These guidelines were updated to include the following significant changes:
These guidelines outline actions that Skilled Nursing Facilities (SNFs) should take to help prevent and manage COVID-19, based on the current status of and trends in community transmission in LA County.
We ask that you continue to ensure that your staff is trained, equipped, and capable of practices needed to:
The purpose of these visitation guidelines is to help each facility develop a resident-centered visitation policy that balances the need to protect staff and residents from COVID-19 transmission with the need to provide timely care that optimizes residents’ physical and psychological health in alignment with state and federal requirements.
The following recommendations for communal dining, group activities, and visitation are based upon the most recent CDPH All Facility Letter (AFL) and CMS Quality Safety & Oversight memo (QSO):
Criteria for Limited Communal Dining, Group Activities, and General Visitation for Select Cohorts
Currently, these activities are only allowed for residents in the Green Cohort and those residents in the Yellow Cohort who frequently leave the facility (e.g. residents receiving dialysis) and are not symptomatic, close contacts, or exposed. For facilities to allow limited gathering for these select cohorts facilities must meet these baseline CMS criteria:
1Per CMS Guidance, contingency PPE capacity strategy is allowable, such as CDC’s guidance Optimizing Supply of PPE and Other Equipment during Shortages. However, facilities’ crisis capacity PPE strategy does not constitute adequate access to PPE. Staff wear cloth face covering if facemask is not indicated, such as administrative staff.
Case status in the community: In addition to the above facility criteria, case status in the community as determined by local public health is a CMS criteria for the relaxation of gathering restrictions. In LA County, Public Health considers multiple metrics including but not limited to county test positivity rate, hospitalization rates, trends in cases and deaths in nursing homes and/or the community, and trend in new nursing home outbreaks. Public Health will notify all facilities about any changes in visitation and gathering guidance.
Communal Dining and Group Activities
Limited communal dining and group activities are permitted for select cohorts in facilities that meet the above criteria. They are permitted for residents in the Green Cohort and those residents in the Yellow Cohort who leave the facility frequently for outside appointments (e.g. residents receiving dialysis) who are not symptomatic, close contacts, or exposed. These permitted activities must not allow mixing of the Cohorts.
Facility should adhere to the following measures:
If a new facility-onset case is identified among residents, then the following applies:
HCP and essential visitors are exempted from visitation restrictions. General visitors are limited to residents in the Green Cohort and certain residents of Yellow Cohort and are subject to restrictions based on CMS criteria. See definitions and guidance below.
Below are recommendations for testing and cohorting in SNFs based upon California Department of Public Health (CDPH) requirements outlined in recent CDPH AFLs:
Testing of all admissions and readmissions. All newly admitted residents or readmissions should be tested upon admission. These patients should follow the transfer rules per LAC DPH. Lack of testing at discharge/transfer is not a reason to deny admissions of patients.
Testing of symptomatic residents or staff.
Response testing. If a single positive COVID-19 case is identified among either staff or residents, the SNF must conduct comprehensive testing of all residents and staff to identify potential asymptomatic infections. All residents should be tested once weekly and all staff should be tested at the same frequency as routine staff testing. If testing capacity is limited, testing may be prioritized for the residents and staff in the same area (e.g., nursing station, floor, etc.) as the COVID-19 positive individual. Any close contacts and exposed residents of confirmed COVID-19 cases will need to be quarantined accordingly in the Yellow Cohort (see below). All residents and staff who test negative will need to be included in response testing until there are at least 2 weeks with no additional infections identified. After 2 weeks of negative testing for residents, the facility could restart routine testing for residents as outlined below, in consultation with local Public Health.
Routine testing of staff and residents. Routine testing is initiated when either no cases were identified at baseline testing OR after no new cases are identified from two sequential weeks of response testing. If any resident or staff tests positive, the SNF must report the positive case to LAC DPH and proceed with outbreak/response testing as described above.
Retesting Previously Positive Staff/Residents
Figure 1. Testing Schematic
Refusal of Testing
Facilities should have 3 separate cohorting areas as described below and shown in Figure 2.
Figure 2. Cohorting
Special staffing considerations in cohort areas
Below are general and COVID-19 specific recommendations. For more information on infection control recommendations, visit https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html.
Universal Source Control
Hand Hygiene (HH)
Respiratory Hygiene/Cough Etiquette:
Transmission Based Precautions and Personal Protective Equipment (PPE)
HCP should follow transmission- based precautions for each cohort including standard precautions and wearing of appropriate PPE while providing patient care as detailed below.
Figure 3. PPE in Each Cohort
In addition to CDC guidelines, the recommendations below are referenced from the California Department of Public Health AFL for Environmental Infection Control for the Coronavirus Disease 2019 (COVID-19).
Refer to the LAC DPH Guidance for Monitoring Health Care Personnel for more detailed information including the management of close contacts to confirmed cases. Please note one exception for SNFs: As per CDPH Quarantine Recommendations, in the absence of staffing shortages, HCP who are a close contact to a confirmed COVID-19 case (either in the community or who have a high-risk occupational COVID-19 exposure) should be excluded from work for 14 days from last exposure. For staffing shortages, refer to Facilities Experiencing Staffing Shortages in LAC DPH Guidance for Monitoring Health Care Personnel.
Return to Work for Symptomatic HCP and for HCP with Confirmed COVID-19
Facilities are required to follow relevant sections in the LAC DPH Guidance for Monitoring Health Care Personnel.
Facilities are required to follow transfer rules as listed on the LAC DPH website (http://publichealth.lacounty.gov/acd/NCorona2019/InterfacilityTransferRules.htm).
Los Angeles County Department of Public Health
Other reliable sources of information about COVID-19 are: