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Coronavirus Disease 2019

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


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.

Summary of Recent Changes

9/27/22

  • Routine screening testing is no longer required or recommended for staff who are asymptomatic and do not have higher-risk exposure but may be conducted at the discretion of individual facilities. 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.

9/22/22

  • Clarified that routine screening testing requirements for staff who are not up to date are dependent on the CDC COVID-19 Community Transmission for Los Angeles County. This is different from the CDC COVID-19 Community Level. Please see COVID-19 Testing for more details.

9-19-22

  • COVID-19 vaccination “up to date” definition now includes receipt of the updated (bivalent) booster dose at least 2 months after completion of the primary series or last monovalent booster dose per CDC recommendations released Sep 2, 2022.
  • New section on “Outpatient COVID-19 Treatment and Pre-exposure Prophylaxis”, which includes the requirement for all residents with confirmed COVID-19 to be immediately assessed by their healthcare provider for outpatient COVID-19 treatment eligibility and offered if eligible and no contraindications.
  • N95 respirators are no longer required, but recommended, for staff working in the Green Cohort, especially for staff who are not up to date with all recommended COVID-19 vaccine doses.
  • Entry screening guidance is updated to clarify visitor entry screening and allow other options besides in-person screening at the facility.
  • Updated communal dining and group activities guidance to clarify which cohorts are permitted to participate in these activities.
  • Vaccine status and negative test verification is a consideration, and not a requirement, for general visitors seeking indoor visitation at this time.
  • Changes to routine screening testing recommendations for both staff and residents.
  • Asymptomatic residents who are close contacts/exposed and are 31-90 days from their prior COVID-19 infection are now recommended, but not required, to be tested with a point-of-care antigen test.
  • Updated cohorting guidance:
    • Yellow Cohort: revised duration of quarantine, testing interval recommendations, and which residents should be quarantined in this cohort.
    • Red Cohort: clarifies isolation duration for residents with critical illness due to COVID-19 or residents with severely immunocompromising conditions.
  • Added a “Reporting Requirements” section, which details reporting for positive point-of-care SARS-CoV-2 antigen tests, any suspected COVID-19 outbreak, and all fatalities associated with COVID-19.
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.

COVID-19 Vaccination Guidance

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:

  • Completed their primary series but are not yet eligible for a booster dose, OR
  • Received primary series AND the updated (bivalent) booster dose at least 2 months after completion of the primary series or after the last monovalent booster dose for both immunocompetent and immunocompromised individuals 12 years and older.

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.

  1. COVID-19 Vaccination Record Card (issued by the Department of Health and Human Services Centers for Disease Control & Prevention or WHO Yellow Card which includes name of person vaccinated, type of vaccine provided, and date last dose administered); OR
  2. A photo of a Vaccination Record Card as a separate document; OR
  3. A photo of the client's Vaccination Record Card stored on a phone or electronic device; OR
  4. Documentation of COVID-19 vaccination from a healthcare provider; OR
  5. Digital record that includes a QR code that when scanned by a SMART Health Card reader displays to the reader client name, date of birth, vaccine dates and vaccine type.
  6. Additional option for staff only: documentation of vaccination from other contracted employers who follow these vaccination guidelines and standards.

Track, Increase, and Maintain COVID-19 Vaccination & Booster Coverage

  1. All facilities should increase and maintain vaccination coverage, including for all recommended booster doses, for both staff and residents.
    1. Regardless of staff vaccination requirements from state or county Health Officer Orders, facilities must offer recommended additional/booster doses as soon as recommendations are released by the CDC and doses are made available to the facility, especially for residents.
    2. Facilities should utilize Best Practices for Improving Vaccination in SNFs including but not limited to re-offering the vaccine/booster doses, providing education, hosting listening sessions including to persons who have previously declined, etc.
    3. Per CMS QSO 21-19-NH Interim Final Rule – COVID-19 Vaccination Immunization Requirements for Residents and Staff, facilities must document when COVID-19 vaccine education took place and provide samples of educational materials used for both staff and residents.
  2. All facilities must track all vaccine doses, including additional primary and booster 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 (such as a password protected spreadsheet - please see sample vaccination tracker templates for residents and staff) for all current residents in a single file and all current staff in a single file:
      1) vaccination status (e.g., up to date, fully, partially, un-vaccinated, or not yet assessed)
      2) the dates of all vaccination doses, including additional primary and booster doses, OR date the person declined. This will a) help facilities anticipate when individuals are due for additional primary or booster doses, 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 Los Angeles County Department of Public Health (LAC DPH), California Department of Public Health (CDPH), and/or National Healthcare Safety Network (NHSN).

Residents:

  1. Immediately assess all residents on admission, and at regular intervals during their time in the facility, for their COVID-19 vaccination and booster status.
  2. 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.
  3. For residents coming from a hospital, including stays in the emergency department or observation, please ask the hospital to offer COVID-19 vaccine to the resident prior to transfer as per CDPH AFL 21-20.
  4. If a resident is not up to date with COVID-19 vaccines, immediately contact the facility’s long-term care (LTC) pharmacy to schedule an appointment or delivery of vaccine to get the resident vaccinated.
    1. If the resident is unvaccinated, the first dose should be administered within a week of admission.
    2. All recommended COVID-19 doses, primary series and booster(s), should be offered and administered to residents and staff per the CDC COVID-19 vaccination schedule as soon as official clinical recommendations are released and doses made available to facilities.
    3. 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.

Staff:

  1. Per CDPH’s Public Health Officer Order on “Health Care Worker Vaccine Requirement" and LAC DPH’s Health Officer Order on Health Care Worker Vaccination Requirement all workers* in skilled nursing facilities (including subacute facilities) are required to complete a primary COVID-19 vaccine series and receive a single booster dose. Workers not yet eligible for boosters must be in compliance no later than 15 days after becoming eligible for the booster dose. Workers who have completed their primary series who provide proof of subsequent COVID-19 infection may defer booster administration for up to 90 days after infection. See AFL 21-34.3. Workers that are eligible for a second booster dose should be encouraged to receive it.
  2. Workers who are recommended to receive additional booster dose(s) per the CDC should be strongly encouraged to receive them. Please note that even though workers are not required to stay up to date per the CDPH and LAC DPH’s Health Officer Orders, their up to date status does affect the facility’s up to date coverage and in turn can affect cohorting decisions (see Cohorting).
  3. Staff who are not vaccinated and/or boosted against COVID-19 due to qualified medical reasons or religious exemptions must undergo routine screening testing and have additional PPE recommendations. Please see relevant sections below. There are no exemptions from testing requirements for those with qualified medical reasons or religious exemptions to COVID-19 vaccination.

*Please read the full orders for description of who is included in “workers”.

Outpatient COVID-19 Treatment and Pre-exposure Prophylaxis

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:

  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 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.
  2. In advance of COVID-19 diagnoses and/or COVID-19 outbreaks, facilities should evaluate all residents for any oral 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 (specifically the oral antivirals Paxlovid and molnupiravir). 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 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.

Pre-exposure Prophylaxis

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.

Infection Prevention and Control Guidance

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

General Requirements

  1. CDPH guidance (https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/AFL-20-52.aspx) requires that facilities employ a full-time, on-site infection preventionist (IP) who will implement an infection prevention and control program. Facilities deemed by Los Angeles County Public Health to have insufficient IPs to meet these requirements will be directed to attain additional IPs as per LAC DPH’s “Order of the Health Officer for Control of COVID-19: Prevention of COVID-19 Transmission in Skilled Nursing Facilities.”
  2. All staff in the facility should undergo basic infection prevention and control training at hire and annually. Recommended trainings are listed here: http://publichealth.lacounty.gov/acd/ICPTrainingforSNFs.htm.
  3. 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

Residents

  1. All residents must be provided a clean mask daily.
  2. Medical-grade surgical/procedure masks are required for any resident that is COVID-19-positive or assumed to be COVID-19-positive.
  3. All residents, if tolerated, should wear a mask when outside their room including those who regularly leave the facility for care (e.g., dialysis), unless they are not able to wear a mask or if they are participating in an activity where masking is not required as outlined in "Communal Dining, Group Activities, and Visitation".
  4. Residents should remain in their room during an outbreak when possible and appropriate.
  5. Residents who due to underlying cognitive or medical conditions cannot wear a mask should not be forcibly required to wear one (and should not be forcibly kept in their rooms). However, masks should be encouraged as much as possible.
  6. Contraindications to mask wearing: a mask should not be placed on anyone who has trouble breathing, or is unconscious, incapacitated, or otherwise unable to remove it without assistance.
  7. Face shields with a drape may be offered to residents who are not able to wear masks.

Staff

  1. All staff, regardless of vaccination status, must wear a medical-grade surgical/procedure mask or N95 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.

Physical Distancing

  1. All staff, regardless of vaccination status, must adhere to physical distancing of at least 6 feet throughout the facility while on facility premises including in break rooms and in common areas, including when not providing resident care.
  2. Residents should keep at least 6 feet apart during group activities and communal dining except during special circumstances described in “Communal Dining, Group Activities, and Visitation”.
  3. All visitors, regardless of vaccination status, must practice physical distancing of at least 6 feet from persons they are not visiting (e.g., other resident’s visitors, staff, and other residents) while in resident rooms and common areas.

Hand Hygiene (HH)

  1. Healthcare personnel (HCP) and all other staff members should perform HH before and after ALL resident encounters including in multi-occupancy rooms as per WHO’s 5 Moments of Hand Hygiene.
  2. Facilities should have a process for auditing adherence and providing feedback on recommended HH practices by HCP.
  3. All staff, residents, and visitors should perform HH frequently including every time they enter and exit the facility, resident rooms, and common areas; before and after eating; after using the restroom; etc.
  4. Make sure HH supplies, such as soap and water or alcohol-based hand sanitizers (ABHS), are readily accessible and well-stocked throughout the facility including at facility entrances, near resident rooms including areas where HCP don and doff PPE, at nursing stations, on medication carts, in common areas, etc.

Respiratory Hygiene/Cough Etiquette:

  1. Support respiratory hygiene such as cough etiquette by residents, staff, and visitors.
  2. Encourage all residents, staff, and visitors to perform HH after contact with respiratory secretions or contact with contaminated materials (e.g. tissues).

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

SNF Figure 1 Diagram
  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: http://publichealth.lacounty.gov/acd/TransmissionBasedPrecautions.htm
    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 to have at least a 2-week supply of PPE and other infection prevention and control supplies, e.g., medical-grade surgical/procedure masks, N95 respirators, gowns, gloves, goggles/face shields, hand hygiene 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 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 resident care
    1. Gloves should be changed between every resident encounter including in multi-occupancy rooms.
    2. Hand hygiene should be performed as per CDC's 5 Moments of Hand Hygiene including 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 resident 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. Face masks and N95 respirators
    1. In the Green Cohort, medical-grade surgical/procedure masks or higher (N95 respirators) must be worn indoors at all times in areas where resident care is provided and/or residents may have access for any purpose including but not limited to resident rooms, dining rooms, rehab gyms, hallways, etc. Staff working in the Green Cohort who are not up to date with COVID-19 vaccines including boosters are strongly encouraged to wear N95 respirators whenever indoors.
    2. In the Yellow and Red Cohorts, all staff regardless of vaccination status must wear N95 respirators when providing resident care, working in resident care areas, or working in areas where residents may access for any purpose. If there is a need to preserve supply, N95 respirators can be worn in extended use (same N95 for duration of the shift).
    3. N95 respirators should be worn for all aerosol generating procedures (suction, ventilation, CPR, nebulizer treatments, etc.) for all cohorts including the Green Cohort regardless of the staff's vaccination status if the facility has an active outbreak.
    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, in which case either a surgical N95 respirator should be used or a face shield can be worn without compromising the fit of the respirator.
    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 shifts) of N95 respirators or extended use (with multiple residents in the same shift) when used for respiratory protection for confirmed or suspected cases, (e.g., in Yellow and Red Cohorts). However, staff may wear N95 respirators in an extended fashion if they are not interacting with confirmed or suspect cases of COVID-19.
    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 extended and/or re-use of N95 respirators and must document their reasoning in a written risk assessment.
  4. Eye protection
    1. Eye protection, which can be goggles or face shields, should be worn when staff are providing resident care, within 6 ft of residents, or while in resident rooms in all cohorts.
    2. Donning and doffing single-use eye protection for each resident encounter is recommended if there is sufficient PPE supply. However, if there is not sufficient PPE supply, extended use (worn over multiple resident encounters in a single shift) can be considered with proper storage between resident encounters that ensures no sharing between staff. If that cannot always be ensured, it’s advised to wear eye protection for the duration of the shift including in common areas, e.g., hallways.
  5. Gown use
    1. Gowns should be used for each resident encounter in Yellow and Red cohorts for COVID-19 precautions including in resident rooms, shower rooms, rehab gyms, and other areas where close contact may occur during resident care. Gown use is not recommended for resident care in the Green cohort for COVID-19 precautions but may be needed for transmission-based precautions for another pathogen.
    2. Gowns should be donned prior to entering and doffed prior to exiting resident care areas, which includes but are not limited to resident rooms and shared shower rooms. Gowns worn during close contact activities must be doffed prior to re-entering common areas, e.g., hallways. Gowns should also be changed (donned and doffed) between every resident encounter in multi-occupancy rooms.
    3. Re-use (over multiple days) and extended use (over multiple residents) of gowns are not allowed.
    4. The same gowns should never be worn for care of both COVID-19 positive and negative patients.
    5. If there is a shortage of gowns, facilities should contact LAC DPH immediately for guidance.

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 frequently touched surfaces such as light switches, bed rails, bedside tables, devices and equipment in resident rooms (e.g., walkers), etc.
  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 resident 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)

COVID-19 Prevention - General and Administrative Practices

  1. Conduct entry screening.
    1. All persons, regardless of vaccination status, should be screened for a recent diagnosis of COVID-19, symptoms of COVID-19 infection, AND close contact exposure (visitors) or higher-risk exposure (staff). This includes facility staff, essential visitors, and general visitors.
      1. All staff should follow Healthcare Personnel Monitoring and Return to Work on guidance for self-monitoring, entry screening, and return to work guidance for staff who are symptomatic, exposed and asymptomatic, or infected.
      2. Any visitor, essential or general, with a recent diagnosis of COVID-19 (a positive viral test for SARS-CoV-2) are prohibited from entry until they have met the same criteria for discontinuing isolation as for residents*.
      3. Any visitor, essential or general, with symptoms of possible COVID-19 infection is prohibited from entry and should reschedule their visit. Symptoms include but are not limited to the following: fever, chills, new onset cough or 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.
      4. 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. Any visitor reporting recent close contact exposure is prohibited from entry, regardless of vaccination status, until they have met the same criteria for discontinuing quarantine as for residents*.
      5. Options to conduct entry screening include, but are not limited to, in-person screening on arrival at the facility or via an electronic monitoring system in which individuals self-report any of the above before coming to work. Temperature-taking is not required but is allowed. The facility must ensure there is a process in place that prohibits those who screen positive from entering the facility until further follow up as outlined above.

        * This is purposefully more protective than the guidance for the general public given the high-risk nature of these settings.
    2. Facility must counsel general visitors on their exposure risk prior to entry when visiting residents with suspected COVID-19 infection (Yellow Cohort) or confirmed COVID-19 infection (Red Cohort) for both indoor and outdoor visits.
    3. An exception to entry screening: Emergency Medical Service (EMS) workers, including ambulance transport personnel. They do not have to be screened regardless of the urgency of the situation, as they are typically screened separately and are required to be up to date with COVID-19 vaccines or undergo regular COVID-19 screening testing per LAC DPH Health Officer Order.
  2. Conduct symptom screening for all residents.
    1. All asymptomatic 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 symptomatic residents under investigation (Yellow Cohort), for example every shift, and especially for residents with confirmed COVID-19 (Red Cohort), for example every 4 hours.
    2. Records should be kept of these staff and resident symptom and temperature checks.
  3. Support good workforce health.
    1. Facilities should have non-punitive sick leave policies to support staff to stay home when sick, if under isolation or quarantine orders, or when caring for sick household members. Make sure staff are aware of the non-punitive sick leave policy.
    2. Make sure that your employees are aware that they may be eligible for benefits such as paid sick leave or workers’ compensation if they become sick with COVID-19, are caring for someone with COVID-19, or if they need to quarantine due to exposure. Workers may also be eligible for paid leave to go to COVID-19 vaccination appointments or to recover from symptoms after getting their vaccination.
Communal Dining, Group Activities, and Visitation

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.

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 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:

  1. Universal source control and physical distancing
    1. All staff, regardless of vaccination status, must wear medical-grade surgical/procedure masks or N95 respirators at all times, including when caring for or assisting with residents during group activities and communal dining.
    2. Physical distancing for residents and visitors:
      When there is no outbreak at the facility and all residents, visitors, and staff participating in communal dining or group activity are up to date with all recommended COVID-19 vaccines including boosters they are eligible for, then residents and resident-visitor groups may participate without physical distancing; however, if any resident, visitor, or staff is not up to date with vaccines is participating in a communal dining or group activity, either outdoors or indoors, then all residents and visitors, regardless of vaccination status, should maintain at least 6 feet physical distancing from other visitors and/or resident-visitor groups.
    3. Universal source control for residents and visitors:
      All residents, visitors, and staff participating in communal dining or group activity, regardless of vaccination status, should wear well-fitting face masks when not actively eating or drinking, whether indoors or outdoors.
  2. Communal dining and group activities should be done in shifts with the same group of residents to allow better physical distancing and 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.
  3. All communal, high-touch surfaces should be disinfected after residents or staff vacate an area. Please see “Infection Prevention and Control Guidance” section for more details.
  4. Location of communal dining and group activities: Outdoor settings should be prioritized for communal dining and activities whenever practical, and especially during an outbreak.
  5. For further guidance on communal dining and activities during the holidays, please refer to CDPH AFL 20-86 (COVID-19 Infection Control Recommendations during Holiday Celebrations).

If there is a COVID-19 outbreak in the facility, then the following applies:

  1. Outdoor communal dining and group activities are strongly preferred, where practical, for residents who are not in quarantine nor isolation (Green Cohort). Otherwise, indoor communal dining and group activities may also occur.
  2. Residents should wear well-fitting face masks and maintain physical distancing of at least 6 feet regardless of vaccination status when not actively drinking or eating.
  3. Please note Public Health may be more protective and, on a case-by-case basis, can direct facilities with active outbreaks to temporarily cease all communal dining and activities for all residents regardless of vaccination status, both indoors and outdoors, to assist with outbreak investigation and/or management. 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

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).

  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. Essential visitors are exempt from a facility’s visitation requirements and may have access to a resident in any zone regardless of vaccination status. However, if they are regularly visiting a facility, e.g., once a week or more, then they may be required to be undergo routine screening testing as described below. Based on CDPH AFL 22-07, CMS QSO 20-39-NH-revised, and State Public Health Officer Order - Requirements for Visitors in Acute Health Care and Long-Term Care Settings, essential visitors include the following:
    • Ombudsman
    • CDPH surveyors and Public Health workers
    • Students obtaining their clinical experience as part of an approved nurse assistant, vocational nurse, registered nurse, pharmacy, social work, or other healthcare training program. Students may need to be treated as facility staff in regard to routine screening testing if they’re regularly entering the facility (at least once per week).
    • Visitors for legal matters that cannot be postponed including, but not limited to, voting, estate planning, advance health care directives, Power of Attorney, and transfer of property title if these tasks cannot be accomplished virtually.
    • Protection and Advocacy (P&A) program representatives
    • Individuals authorized by federal disability rights laws related to federal disability rights laws such as Section 504 of the Rehabilitation Act and the Americans with Disabilities Act (e.g., qualified interpreter when video remote interpretation is not possible or sufficient).
    • Compassionate care visitors
      1. Visitors for residents in critical condition including end-of-life situations
      2. Support persons for residents experiencing weight loss, dehydration, failure to thrive, psychological distress, functional decline, or struggling with a change in environment.**
      3. Support persons for residents with physical, intellectual, developmental disability, or cognitive impairment.**
      4.  ** NOTE: The determination of which residents may benefit from in-person visitation and who is the appropriate support person(s) should be made by an interdisciplinary team that includes the care team, resident, and/or resident representative(s), e.g., family, caregivers, ombudsman, etc.
  3. General visitors: General visitors are defined as visitors who do not fall under the definition of HCP or Essential Visitors. Facilities should support general visitation for all residents regardless of cohort status, COVID-19 status, vaccination status, or the facility’s outbreak status. However, Public Health may be more protective and, on a case-by-case basis, can direct facilities with active outbreaks to temporarily cease all general visitation for all residents, both indoors and outdoors, to assist with outbreak investigation and/or management. The facility should have documentation of communication with their Public Health contact directing them to do so including an anticipated date to resume general visitation.
  4. Visitor Requirements:
    • Visitors must follow the same criteria used to discontinue isolation and quarantine for SNF residents. Criteria for the general public does not apply in this setting given the high-risk nature of these facilities and their residents.
    • All visitors, essential and general, must adhere to the measures laid out in CDPH AFL 22-07 including the core principles of COVID-19 infection prevention or the facility may remove them from facility premises and restrict their entry.
    • In addition to AFL 22-07, the following apply to all visitors, essential and general, of SNFs in Los Angeles County:
      1. In a visitor log, visitors should document their name, contact information, and locations within the facility premises they are visiting in order to assist with contact tracing if needed.
      2. 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.
  5. Facility responsibilities: Facilities should do as much as possible to support safe in-person visitation:
    • Facilities should ensure 6 ft physical distancing at all times between resident-visitor groups while also considering individual resident needs (e.g., end-of-life situations).
    • 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.
    • Facilities are encouraged to regularly communicate visitation guidelines and expectations with residents, family, caregivers, designated decision makers, etc.
    • Facilities should place clear signage for visitors in relevant languages throughout the facility regarding education on COVID-19 symptoms, infection control precautions including hand hygiene and universal masking, specified entries/exits and routes to designated visitation areas, etc.
  6. Facilities should continue to support other visitation options as described in AFL 22-07 to help keep residents and loved ones connected and minimize social isolation among residents.
  7. The following infection prevention and control measures must be followed for all visitation, essential and general:
Table 1. Infection Prevention & Control Requirements for All Visitation (General and Essential)
Green Cohort Yellow & Red Cohorts
Entry Screening
  • Entry screening (recent positive viral test for SARS-CoV-2, COVID symptoms, close contact ≤14 days) is required for all visitors.
  • General visitors entering the facility for indoor visitation must be screened for vaccination status.
  • Entry screening (recent positive viral test for SARS-CoV-2, COVID symptoms, close contact ≤14 days) is required for all visitors.
  • General visitors entering the facility for indoor visitation must be screened for vaccination status.
  • Facility must counsel general visitors on their exposure risk due to visiting residents with suspected COVID-19 infection (Yellow Cohort) or confirmed COVID-19 infection (Red Cohort) for both indoor and outdoor visits.
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
  • Outdoor visitation is preferred whenever practical and if the outdoor visitation area is easily accessible without needing to go through other zones/cohorts.
  • Large indoor spaces that allow for ≥6 ft physical distancing with good ventilation should be offered as an alternative when outdoor visitation is not practical (e.g., inclement weather, poor air quality, inability to move resident outside).
  • Visits for residents who share a room should be conducted in a separate indoor space or with the roommate not present regardless of the resident’s or roommate’s vaccination status.
  • Indoor visitation should preferably be conducted in-room or if it must be conducted in an indoor common area, then it should be alone between the resident and their visitor(s) without any other residents present or visitation taking place.
  • Outdoor visitation is another option when it’s practical for the resident and if the outdoor visitation area is easily accessible without needing to go through other zones/cohorts.

COVID-19 Testing

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 22-13 COVID-19 Mitigation Plan Recommendations for Testing of Health Care Personnel (HCP) and Residents at Skilled Nursing Facilities (SNF) AFL
  • AFL 21-28 COVID-19 Testing, Vaccination Verification and Personal Protective Equipment for HCP at SNFs AFL

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

General Requirements

  1. Establish a relationship with a commercial lab to do 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 faster turnaround testing results including communication with the local and state health departments.
  2. COVID-19 Antigen point of care testing may be used to complement PCR testing per LA County Antigen Testing Guidance.
  3. Outside test results are acceptable if documentation of test date and test result can be provided. Results from antigen self-tests are acceptable if the test is done on site at the facility observed by facility staff who can verify the test result corresponds to the appropriate person for the appropriate date/time.
  4. Establish cohorting plan as part of CDPH-required COVID-19 mitigation plan.
  5. 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.
  6. Thorough documentation to demonstrate compliance with testing regulations in accordance with CDPH AFL 22-13.

Testing of Symptomatic Residents or Staff.

  1. Every staff member or resident with symptoms of COVID-19 should be tested as soon as possible, regardless of vaccination status. 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 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.

  1. Staff including regular essential visitors: Routine screening testing of asymptomatic staff includes essential visitors who regularly visit the facility at least once a week.
    1. Staff, including essential visitors who regularly visit the facility at least once a week, who are asymptomatic and who do not have higher-risk exposures do not need to undergo routine screening testing regardless of their vaccination status as per CMS QSO 20-38-NH-Revised.
    2. 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.
  2. Residents: Routine screening testing of residents is generally not required or recommended regardless of vaccination status. Please see below for exceptions.
    1. Residents, regardless of their vaccination status, who frequently leave the facility, remain asymptomatic, and do not have known close contact to a confirmed case may be tested once weekly but should remain in Green Cohort.
    2. Residents who are not up to date with COVID-19 vaccines in the Green Cohort who leave the facility for less than 24 hours, remain asymptomatic, and do not have known close contact to a confirmed case should return to the Green Cohort and should be tested 5-7 days after their return.

Figure 2. Testing Schematic

SNF Figure 2 Diagram

Retesting Previously Positive Staff/Residents

  1. Staff or residents who previously tested positive and are asymptomatic are not included in the above routine screening and facility-wide response testing requirements for 90 days since the date of symptom onset or date of the prior positive test indicating recent COVID infection.
    • Exception: If a staff or resident develops new symptoms consistent with COVID-19 ≤ 90 days of the initial positive test, if an alternative etiology cannot be identified, then retesting can be considered in consultation with the medical director, infectious disease, or infection control experts. In this situation, a point-of-care antigen testing is preferred.
  2. Staff or residents who previously tested positive who then 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 routine screening and facility wide response testing for another 90 days.
  3. Testing recommendations for asymptomatic residents who recently recovered from a COVID infection and who become a close contact or who are exposed to a confirmed case in the same unit/wing are as follows. If their first positive test was:
    1. ≤30 days ago, then repeat testing is not recommended and the resident should remain in the Green Cohort.
    2. 31-90 days ago, then point-of-care antigen testing is recommended, but not required, at least 5 days after the most recent exposure. Quarantine in the Yellow Cohort may be considered, e.g., for individuals who are moderately-severely immunocompromised.

Refusal of Testing

  1. Staff: The following restrictions only apply to staff directly employed by the facility.
    • 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.
    • 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.
  2. Residents:
    • 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.
      • If a resident (or resident representative) refuses routine screening testing (i.e., the resident is asymptomatic, not a close contact/considered exposed, and there is no active outbreak in the facility), then all efforts should be made to educate the resident/resident representative to undergo testing. The resident should stay in Green Cohort and be permitted to continue with their usual activities including any permitted group activities, communal dining, and visitation as per guidelines above for the Green Cohort. Their refusal should also not be used to determine their quarantine/cohort status.
      • Residents who refuse testing AND who have signs/symptoms of COVID-19 or who are close contact/considered exposed must be placed in the Yellow quarantine cohort (preferably in a single room if symptomatic), until the time-based criteria for discontinuing transmission-based precautions have been met.
      • 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 mask, and practices effective hand hygiene until the outbreak has been closed.

Cohorting

Facilities should have 3 separate cohorting areas as described below and shown in Figure 4.

  1. 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, recovered from a prior COVID-19 infection without new COVID-19 symptoms, and/or tested negative and remained asymptomatic after last negative testing. Additionally, the following residents should be in this cohort:
    • Residents, regardless of their vaccination status, who frequently leave the facility, remain asymptomatic, and do not have close contact to a confirmed case. Please see "Routine Screening Testing" for additional testing guidance.
    • New admissions, re-admissions, and residents who have left the facility for more than 24 hours and are up to date with all recommended COVID-19 vaccine doses they are eligible for.
    • Residents, regardless of their vaccination status, who leave the facility for less than 24 hours
      • Additionally, residents not up to date with COVID-19 vaccines who leave the facility for less than 24 hours should remain in Green Cohort with additional testing recommendations as described in "Routine Screening Testing".
  2. Red Cohort (Isolation Area). This area is only for residents who have confirmed COVID-19 with or without symptoms, regardless of vaccination status. Residents may be transferred to the Green Cohort once they have completed the appropriate isolation period as follows:
    • For symptomatic residents:
      • 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); and
      • At least 10 days have passed since symptoms first appeared without re-testing to end isolation (time-based strategy).
        • NOTE: Residents who had critical illness due to COVID-19 could have their isolation duration extended up to 20 days since symptom onset. Residents with severely immunocompromising conditions could have their isolation duration extended beyond 20 days since symptom onset (please see below for a list of severely immunocompromising conditions). For both these groups of residents, use of a test-based strategy in consultation with an infectious disease specialist, if available, is recommended to inform when isolation can be discontinued.
    • For asymptomatic residents with laboratory-confirmed COVID-19:
      • Regardless of vaccination status, these residents need to be isolated. Additional evaluation including repeat testing should be conducted in consultation with Public Health as soon as possible.
      • Unless cleared by Public Health, asymptomatic residents should isolate for 10 days since the date of first positive COVID-19 diagnostic test without the development of symptoms of COVID-19 without re-testing to end isolation (time-based strategy).
        • NOTE: Residents with severely immunocompromising conditions could have their isolation duration extended beyond 20 days since date of first positive COVID-19 diagnostic test. Please see below for a list of severely immunocompromising conditions. Use of test-based strategy in consultation with an infectious disease specialist, if available, is recommended to inform when isolation can be discontinued.
      • If they develop symptoms during their infection, the isolation period should be restarted from the onset of symptoms per the symptomatic resident criteria outlined above.
    • 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.
  3. Yellow Cohort (Mixed quarantine & symptomatic cohort)
    • This cohort is for the residents listed in figure 3. Room placement, duration of quarantine, and testing guidance for the Yellow Cohort are described in table 2 below.

    Figure 3. Indication to Quarantine in Yellow Cohort

    SNF Figure 3
    • If a test result is positive for COVID-19, the resident should be moved into the Red Cohort for isolation.
    • 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.
    • 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 resident contact in the same room.

Table 2. Quarantine Guidance for the Yellow Cohort

Indication to quarantine in Yellow CohortRoom 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.
Symptomatic

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

SNF Figure 4 Diagram

 

Special Staffing Considerations in Cohort Areas

  1. Staff assigned to the Red Cohort should not care for residents 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.

Healthcare Personnel Monitoring and Return to Work

Monitoring

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:

Inter-facility Transfers

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).

Reporting Requirements

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.

Resources

Relevant Webinars

Reliable sources of information about COVID-19 infection prevention/control and vaccination in SNFs:


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