Safety and Health (Cal-OSHA).
   6. Cal-OSHA no longer allows for re-use (over multiple days) of N95 respirators, but still allows for extended use (with multiple residents in the same shift/day).
   7. If there is a shortage of N95 respirators, facilities should make efforts to acquire more supply including documented communication with Public Health (see contact information above). If, despite these efforts, the facility is still experiencing a shortage, facilities could consider re-use of N95 respirators and must document their reasoning in a written risk assessment.

Environmental cleaning:

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).

1. Facilities must have a plan to ensure proper cleaning and disinfection of environmental surfaces (including high touch surfaces such as light switches, bed rails, bedside tables, etc.) and equipment in the patient room.
2. All staff with cleaning responsibilities must understand the contact time for the cleaning and disinfection products used in the facility (check containers for specific guidelines).
3. Ensure shared or non-dedicated equipment is cleaned and disinfected after use according to the manufacturer’s recommendations.
4. Routine cleaning and disinfection procedures (e.g., using cleaners and water to pre-clean surfaces prior to applying an EPA-registered, hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product’s label) are appropriate for COVID-19 in healthcare settings.
1. 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
5. Set a protocol to terminally clean rooms after a patient is discharged from the facility. If a known COVID-19 resident is discharged or transferred, staff should refrain from entering the room until sufficient time has elapsed for enough air exchanges to take place (more information on air exchanges at https://www.cdc.gov/infectioncontrol/guidelines/environmental/appendix/air.html#tableb6)

Monitoring

1. All HCP should self-monitor twice daily, once prior to coming to work and the second, ideally timed approximately 12 hours later for fever or symptoms consistent with COVID-19.
2. If HCP have symptoms, they should stay home from work and contact the health care facility (HCF) immediately to arrange for medical evaluation and/or testing as soon as possible.
3. HCF should inquire about symptoms of COVID and do temperature checks of all HCP prior to the start of working their shifts AND at the end of the shift.
4. Identify staff who can monitor sick staff with daily “check-ins” using telephone calls, emails, and texts.

Refer to the LAC DPH Guidance for Monitoring Health Care Personnel for more detailed information including the management of close contacts to confirmed cases. Please note one exception for SNFs: As per CDPH Quarantine Recommendations, in the absence of staffing shortages, HCP who are a close contact to a confirmed COVID-19 case (either in the community or who have a high-risk occupational COVID-19 exposure) should be excluded from work for 14 days from last exposure. For staffing shortages, refer to Facilities Experiencing Staffing Shortages in LAC DPH Guidance for Monitoring Health Care Personnel.

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).

Relevant Webinars

• LAC DPH: every other Friday at 2pm, by email invitation; if your facility is not receiving emails, please contact ACDC at LACSNF@ph.lacounty.gov to update your contact information. Recordings and slides from past webinars are on the general ACD SNF page.
• CDPH: Infection Prevention Webinars every Wednesday 3-4pm (https://www.hsag.com/cdph-ip-webinars) and calls every Thursday 12-1pm (https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/AFL-20-50.aspx)

Los Angeles County Department of Public Health

• LAC DPH COVID-19 Skilled Nursing Facilities Hub: http://ph.lacounty.gov/acd/ncorona2019/healthfacilities/snf/
• LAC DPH COVID-19 website: ph.lacounty.gov/media/Coronavirus/
• LAC DPH COVID-19 Provider Information Hub: ph.lacounty.gov/acd/nCorona2019.htm
• Los Angeles Health Alert Network: The Department of Public Health (DPH) emails priority communications about COVID-19 and other outbreaks to health care professionals: ph.lacounty.gov/lahan/
• Social media: @lapublichealth
• The Los Angeles County Department of Mental Health Access Center 24/7 Helpline (800) 854-7771

Other reliable sources of information about COVID-19 are:

• CDPH All Facilities Letters – 2020: https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/LNCAFL20.aspx
• CDPH COVID-19 Updates: https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/Immunization/nCOV2019.aspx
• CDC Coronavirus main website https://www.cdc.gov/coronavirus/2019-ncov/index.html
• CDC Healthcare Infection Prevention and Control FAQs for COVID-19 https://www.cdc.gov/coronavirus/2019-ncov/infection-control/infection-prevention-control-faq.html
• CDC Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html
• CDC Healthcare Supply of Personal Protective Equipment https://www.cdc.gov/coronavirus/2019-ncov/hcp/healthcare-supply-ppe.html
• CDC Preparing for COVID-19: Long-term Care Facilities, Nursing Homes https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html
• CDC Resources for Healthcare Facilities https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/index.html
• CDC Strategies to Optimize the Supply of PPE and Equipment https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html
• CMS COVID-19 Long-Term Care Facility Guidance April 2, 2020 https://www.cms.gov/files/document/4220-covid-19-long-term-care-facility-guidance.pdf
• CMS Long-term Care Facility Testing Requirements for Nursing Homes https://www.cms.gov/files/document/qso-20-38-nh.pdf