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Coronavirus Disease 2019

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


1-19-23 This SNF Guidance is currently being updated to remove certain requirements that were put in place for extra protection during the winter surge. As of 1-18-23:

  • SNF staff are no longer required to wear N95 respirators in all areas of the facility where residents are present or where residents may have access to for any purpose. N95s are still required for staff that work with residents who are suspected to have COVID-19 or who are positive for COVID-19.
  • Visitors are no longer required to have a negative test prior to visiting. The SNF can provide antigen tests to visitors who choose to self-test prior to entering the facility.

Please note that the guidelines below have not yet been updated to reflect these changes.

Summary of Recent Changes

12/12/22

  • New definitions section including case (confirmed, suspect), close contacts, isolation, quarantine, up to date, and essential visitors.
  • Many parts of the guidance now depend on Los Angeles County’s CDC COVID-19 Community Level, which can be located here and is currently High as of Dec 8, 2022.
  • Vaccination guidance now includes CDC’s recommendation for everyone ages 5 and older to get an updated (bivalent) booster 2 months or more after their last COVID-19 vaccine dose once their primary series has been completed. This is the new up to date definition as of Sep 1, 2022.
  • Updated personal protective equipment (PPE) recommendations for staff caring for residents in isolation, whether in the Red Cohort or in-place. Please see Figure 1 “PPE for COVID-19” and the “Infection Prevention and Control” section for complete details.
    • Effective Dec 2, 2022, all staff must wear N95 respirators in all areas of the facility where residents are present or where residents may have access to for any purpose.
    • Eye protection is no longer indicated for all staff and is a consideration when CDC Community Level is high. Public Health may require eye protection on a case-by-case basis for facilities in active outbreaks.
    • Clarified gown use in hallways.
  • Added guidance regarding ventilation, filtration, and air quality.
  • New table (table 2) on “Resident Masking Requirements During Communal Dining and Group Activities”.
  • Revised visitation guidance to remove distinction between general and essential visitors. Facilities must support visitation for all residents regardless of COVID-19 status, vaccination status, or the facility’s outbreak status.
  • Effective Dec 7, 2022 (as previously noted in 11/30/22 email to all SNFs), all visitors are expected to test within 24 hours before an indoor visit. If testing is not done prior to arrival at the facility, facilities should offer antigen tests for visitors to self-test prior to entry. Proof of a negative viral test is not a condition for visitation. Essential visitors are exempt from this testing recommendation (please see definitions below for more details).
  • Clarified that if COVID-19 antigen testing is used, facilities should confirm with PCR/NAAT testing when an asymptomatic individual tests positive via antigen or a symptomatic individual tests negative via antigen.
  • New guidance on post-exposure and response testing based on AFL 22-13.1 released Oct 5, 2022. Figure 2 “Post-exposure and Response Testing” details when close contact testing, group-level testing, and facility-wide testing strategies are appropriate and when to broaden the testing approach to help mitigate transmission.
  • Revised routine screening testing for staff: while still not required, facilities are encouraged to consider routine screening testing of all staff, regardless of vaccination status, once or twice per week when the CDC Community Level for LA County is Medium to High. Clarified the guidance for usage of antigen tests for routine screening testing.
  • Testing of residents who are new admissions, re-admissions, and returning after leaving the facility >24 hrs is now on days 0, 3, and 5 after admission (day 0) as per AFL 22-13.1.
  • Figure 3, “Testing Schematic” has been updated to reflect all changes for new admissions/re-admissions testing, routine screening testing, and post-exposure and response testing.
  • Quarantine is not routinely recommended for residents who are close contacts, included in group-level or facility-wide post-exposure and response testing, new admissions, re-admissions, or returning after leaving the facility >24 hours. However, these resident groups should wear well-fitting face masks when not in their rooms for 10 days after admission or last exposure. Public Health may direct facilities to quarantine these resident groups on a case-by-case basis.
  • Isolation: Clarified that confirmed resident cases should isolate in a physically separate and dedicated Red Cohort while suspect resident cases should isolate in place.
  • New table 3 summarizes testing and infection control guidance for residents at the end of the “Isolation and Quarantine” section.
Introduction

These guidelines outline actions that Skilled Nursing Facilities (SNFs) should take to help prevent and manage COVID-19, based on the current status of and trends in community transmission in LA County.

The current CDC COVID-19 Community Level for Los Angeles County is High as of Dec 8, 2022.

Definitions

Case: A case is defined as an individual with a positive viral test (e.g., PCR/NAAT or antigen test) regardless of symptoms unless a confirmatory PCR/NAAT test is negative for an asymptomatic individual with a positive antigen test.

  • The infectious period is defined as 2 days prior to the date of symptom onset (or the positive specimen collection date, if asymptomatic) through day 10 after symptom onset or date of positive specimen collection.
  • Confirmed: resident cases who are either symptomatic with a positive viral test (PCR/NAAT or antigen) or asymptomatic with a positive molecular (PCR/NAAT) test.
  • Suspect: resident cases who are symptomatic with pending/unknown test results or asymptomatic with a positive antigen test pending confirmatory PCR/NAAT testing.
  • Residents: a close contact is defined as sharing the same indoor airspace (e.g., resident room, rehab gym, communal dining room, communal activity/visitation area, shower room, hallway, nursing station, etc.) for a cumulative total of 15 minutes or more over a 24-hour period with a case during their infectious period regardless of source control.
  • Staff: Please see the LAC DPH COVID Infection Prevention Guidance for Healthcare Personnel for definition of higher risk exposure.

The separation of persons with COVID-19 from persons without COVID-19. Isolation measures in SNFs include restricting the resident to their room, infected residents wearing well-fitting masks when not in their rooms, and staff donning full PPE prior to providing care or entering rooms where there are infected persons (i.e., placing on transmission based precautions). Please see “Isolation and Quarantine” section below for more details.

Quarantine keeps asymptomatic persons who might have been exposed to SARS-CoV-2 away from others to see if they become infected. Quarantine in SNFs, when required, involves restricting the resident to their room as much as possible, exposed residents wearing well-fitting masks when not in their rooms, and staff donning full PPE prior to providing care or entering rooms where there are exposed persons (i.e., placing on transmission-based precautions). Residents in quarantine should be managed in-place; avoid movement of residents to different rooms that could lead to new exposures. Please see “Isolation and Quarantine” section below for more details.

An individual is considered up to date with COVID-19 vaccines when they have received all recommended doses in the primary series and the most recent booster dose recommended for them by the CDC.

  • In other words, individuals falling into the following categories are considered up to date with COVID-19 vaccines. Those who:
    • Completed their primary series but are not yet eligible for a booster dose (i.e., it has been less than 2 months since completing their primary series or receiving their last monovalent booster dose), OR
    • Completed their primary series AND have received the updated (bivalent) booster dose.
  • An individual is still considered up to date if they receive all recommended COVID-19 vaccine doses and then become infected with COVID-19. They do not need to be immediately revaccinated or receive an additional booster.
  • Proof of vaccination: Individuals must show acceptable proof of vaccination that confirms the above definition. Proof of vaccination is listed in AFL 21-28.

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 post-exposure and response 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
  • Emergency medical services personnel
  • Building safety inspectors
  • 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
    • Visitors for residents in critical condition including end-of-life situations
    • Support persons for residents experiencing weight loss, dehydration, failure to thrive, psychological distress, functional decline, or struggling with a change in environment. *
    • Support persons for residents with physical, intellectual, developmental disability, or cognitive impairment. *
    • *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.

COVID-19 Vaccination Guidance

Staying up to date with COVID-19 vaccines including recommended boosters 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.

The updated (bivalent) boosters are recommended for everyone ages 5 and older if it has been at least 2 months after the last COVID-19 vaccine dose. These boosters have been updated to target the most recent Omicron subvariants (BA.4/BA.5) as well as the original COVID-19 virus. The BA.4/BA.5 subvariants are more contagious than earlier strains of Omicron. The updated boosters can help restore protection against COVID-19 that has decreased over time and provide broader protection against newer variants. Keeping everyone up to date with their COVID-19 vaccines, including the updated booster can help significantly protect SNF residents and staff from transmission and severe outcomes like hospitalizations and deaths related to COVID-19.

Visit the LAC DPH COVID-19 Vaccine Schedule website for more information including color-coded vaccine schedules in English and Spanish. Additional vaccine resources from are located on the DPH vaccine resources page.

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

  1. All facilities should increase and maintain vaccination coverage, including 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;
      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 the recommended timeframe in the orders. 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.
  2. Staff that have satisfied the healthcare worker booster requirement with a monovalent booster (i.e., their booster was prior to Sept 2022) should be strongly encouraged to receive their updated (bivalent) booster to stay up to date with COVID-19 vaccines. Staff who are not vaccinated and/or boosted against COVID-19 due to qualified medical reasons or religious exemptions have additional PPE recommendations. Please see Infection Prevention and Control Guidance 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

There are highly effective outpatient COVID-19 treatments to prevent severe outcomes, including hospitalizations and death, among high-risk individuals infected with COVID-19 including nursing home residents. The preferred outpatient treatment is ritonavir-boosted nirmatrelvir (Paxlovid), an oral antiviral, or intravenous remdesivir. Molnupiravir (Lagevrio) is an alternative if these preferred treatments are not appropriate or accessible. 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/NAAT or point of care antigen in a symptomatic individual AND any new COVID-19 admission/re-admission.
    • During a COVID-19 outbreak at the facility, all residents testing positive for SARS-CoV-2 should be assessed daily following this protocol, including asymptomatic residents who are not initially eligible.
  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 IV remdesivir. For more information please see LAC DPH’s COVID-19 Outpatient Therapeutics page and NIH’s Therapeutic Management of Nonhospitalized Adults with COVID-19 for the most up to date information.

Pre-exposure Prophylaxis

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 (i.e., not in quarantine or isolating in the Red 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 basics and the difference between standard and transmission-based precautions, 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.

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 suspected or confirmed to have COVID-19. Masks are also required for 10 days for close contacts, new admissions, re-admissions, and those who left the facility >24 hrs.
    1. 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.
    2. 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.
    3. Face shields with a drape may be offered to residents who are not able to wear masks.
  3. All other residents are strongly recommended to wear masks when not in their rooms.

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. In low and medium periods of COVID transmission when N95 respirators are optional, staff who are not up to date with COVID-19 vaccines are strongly encouraged to wear N95 respirators whenever indoors regardless of the COVID-19 status of residents for which they are caring.
  3. Please see Cohort-Specific Transmission Based Precautions and PPE section for appropriate mask use for each cohort.

Visitors

  1. 1. All visitors, regardless of vaccination status, must wear a well-fitting face mask with good filtration for the duration of their visit while indoors, unless actively eating or drinking.

Hand Hygiene (HH)

  1. Healthcare personnel (HCP) and all other staff members should perform HH before and after all resident encounters, regardless of a resident’s COVID-19 status. They should follow the instructions in the LAC DPH’s Hand Hygiene Poster, which goes beyond WHO’s 5 Moments of Hand Hygiene for the nursing home setting.
  2. HH should preferentially be done with alcohol-based hand rub (ABHR) with at least 60% alcohol in most cases. HH can also be done with soap and water especially when hands are visibly soiled.
  3. Facilities should have a process for regularly auditing (also called adherence monitoring) HH adherence using “secret shoppers” and providing on the spot feedback for all staff types in all shifts. Facilities can use CDPH’s HH adherence monitoring tool.
  4. 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. Please see LAC DPH’s Hand Hygiene Poster.
  5. 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 residents in isolation including standard precautions as summarized in figure 1 and detailed below.

Figure 1. PPE for COVID-19

SNF Figure 1 Diagram
  1. General
    1. Standard precautions must always be followed regardless of the resident’s COVID-19 status for general prevention of all infectious diseases.
    2. Transmission based precautions are based on the COVID-19 status of the resident. Facilities should post and follow the signage for residents in isolation (Red Cohort or in-place).
    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 must regularly audit their HCP’s adherence to appropriate PPE use.
    5. 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).
    6. 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. N95 respirators
    1. Effective Dec 2, 2022 until further notice, all staff must wear N95 respirators in all areas of the facility where care is provided or where residents may have access to for any purpose. This includes all staff regardless of paid and unpaid, directly employed by the facility or by a registry, direct resident facing and non-resident facing, and include volunteers, students, contractors, and consultants.
    2. All staff must wear fit tested NIOSH-approved N95 respirators in any indoor space where there are residents who are in isolation (Red Cohort or isolating in place).
    3. N95 respirators must be worn for all aerosol generating procedures (suction, sputum induction, ventilation, CPR, nebulizer treatments, etc.) regardless of the resident’s COVID-19 status.
    4. NIOSH-approved N95 respirators with an exhalation valve can be used as protection (i.e. as PPE) and source control when there is no anticipated high velocity body fluids as per CDC. If high velocity body fluids are possible, then the CDC recommends wearing a surgical N95 or, if a surgical N95 is not available, cover their respirator with an additional surgical/procedure face mask or a face shield. The additional face mask or face shield should be worn in a way that does not compromise the fit of the respirator.
    5. 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) or extended use (with multiple residents in the same shift) of N95 respirators when used for respiratory protection for residents in isolation for suspected and confirmed cases. However, staff may wear N95 respirators in an extended fashion if 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 use of N95 respirators and must document their reasoning in a written risk assessment.
  3. Eye protection
    1. Eye protection, which can be goggles or face shields, may be considered at the facility’s discretion for staff providing care to residents not in isolation or quarantine when the CDC Community Level for LA County is high or when the facility is in an active outbreak. Public Health may direct facilities in active outbreaks to require eye protection for all areas of the facility on a case-by-case basis to mitigate transmission.
    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.
  4. Gown use
    1. As a part of transmission based precautions for COVID-19, gowns should be worn prior to providing direct care or entering rooms/care areas where residents are in isolation (Red Cohort or isolating in place). Care areas include but are not limited to resident rooms, shower rooms, rehab gyms, etc.
    2. Gowns should be doffed prior to exiting resident care areas and re-entering common areas, e.g., hallways. Gowns should also be changed (i.e., doff used gown and don new gown) for every resident encounter in multi-occupancy rooms.
    3. Re-use (over multiple days) and extended use (over multiple residents) of gowns are not allowed.
    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 Public Health (LTC_NCoV19@ph.lacounty.gov) immediately for guidance.

Ventilation, Filtration, and Air Quality: Effective ventilation is one of the most important ways to control small aerosol transmission. Facilities should consult with professionals (facilities engineers, mechanical engineers, indoor air quality or industrial hygiene consultants, etc.) to perform comprehensive evaluations of their HVAC (Heating, Ventilation, and Air Conditioning) systems and indoor air quality and obtain permits or approvals from any applicable regulatory bodies as necessary prior to implementing changes. Facilities should not rely on any single solution to effectively improve the ventilation and air quality of their buildings. Importantly, ventilation and other indoor air quality improvements are additions to and not replacements for infection prevention and control including any applicable state or local directives. Please carefully review in full the following guidance from CDPH, Department of Health Care Access and Information (HCAI) formerly OSHPD, and Cal/OSHA: Interim Guidance for Ventilation, Filtration, and Air Quality in Indoor Environments.

Please note SNFs have a second opportunity to apply for Civil Money Penalty (CMP) Reinvestment funds to purchase portable fans and portable room air cleaners with high-efficiency particulate air (HEPA, H-13 or -14) filters to increase air exchange or improve air quality. Facilities should only use portable air cleaners with the involvement of professionals and following the Interim Guidance for Ventilation, Filtration, and Air Quality in Indoor Environments. Placement of portable air cleaners must be carefully considered to avoid blowing air from one person to another especially in multi-occupancy rooms and communal areas and should not be placed in corners of rooms or beneath tables where they will not effectively clean the air. Do not create tripping hazards with these devices or associated electrical cords that increase fall risk for SNF residents. Finally, please note LAC DPH does not necessarily endorse the usage of portable air cleaners as the most effective or only strategy to improve ventilation and indoor air quality in SNFs, but recommend SNFs to consult with professionals on a comprehensive evaluation and plan.

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 and 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 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 with symptoms of possible COVID-19 infection is prohibited from entry. They should reschedule their visit after they have met the same criteria for discontinuing isolation-in-place as for residents*. 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. 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 recommended but not required. 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.

        * Please see table 3 (Summary of Testing and Infection Control Guidance for Residents) and Quarantine and Isolation guidance section isolation durations for residents.
    2. Prior to entry, visitors of residents in isolation (Red Cohort or in-place) should be advised of their possible exposure risk. When there is an active outbreak at the facility, all visitors should be advised of their possible exposure risk.
    3. Effective Dec 7, 2022, until further notice (as previously noted in 11/30/22 email to all SNFs): All visitors* are expected to test for COVID-19 within 24 hours before an indoor visit and attest that their test result being negative. If testing is not done prior to arrival at the facility, SNFs should offer over the counter (OTC) antigen tests for visitors to self-test prior to entry and attest to the result to staff. Any visitor with a positive test result, regardless of symptoms, should reschedule their visit until after they have completed isolation. Positive results from self-performed tests without facility supervision do not have to be reported to Public Health. Please note that implementation of this guidance should not effectively restrict visitation, and proof of a negative viral test is not a condition for visitation.
      * Essential visitors are exempt from this testing recommendation.
    4. 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 residents who are suspect cases, 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 who are not in isolation (suspect isolating in-place or confirmed isolation in the Red Cohort), not a close contact, nor undergoing testing as a part of broad-based response testing. These activities may take place indoors or 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. Source control (well-fitting face masks) for residents permitted to participate in communal dining and group activities depend on the facility’s outbreak status and the CDC Community Level for LA County:

    Table 1. Resident Masking Requirements During Communal Dining and Group Activities

    Active outbreak or within 14 days of outbreak closure No outbreak for 14 days or more
    CDC Community Level: Low Well-fitting face masks are required* when not actively eating or drinking, regardless of vaccination status Well-fitting face masks are optional^ but recommended when not actively eating or drinking, regardless of vaccination status
    CDC Community Level: Medium to High Well-fitting face masks are required* when not actively eating or drinking, regardless of vaccination status Well-fitting face masks are required* when not actively eating or drinking, regardless of vaccination status

    *When safe and practical. Please see contraindications under source control for residents.
    ^Exception: Residents who are new admissions, re-admissions, or have returned after leaving the facility more than 24 hrs must wear face masks for 10 days.

  2. Communal dining and group activities should be done in shifts with the same group of residents to minimize broad exposure as much as possible.
    1. Additionally, the same group of residents should be assigned to specific areas as much as possible to further minimize exposure.
    2. Use a sign-in sheet/roster of residents present during these activities to help with contact tracing should a resident later test positive for COVID-19.
  3. All communal, high-touch surfaces should be cleaned and disinfected after residents or staff vacate an area. Please see “Infection Prevention and Control Guidance” section for more details.
  4. 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 in non-COVID areas. Otherwise, indoor communal dining and group activities may also occur.
  2. Residents should wear well-fitting face masks 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 COVID-19 status and 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. Facilities must support visitation for all residents regardless of 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 visitation, 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 visitation. However, even when there is a temporary suspension of visitation, there must be a consideration of resident rights which means some visitation may still occur. This includes but is not limited to compassionate care visitation for residents in critical condition or end-of-life situations; essential support person visitation for residents who are experiencing weight loss, dehydration, failure to thrive, psychological distress, or functional decline or struggling with a change in environment; and essential support person visitation for residents with physical, intellectual, or developmental disability or cognitive impairment.
  3. Visitor Requirements:
    • Effective Dec 7, 2022, as previously noted in 11/30/22 email to all SNFs, all visitors* are expected to test within 24 hours before an indoor visit. If testing is not done prior to arrival at the facility, facilities should offer antigen tests for visitors to self-test prior to entry. Proof of a negative viral test is not a condition for visitation.
      * Essential visitors are exempt from this testing recommendation.
    • Visitors must follow the same criteria used to discontinue isolation 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. Please see table 3 (Summary of Testing and Infection Control Guidance for Residents) and “Quarantine and Isolation” guidance section for isolation durations for residents.
    • All visitors 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 of SNFs in Los Angeles County:
      1. Visitors should document, e.g., 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.
      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 7 days of visiting the facility. Facilities should promptly conduct contact tracing and perform post-exposure testing where indicated by the contact tracing.
  4. Facilities should do as much as possible to support safe in-person visitation:
    • 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.
  5. 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.
  6. The following infection prevention and control measures must be followed for all visitation:
Table 2. Infection Prevention & Control Requirements for Visitation
Residents Not in Isolation or Quarantine Residents in Isolation (Red Cohort or in-place)
Entry Screening
  • Entry screening (recent positive viral test for SARS-CoV-2, COVID symptoms, close contact ≤14 days) is required for all visitors.
  • Prior to entry, all visitors should be advised of their possible exposure risk when there is an active outbreak at the facility.
  • All visitors are expected to test for COVID-19 within 24 hours before an indoor visit and attest to their test having a negative result. If testing is not done prior to arrival at the facility, SNFs should offer over the counter (OTC) antigen tests for visitors to self-test prior to entry and attest to the result to staff Proof of a negative viral test is not a condition for visitation.
  • Entry screening (recent positive viral test for SARS-CoV-2, COVID symptoms, close contact ≤14 days) is required for all visitors.
  • Prior to entry, visitors should be advised of their possible exposure risk.
  • All visitors are expected to test within 24 hours before an indoor visit and attest to their test having a negative result. If testing is not done prior to arrival at the facility, facilities should offer antigen tests for visitors to self-test prior to entry. Proof of a negative viral test is not a condition for visitation.
Face Masks All visitors must wear well-fitting mask with good filtration (N95, KF94, KN95, or surgical masks are preferred over cloth face coverings) throughout the visit when indoors or in-room when not actively eating/drinking. Residents should also wear well-fitting 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   Visitors are required to properly don and doff any additional PPE (eye protection, gowns, gloves) required per COVID-19 transmission based precautions according to instruction by facility staff.
Physical Distancing There is no recommendation to physically distance or avoid physical contact (e.g., hugs, holding hands) between a resident and their visitor(s), regardless of vaccination status. However, physical distancing should be maintained between other resident-visitor groups both indoors and outdoors.
Location of Visit
  • Outdoor visitation is preferred whenever practical and if the outdoor visitation area is easily accessible from the facility entrance.
  • Large indoor spaces that allow for ≥6 ft physical distancing between resident-visitor groups 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 with roommate(s) 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 from the facility entrance.

COVID-19 Testing

Below are recommendations for testing 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 molecular (PCR/NAAT) 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/NAAT 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. If COVID-19 antigen testing is used, facilities should confirm with PCR/NAAT testing when an asymptomatic individual tests positive via antigen or a symptomatic individual tests negative via antigen.
  3. Outside test results are acceptable for staff and visitors if documentation of test date and test result can be provided. Results from 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 testing plan as part of CDPH-required COVID-19 mitigation plan.
  5. 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 with a SARS-CoV-2 viral test (PCR/NAAT or antigen) as soon as possible, regardless of vaccination status and regardless of time since prior COVID-19 infection*. 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.
    1. * NOTE: If a staff or resident develops new symptoms of COVID-19 ≤ 90 days of the prior positive test and 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. If point of care (POC) antigen testing is used initially and is negative, then testing should be repeated in 48 hours with a molecular (PCR/NAAT) test for a total of at least two tests.
  2. All symptomatic residents should be presumed infectious pending test results and should isolate in place in their current rooms on transmission-based precautions for COVID-19.
  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. All symptomatic staff must be immediately restricted from working (see LAC DPH’s COVID-19 Infection Prevention Guidance for Healthcare Personnel).
  5. Any staff or resident testing positive for COVID-19 should prompt post-exposure and response testing (see below). Staff testing positive must isolate at home and be excluded from work. Symptomatic residents testing positive must isolate in the Red Cohort.

Post-exposure and Response Testing. If a single positive COVID-19 case is identified among either staff or residents, the SNF must immediately conduct contact tracing to identify all residents who may have had close contact with the case(s) and all staff who may have had higher-risk exposures with case(s). Post-exposure and response testing should occur depending on the level of the exposure or ability to contact trace as described in figure 2 and detailed below.

Figure 2. Post-exposure and Response Testing

SNF Figure 2 Diagram
  1. Close contact testing: This testing approach involves testing only the residents who are close contacts and staff with higher-risk exposures identified in contact tracing on days 1, 3, and 5 after exposure. This approach should only be utilized when exposure is known to be limited and contact tracing can be done immediately.
    1. If additional cases are identified among one or more resident, then the facility should immediately broaden their testing strategy to group-level or facility-level response testing serially every 3-7 days. For example, if one additional resident case is identified in the same unit, floor, nursing station, or other specific area, then group-level response testing should be immediately initiated. However, if multiple resident cases are identified regardless of location or at least one resident case is identified in a different unit, floor, nursing station, or other specific area of the facility, then facility-wide response testing of all residents and staff should immediately begin.
    2. Either antigen tests or PCR/NAAT tests (if TAT is <48 hrs) may be utilized. Any asymptomatic residents with positive antigen test results must immediately be isolated in place on COVID-19 precautions pending results of confirmatory PCR/NAAT tests.
  2. Group-level and facility-wide testing: When the initial case has potential for only moderate exposure (see figure 2 for example), then group-level testing should be initiated (e.g., testing all residents in the same unit, floor, nursing station, or other specific area of the facility). Facility-wide testing should be performed when there is widespread exposure or when the exposure is unknown (see figure 2 for example). Facility-wide testing should also be implemented when it is difficult to perform contact tracing in a complete and timely way.
    1. Initial group-level and facility-wide testing should occur on days 1, 3, and 5 after potential exposure (day 0). If the initial round of testing on days 1, 3, and 5 yields additional cases among residents, then response testing must be further broadened to facility-wide if not done so already, and all residents and staff who test negative should be included in response testing every 3-7 days until there are at least 14 days with no additional infections identified. After 14 consecutive days of negative testing for residents, the facility could stop response testing and resume routine testing for residents (if applicable) as outlined below, in consultation with their outbreak investigation team at Public Health.
    2. Either antigen tests or PCR/NAAT tests (if TAT is <48 hours) may be utilized. Antigen testing, if used for subsequent rounds of serial testing, should occur at least twice per week or every 3 days at the minimum. Any asymptomatic residents with positive antigen test results must immediately be isolated in place on COVID-19 precautions pending results of confirmatory PCR/NAAT tests.

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. Routine screening testing is resumed when no new cases are identified from two sequential weeks of response testing.

  1. Staff including regular visitors: Routine screening testing (i.e., testing individuals who are asymptomatic, do not have higher-risk exposures, and when there is no outbreak) is currently not required regardless of their vaccination status as per CMS QSO 20-38-NH-Revised.
    1. However, if facilities choose to conduct routine screening testing of staff, all staff should be included in screening testing regardless of vaccination status. 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. When the CDC Community Level for LA County is Medium to High, facilities are encouraged to consider conducting routine screening testing of all staff, regardless of vaccination status, once or twice per week. Routine screening testing could be prioritized for staff who provide care or work in areas where there are residents with moderate-severely immunocompromising conditions, residents who are dependent on mechanical ventilation (e.g., subacute units), or residents who are otherwise at higher risk for severe COVID-19 outcomes.
  2. Residents: Routine screening testing of residents is generally not required or recommended regardless of vaccination status. Please see below for an exception.
    1. Once weekly screening testing of residents who frequently leave the facility is recommended, regardless of vaccination status, when the CDC Community Level for LA County is Medium to High. These residents should not be quarantined nor should refusal of testing influence decisions on their rooming or placement.
  3. Antigen tests: If COVID-19 point of care antigen tests are used for routine screening testing, then they should be administered at least twice per week and confirmatory PCR/NAAT testing should immediately be performed for any positive antigen test results in asymptomatic individuals. While the confirmatory PCR/NAAT test results are pending, residents should be isolated in place on COVID-19 transmission-based precautions and staff should be restricted from work. Only when a PCR/NAAT test confirms a positive result should an asymptomatic resident be moved to the Red Cohort to finish their isolation as per the “Quarantine and Isolation” section.

New Admission and Re-admission Testing. Residents who are asymptomatic and newly admitted or re-admitted to a facility should undergo serial testing on days 0, 3, and 5 after admission (day 0). New admissions and re-admissions do not need to quarantine. New admissions and re-admissions who are asymptomatic, not close contacts, and within 90 days of a prior COVID-19 infection do not need to undergo testing. If a new admission or re-admission tests positive by a PCR/NAAT test, then they should be immediately isolated following guidance in the “Isolation and Quarantine” section. If a new admission or re-admission who is asymptomatic tests positive by antigen testing, then they should be isolated in place pending confirmatory PCR/NAAT test results. The results of the PCR/NAAT test will determine whether the resident should be isolated in the Red Cohort or if isolation can be discontinued.

Residents who have returned after leaving the facility for 24 hours or longer should be managed as an admission.

 

Figure 3. Testing Schematic

SNF Figure 3 Diagram

Retesting Previously Positive Staff/Residents

  1. Staff or residents who previously tested positive within the last 90 days and are asymptomatic should not be included in routine screening, facility-wide or group-level response testing, and new admission/re-admission testing requirements.
  2. 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.
  3. 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.

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, and there is no active outbreak in the facility), while all efforts should be made to educate the resident/resident representative to undergo testing, the resident should not be quarantined or be restricted to their rooms. They should be permitted to continue with their usual activities including any permitted group activities, communal dining, and visitation as per guidelines above.
    • Residents who refuse testing AND who have signs/symptoms of COVID-19 or who are close contacts must be placed on COVID-19 transmission based precautions (preferably in a single room if symptomatic), until the time-based criteria for discontinuing quarantine (close contact) or isolation (symptomatic) have been met.
    • 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.

Quarantine and Isolation

Isolation Area (Red Cohort): This designated, physically separate area is only for residents who have confirmed COVID-19 with or without symptoms.

  1. The COVID-19 isolation area should include ventilation measures to prevent transmission to other residents outside the isolation area as per CDPH AFL 22-13. Please see “Infection Prevention and Control Guidance” section for guidance on ventilation.
  2. Residents may be transferred out 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 PCR/NAAT confirmed COVID-19:
      • 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. Special Staffing Considerations:
    • Staff assigned to the Red Cohort should not care for residents outside of the cohort/isolation area. If staff must care for other residents, they should visit the Red Cohort last.
    • If a facility is experiencing critical staffing shortage and there is prior approval from Public Health, asymptomatic staff with lab-confirmed COVID-19 infection may be allowed to work in the Red Cohort. The approval should include the anticipated duration of work for each asymptomatic confirmed staff. The facility must also show they are actively working to secure more staffing. Asymptomatic confirmed staff will need to be able to keep separated from uninfected staff, which includes having dedicated breakrooms and bathrooms until they are no longer considered infectious.

Isolation in place of suspect cases: Residents with COVID-19 signs or symptoms who are pending test results or who refuse to test should isolate in place. Additionally, asymptomatic residents with a positive test pending confirmatory PCR/NAAT testing results should also isolate in place. If SARS-CoV-2 infection is confirmed, then residents should be moved into the Red Cohort to complete the remainder of their isolation.

  1. Isolation in place requires staff entering the resident room or providing direct care in another room (shower room, rehab gym, etc.) to wear full PPE per transmission based precautions for COVID-19.
  2. Residents should be restricted to their rooms as much as possible and wear well-fitting face masks when not in their rooms.
  3. If a point of care (POC) antigen test is used initially and is negative, then isolation should be maintained, and a confirmatory PCR/NAAT test should be collected 48 hours later.
  4. For residents awaiting testing results in multi-occupancy rooms, strategies to reduce exposures between residents should be implemented including but not limited to drawing curtains between resident beds. Staff should change gowns and gloves with frequent hand hygiene between each resident contact in the same room.
  5. Symptomatic residents who decline testing should be isolated in place and should not be placed in a room with other residents with confirmed SARS-CoV-2 infection. Certain Red Cohort staff (e.g., RN, LVN) may provide care for them if infection prevention and control practices are strictly adhered and visit their rooms after providing care in the Red Cohort as much as possible.
  6. Isolation in place duration:
    • Low clinical suspicion: isolation-in-place can be discontinued after PCR/NAAT test is confirmed negative
    • Higher clinical suspicion and/or no clear alternate diagnosis: isolation can be discontinued after two (2) PCR/NAAT tests taken 24 hrs apart are confirmed negative
    • No testing (e.g., resident refuses testing): At least 10 days AND improvement in symptoms AND fever-free for 24 hrs without fever-reducing medications

Quarantine: Quarantine is no longer required for asymptomatic residents who have known or possible exposures to COVID-19. However, in an outbreak, Public Health may direct facilities to quarantine the following resident groups in order to mitigate transmission: asymptomatic residents who are close contacts, included in group-level or facility-wide post-exposure and response testing, new admissions, re-admissions, or returning after leaving the facility >24 hours.

Regardless of decision to quarantine, residents in these above groups should:

  1. Wear source control (well-fitting face mask) when not in their rooms for 10 days after admission or last exposure.
  2. Be closely monitored for signs and symptoms of COVID-19 including temperature and oxygen saturation checks at least once per shift. If symptoms develop, immediately isolate in place and test.

If quarantine is required:

  1. Residents should be restricted to their rooms as much as possible if safe to do so.
  2. Residents should be managed in-place; avoid movement of residents to other rooms that could lead to new exposures.
  3. Duration should be 7 days when all tests are negative or 10 days if testing was not performed.

Table 3. Summary of Testing and Infection Control Guidance for Residents

Testing Who Infection Control Measures
Testing of Symptomatic Residents: One antigen test immediately and if negative, one PCR/NAAT test collected 48 hrs later;
OR
One PCR/NAAT test immediately
Residents with symptoms of COVID-19, regardless of vaccination status Immediately isolate in place** (avoid movement of residents that could lead to new exposures) and place on COVID-19 transmission based precautions while pending clinical evaluation and testing results.

Isolation duration (see “Isolation and Quarantine” section for more details):
  • Low clinical suspicion: isolation can be discontinued when PCR/NAAT test is confirmed negative
  • Higher clinical suspicion and/or no clear alternate diagnosis: isolation can be discontinued when two (2) PCR/NAAT tests taken 24 hrs apart are confirmed negative
  • No testing: At least 10 days AND improvement in symptoms AND fever-free for 24 hrs without fever-reducing medications
Close Contacts Post-exposure and Response Testing: Serially testing 3 times on days 1, 3, and 5 after the last exposure (day 0).

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

If a resident recently recovered from a COVID-19 infection 31-90 days ago, then antigen testing is preferred over PCR/NAAT testing.
Residents who are close contacts identified via contact tracing, regardless of vaccination status
  • Well-fitting face masks are required when residents are not in their rooms through day 10 after last exposure.
  • Quarantine** is not routinely required. Public Health may direct individual facilities on a case-by-case basis to quarantine close contacts to help control transmission.
    • When applicable, quarantine duration should be 7 days when all tests are negative or 10 days if testing was not complete.
  • Closely monitor for signs and symptoms of COVID-19 including temperature and oxygen saturation checks at least once per shift. If symptoms develop, immediately isolate in place and test.
Group-level and Facility-wide Post-exposure and Response Testing: Start by serially testing on days 1, 3, and 5 after the last exposure (day 0); subsequent serial re-testing should be every 3-7 days for PCR/NAAT tests (if TAT <48 hrs) or at least twice per week or every 3 days for antigen tests.

Any asymptomatic residents with positive antigen test results should be immediately followed up with PCR/NAAT testing.
Group-level testing: Residents in the same group* (unit, wing, nursing station area, etc.) where a positive case was identified regardless of vaccination status; OR

Facility-wide testing: All residents in the facility*, regardless of vaccination status
  • Well-fitting face masks are required when residents are not in their rooms.
  • Quarantine** is not required regardless of vaccination status when the CDC Community Level is Low but is recommended when the CDC Community Level is Medium to High or when directed by Public Health to mitigate transmission in an outbreak.
    • When applicable, quarantine duration should be 7 days when all tests are negative or 10 days if testing was not complete.
  • Closely monitor for signs and symptoms of COVID-19 including temperature and oxygen saturation checks at least once per shift. If symptoms develop, immediately isolate-in place and test.
Routine screening testing: Generally not required or recommended for residents.

Exception: Once weekly screening testing of residents who frequently leave the facility is recommended, regardless of vaccination status, when the CDC Community Level is Medium to High.
Residents who are asymptomatic, not a new admission or re-admission, has not left facility ≥24 hours, not a close contact, and when there is no facility-wide or group-level post-exposure and response testing. Regardless of vaccination status.
  • Strong recommendation to adhere to source control (wear well-fitting face mask) except for situations mentioned in Communal Dining and Group Activities
  • See Infection Prevention and Control Guidance section for more details
New Admission and Re-Admission Testing: serially test a total of 3 times on days 0, 3, and 5 after admission (day 0).

Antigen tests or PCR/NAAT tests (if TAT is <48 hrs) may be utilized.
Residents who are new admission, re-admissions, or returning after leaving the facility >24 hrs*, regardless of vaccination status.
  • Well-fitting face mask is required through day 10 after admission when residents are not in their rooms, regardless of vaccination status.
  • Quarantine** is not routinely required. Public Health may direct individual facilities on a case-by-case basis to quarantine these resident groups to help control transmission.
    • When applicable, then quarantine duration should be 7 days when all tests are negative or 10 days if testing was not complete.
  • Closely monitor for signs and symptoms of COVID-19 including temperature and oxygen saturation checks at least once per shift. If symptoms develop, immediately isolate in place and test.
Footnotes:
*Residents who are asymptomatic, not close contacts, and recently recovered from a prior COVID-19 infection within the last 90 days are exempt from routine screening testing (if applicable), group-level and facility-wide post-exposure and response testing, and new admission/re-admission testing requirements, regardless of vaccination status.
**Quarantine involves 1) restricting the resident to their room; 2) resident wearing well-fitting face masks when not in their rooms; and 2) staff wearing full PPE per COVID transmission based precautions when providing care or entering a room where the resident is (resident room, shower room, rehab gym, etc.). Residents in quarantine should be managed in-place; avoid movement of residents that could lead to new exposures.

Healthcare Personnel Monitoring and Return to Work

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

For more details, please see the LAC DPH COVID-19 Case Reporting Protocol for SNFs flowchart.

Resources

Relevant Webinars

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


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Public Health has made reasonable efforts to provide accurate translation. However, no computerized translation is perfect and is not intended to replace traditional translation methods. If questions arise concerning the accuracy of the information, please refer to the English edition of the website, which is the official version.

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