Preventing and Managing COVID-19 in Long-Term Care Facilities

Long-term care facilities (LTCFs) have been severely impacted by COVID-19, with outbreaks causing high morbidity and mortality. Duration of viral shedding is still not clearly defined for COVID-19 for all patient groups, and residents in LTCFs are at particular risk for poor health outcomes. Because this population is particularly vulnerable to COVID-19 and there are inherent infection risks in congregate living in a healthcare setting, aggressive efforts to limit COVID-19 exposure and to prevent the spread of COVID-19 within LTCFs are warranted. In order to protect Pasadena residents in LTCFs, the Pasadena Public Health Department (PPHD) has developed the following evidence-based guidelines for skilled nursing facilities (SNFs), assisted-living facilities (ALFs), and other applicable congregate residential settings.

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

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

I. COVID-19 Prevention

COVID-19 Prevention—General and Administrative Practices

    1. Conduct entry screening at all LTCFs.
      1. All persons must be screened for symptoms, including a temperature check, before entering the facility. This includes residents, staff, essential visitors, general visitors, essential ancillary professionals, outside healthcare workers, vendors, etc. Symptoms include but are not limited to the following: fever, chills, cough, shortness of breath, new loss of taste or smell, muscle or body aches, headache, sore throat, congestion or runny nose, nausea or vomiting, diarrhea, or not feeling well. CDC Facilities Screening template: https://www.cdc.gov/screening/paper-version.pdf
        1. Anyone with a fever (100.0⁰ F/37.8⁰ C or higher) or other symptom must not be permitted to enter the facility at any time, even essential support persons and in end-of-life situations.
      2. All visitors, including essential support persons and ancillary professionals, must be screened prior to entry for any close contact to a COVID-19 case within the past 14 days. A close contact is someone who was within 6 feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period starting from 2 days before illness onset (or, for asymptomatic patients, 2 days prior to test specimen collection) until the time the patient is isolated, or having unprotected direct contact with infectious secretions or excretions of the person with COVID-19 (e.g., being coughed or sneezed on, sharing utensils or saliva, or providing care without wearing appropriate protective equipment).
        1. Anyone who was a close contact within the past 14 days AND is partially vaccinated or unvaccinated is prohibited from entry.
      3. An exception to entry screening: Emergency Medical Service (EMS) workers responding to an urgent medical need. EMS workers do not have to be screened, as they are typically screened separately by their agency.
    2. Conduct symptom and temperature screening for all staff and residents.
      1. All staff must be screened for symptoms and fever prior to entry at the beginning of their shift (see Section IX. Healthcare Personnel Monitoring).
      2. Residents must be assessed for symptoms and have their temperature checked at least every 24 hours.
      3. Records of staff and resident symptom and temperature checks must be kept in a secure location.
    3. Reinforce physical distancing, hand hygiene, and universal source control.
      1. Residents should remain in their rooms as much as possible and should be encouraged to wear a face covering if they leave. Remind residents to practice physical distancing and perform frequent hand hygiene. Residents who have underlying cognitive conditions must not be forcibly kept in their rooms nor forced to wear a face covering
    4. Support good workforce health.
      1. Implement non-punitive sick leave policies to support staff to stay home when sick or when caring for sick household members. Ensure staff are aware of the non-punitive sick leave policy.
    5. Enhanced environmental disinfection with EPA List N healthcare disinfectants effective against SARS-CoV-2 (COVID-19) virus must be performed on high-touch surfaces (e.g., bed rails, doorknobs, handrails) every two hours. High touch surface cleaning must be completed around the clock (24 hours a day, 7 days a week).
      1. A log must be kept with the location/date/time/staff member who performed high-touch surface cleaning.
    6. Facilities must demonstrate that they have contracted with suppliers and are able to maintain a 30-day supply of PPE and other infection prevention and control supplies.
      1. PPE and other infection prevention and control supplies (e.g., surgical masks, respirators, gowns, gloves, goggles, hand hygiene supplies) that would be used for both healthcare personnel (HCP) protection and source control for infected patients (e.g., facemask on the patient) must be readily accessible for use.
      2. Follow CDC strategies to optimize the Supply of PPE and Equipment during Shortages at https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html.
    7. Facilities are required to use and submit the provided “PPHD Daily COVID-19 Report Log” to the Pasadena Public Health Department via fax 626-744-6115 or email at nursing@cityofpasadena.net daily by noon.
      1. Appendix 1: required PPHD Daily COVID-19 Report Log
    8. If the facility is actively engaged in Response (Outbreak) Testing (defined in Section VI. COVID-19 Testing), the facility must have a notification letter stating that COVID-19 has been confirmed in the facility posted at the entrance of the facility and in community areas, including staff areas.
      1. Appendix 2: sample letter

 

II. Visitation

Visitation

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

  1. Classification of Visitors:
    Visitors are classified into three categories: Healthcare Providers, Essential Visitors, and General Visitors as defined below.

    1. Healthcare Personnel (HCP) are facility staff directly employed by the facility and are exceptions to visitation restrictions.
      1. All HCP must comply with the current facility testing frequency requirements and must submit their test results to the facility before entering.
    2. Essential Visitors are exceptions to visitation restrictions and must be permitted visitation regardless of facility’s outbreak status or COVID-19 status of the resident receiving the visitation. Based on California Department of Public Health (CDPH) AFL 20-22.8, essential visitors are defined as:
      1. HCP not directly employed by the facility, including consultants, contractors, trainees in the facility’s nurse aide training programs, and state and local public health staff.
      2. Compassionate care visits should be conducted using physical distancing unless the resident and visitor are both fully vaccinated. Visitors must be screened for COVID-19 symptoms, be routinely tested for COVID-19 at least weekly if visits are recurring unless fully vaccinated, wear a surgical facemask while in the building, restrict their visit to the resident's room or other location designated by the facility, and be reminded by the facility to frequently perform hand hygiene.
          1. Compassionate care visitation includes, but is not limited to:
            1. End-of-life situations
              1. End-of-life is defined by Part 1.85, Division 1 of the California Health and Safety Code.
            2. A resident, who was living with their family before recently being admitted to a nursing home, is struggling with the change in environment and lack of physical family support.
            3. A resident who is grieving after a friend or family member recently passed away.
            4. A resident who needs cueing and encouragement with eating or drinking, previously provided by family and/or caregiver(s), is experiencing weight loss or dehydration.
            5. Residents experiencing weight loss, dehydration, failure to thrive, psychological distress, functional decline, or struggling with a change in environment.
          2. For residents in hospice care who do not meet the aforementioned criteria above, please contact your assigned Public Health Nurse for individual review.
          3. An interdisciplinary team that includes the resident and/or designated representative should make the determination of who may benefit from in-person visitation.
      3. Caregivers or essential support persons for patients with physical, intellectual, and/or developmental disabilities and patients with cognitive impairments; CDPH recommends that one essential support person be allowed to be present with the patient. The designation of the caregiver/essential support person role should involve the resident and/or designated representative and the facility administrator. PPHD does not designate caregiver/essential support person status.
      4. Protection & advocacy representatives.
      5. Visitors for legal matters that cannot be postponed including, but not limited to, estate planning, advance health care directives, Power of Attorney, and transfer of property title so long as:
        1. These matters that cannot be postponed.
        2. These matters cannot be accomplished virtually.
      6. Individuals authorized by federal disability rights laws including qualified interpreters when assistance is not available by onsite staff or video remote interpretation.
      7. EMS workers responding to an urgent medical need.
      8. Surveyors from CDPH, LHD, and CMS and other licensing agencies.
      9. Ombudsmen: Facilities must permit ombudsmen in the facility. Ombudsmen are required to be asymptomatic and wear appropriate PPE.
        1. CDPH recommends that ombudsmen be tested consistent with same schedule as staff members of the facilities they visit to ensure they do not pose a transmission risk when entering the facility. The facility may not deny the ombudsman entry for not furnishing a COVID-19 test result.
        2. The only circumstance that would prohibit the entry of the ombudsman is if they do not pass the entry health screening; in this instance, the facility must set up an alternative visitation method (i.e., virtual, window or phone).
      10. Nursing students: Students obtaining their clinical experience as part of an approved nurse assistant, vocational nurse or registered nurse training program should be permitted to come into the facility if they meet the CDC guidelines for healthcare workers.
        1. Students entering the facility routinely must participate in the facility wide screening testing and must submit their results to the facility.
      11. Individuals authorized by federal disability rights laws: Facilities must comply with federal disability rights laws such as Section 504 of the Rehabilitation Act and the Americans with Disabilities Act.
        1. For example, if a resident requires assistance to ensure effective communication (e.g., qualified interpreter or someone to facilitate communication) and the assistance is not available by onsite staff or effective communication cannot be provided without such entry (e.g., video remote interpreting), the facility must allow the individual entry into the facility to interpret or facilitate, with some exceptions.
        2. This would not preclude facilities from imposing legitimate safety measures that are necessary for safe operations, such as requiring such individuals to adhere to the core principles of COVID-19 infection prevention and adhering to the same testing schedule as the facility staff.
        3. The facility may not deny these individuals entry due to the lack of a COVID-19 test result or proof of COVID-19 vaccination. The only circumstance that would prohibit entry is if the individual does not pass the entry health screening; in this instance the facility must set up an alternative method (i.e., virtual, window or phone) that can fulfill the resident’s needs or must work to find a suitable substitute to fulfill the need.
    3. General Visitors
      General visitors are defined as visitors who do not fall under the definition of HCP or Essential Visitors. General visitors were previously known as “Non-essential visitors.”

      1. General visitation is only permitted for Green and Yellow Cohort residents.
      2. General visitation is permitted outdoors regardless of a facility’s outbreak status.
      3. Indoor and in-room general visitation is subject to case status in the community and vaccination rate in the facility.
        1. Unvaccinated or partially vaccinated residents in the Green and Yellow Cohort may not engage in indoor and in-room visitation if the COVID-19 county positivity rate is more than 10% and less than 70% of residents in the facility are fully vaccinated.
      4. General visits should be scheduled in advance.
  2. Resident Rights: Facilities may not restrict visitation without a reasonable clinical or safety cause, consistent with resident rights in the federal regulation Title 42 CFR section 483.10(f)(4)(v), as stated in CDPH AFL 20-22.8 and CMS QSO 20-39-NH. Residents, or their designated representative when residents do not have capacity, should be involved and have their preferences prioritized in the determination of essential visitors (e.g., caregivers/essential support persons, compassionate care visitors). Failure to facilitate residents’ visitation rights without adequate reason related to clinical necessity or resident safety constitutes a potential violation of this federal regulation and the facility would be subject to citation and enforcement actions. Visitation must be person-centered, consider the residents' physical, mental, and psychosocial well-being, and support their quality of life.
  3. Place of Visitation
    1. Outdoor visitation is preferred for essential and general visitation whenever practical due to lower risk of transmission from increased space and airflow.
    2. General visitation should be conducted outdoors, but may be conducted indoors or in-room if the resident and facility meet Pasadena Public Health Department criteria.
    3. Large indoor spaces that allow for more than 6 feet physical distancing with good ventilation can be offered as an alternative when outdoor visitation is not possible (e.g., inclement weather, poor air quality, inability to move resident outside, resident has a bedbound roommate).
      1. Yellow Cohort residents are not permitted general indoor space visitation.
      2. Only essential visitation may be conducted in large indoor spaces during an outbreak.
    4. In-room visitation
      1. Essential and general visits may be conducted in-room when visitation outdoors and in large indoor spaces are not practical.
      2. Visits for residents who share a room must be conducted in a separate indoor space or with the roommate not present in the room, regardless of the roommate’s vaccination status. If the health status of the resident prevents leaving the room, facilities should attempt to conduct in-room visitation with the roommate(s) not present in the room if possible. Any in-room visitation must adhere to core principles of infection prevention and control.
        1. Yellow Cohort resident visitors must wear full PPE according to transmission based precautions for COVID-19. This must be donned and doffed according to instruction by HCP.
    5. Facilities must also enable visits to be conducted with an adequate degree of privacy.
  4. Visitor Requirements:
    All visitors, essential and general, must adhere to the following measures or the facility may remove them from facility premises and/or restrict their entry.

    1. Visitors must be screened on entry, regardless of vaccination status. If a visitor screens positive for COVID-19 symptoms, regardless of vaccination status, and/or close contact to COVID-19, if partially vaccinated or unvaccinated, the visit must be postponed until appropriate isolation or quarantine periods are completed.
      1. Visitors who have recently traveled must follow local, state, and federal quarantine and testing guidelines before and after travel. Visitors may be denied entry and on- or offsite visitation until the quarantine period is completed and negative test results have been submitted to the facility administrator.
      2. If local, state, and federal guidelines do not require quarantine and testing before and after travel, visitors must follow the requirements of the facility’s travel policy. Visitors may be denied entry and on- or offsite visitation until the facility travel policy requirements have been met.
    2. Visitors must document their name, contact information, and locations to be visited within the facility in a visitor log to assist with contact tracing if needed.
    3. Visitors must provide proof of vaccination status to the facility. If the visitor is unable or declines to provide proof of vaccination status, they will be considered unvaccinated and must follow the guidelines for unvaccinated visitors.
    4. Visitors must wear the face masks appropriate for the cohort of the resident they are visiting regardless of indoor or outdoor setting (surgical mask or higher). Residents should also be encouraged to wear facial coverings if possible.
      1. Indoor, in-room, and outdoor visits between fully vaccinated residents and fully vaccinated visitors may be conducted without face masks.
      2. Visitors, regardless of vaccination status, must be willing to adhere to the recommended principles of infection prevention, including wearing a well-fitting facemask.
    5. Visitors must don and doff appropriate PPE according to instruction and supervision from facility staff.
    6. Visitors must perform hand hygiene before and after the visit at minimum.
    7. Visitors must maintain physical distancing of 6 feet or more. If 6 feet of distance is not possible, a clear plastic divider may be used.
      1. Indoor, in-room, and outdoor visits between fully vaccinated residents and fully vaccinated visitors may be conducted without physical distancing and may include physical contact.
      2. Visitors, regardless of vaccination status, must be willing to adhere to the recommended principles of infection prevention, including maintaining physical distancing from other visitors from different households, facility staff, and facility residents they are not visiting.
    8. If either the resident or visitor is partially vaccinated or unvaccinated, staff must monitor the visit to make sure infection control guidelines are followed (e.g., physical distancing, face coverings, no physical contact) to assure a safe visitation for both residents and visitors.
    9. All visitors must be instructed to notify the facility if they develop COVID-19 signs and symptoms and/or have a positive test result within 14 days of visiting the facility. Facilities must take all necessary actions including infection control precautions based on findings.
  5. Facility Visitation Requirements:
    Facilities must establish the following to support in-person visitation:

    1. Facilities should limit the number of visitors per resident at one time and limit the total number of visitors in the facility at one time based on the size of the building, size and physical configuration of visitation areas, and individual resident needs (e.g., end-of-life situations).
    2. Facilities should consider scheduling visits for a specified length of time to help ensure all residents are able to receive visitors; facilities may consider shorter indoor visits and longer outdoor visits. Visits are not to be scheduled for less than 30 minutes.
    3. Facilities must limit movement of visitors within the facility, regardless of vaccination status, and encourage visitors to go directly to and from the resident’s room or designated visitation area.
    4. Facilities must disinfect rooms and designated visiting areas after each resident-visitor meeting.
    5. Facilities are encouraged to regularly communicate visitation guidelines and expectations with residents, family, caregivers, designated decision makers, etc. Facilities are also recommended to provide visitation instructions to visitors prior to their scheduled visits and/or upon entry to the facility.
    6. Facilities must place clear signage for visitors in relevant languages throughout the facility regarding education on COVID-19 signs and symptoms, infection control precautions including hand hygiene and universal masking, specified entries/exits and routes to designated areas, etc.
    7. Facilities may consider providing infection prevention and control education for visitors who are regularly visiting (more than one in-person visit every 7 days).
    8. The facility must clean and disinfect frequently touched surfaces in the facility every 2 hours and clean and disinfect designated visitation areas after each visit.
    9. All visits between partially vaccinated or unvaccinated resident or visitor must be fully supervised by a facility HCP to ensure guidance is followed.
      1. The facility will not allow visitors who are unable to adhere to the core principles of COVID-19 infection prevention, regardless of vaccination status and including visitors under age 18, and these visitors will be asked to leave.
    10. All visits should be held outdoors whenever possible.
    11. Advise visitors and any individuals who enter the facility (e.g., hospice staff) to monitor for signs and symptoms of respiratory infection for at least 14 days after exiting the facility.
      1. If symptoms occur, advise the visitor to self-isolate at home and contact their healthcare provider.
      2. Advise the visitor to notify the facility if they test positive within the week following visit.
  6. Outdoor In-Person Visitation Requirements
    1. All facilities must allow outdoor visitation options.
      1. Outdoor visitation is preferred for essential visitation whenever practical due to lower risk of transmission from increased space and airflow.
      2. General visitation should be conducted outdoors.
      3. Facilities should create accessible and safe outdoor spaces for visitation, such as in courtyards, patios, or parking lots, including the use of overhead canopies for shade, if available.
      4. Visits must occur in a location that allows physical distancing of 6 feet or more between the visitor, resident and facility staff.
        1. If both resident and visitor are fully vaccinated, they are not required to maintain physical distancing of 6 feet or more.
      5. Both residents and visitors must wear facial coverings, unless contraindicated or unless both resident and visitor are fully vaccinated.
      6. A facility staff member trained in COVID-19 infection control must be present for the duration of visits between partially vaccinated or unvaccinated residents or visitors to monitor interactions and ensure infection control guidelines are followed.
      7. Consider setting up the visitation area with a physical divider to help ensure physical distancing is maintained (e.g., positioning large tables 6 feet apart to serve as a physical barrier), and designing the area with a one-way entrance and exit for both the resident and visitor.
      8. Aside from weather considerations (e.g., inclement weather, excessively hot or cold temperatures, poor air quality), an individual resident’s health status (e.g., medical condition(s), COVID-19 status), or a facility’s outbreak status, outdoor visitation should be facilitated routinely.
    2. Outdoor Visitation is currently open for: residents in Green and Yellow Cohorts.
  7. Other Visitation Options in Addition to Outdoor Visitation
    1. To maximize visitation opportunities and keep residents and families connected, facilities are encouraged to:
      1. Offer alternative means of communication, such as virtual communications (phone, video-communication, etc.).
      2. Assign staff as primary contact to families for inbound calls and conduct regular outbound calls to keep families up to date.
      3. Offer a phone line with a voice recording updated at set times (e.g., daily) with the facility's general operating status, such as when it is safe to resume visits.
      4. Create/increase listserv communication to update families, such as the status and impact of COVID-19 in the facility.
  8. Indoor Visitation for Facilities Meeting Specific Criteria
    1. Facilities will be cleared to accommodate and support indoor visitation, including in Large Communal Spaces for visits beyond compassionate care situations, based on the following criteria:
      1. FACILITY COVID-19 STATUS
        1. There has been no new onset of COVID-19 cases in the last 14 days among residents; AND
        2. The facility is not currently conducting response testing; AND
        3. The facility has not experienced more than 3 cases of acute illness compatible with COVID-19 symptoms in residents or staff with onset within a 72-hour period.
      2. FACILITY INFECTION MITIGATION STATUS
        1. Effective cohorting of residents; AND
        2. No current staffing shortages; AND
        3. Access to testing is adequate and the facility is in compliance with resident and staff testing and reporting as required by PPHD; AND
        4. The facility has an approved COVID-19 Mitigation Plan and Indoor Visitation Plan that are in regulatory compliance with CDPH guidance for safety. NOTE: Meeting the above criteria does not guarantee visitation will be allowed. Visitation approval is also based on the determination and interpretation of CDPH, CMS guidelines, and licensing requirements.REMINDER: Outdoor visitation is preferred. All visitation should be held outdoors instead of indoors whenever practicable, even if a facility is approved for indoor visitation.
    2. Indoor Visitation in Large, Well-Ventilated, Communal Spaces
      1. If outdoor visitation is not possible (e.g., inclement weather, poor air quality, resident inability to be moved outside), facilities must accommodate visitation in large communal indoor spaces such as a lobby, cafeteria, activity room, physical therapy rooms, etc., where 6 foot physical distancing is possible.
      2. Facilities may need to rearrange these spaces or add barriers to separate the space to accommodate the need for visitation of multiple residents (e.g., positioning large tables 6 feet apart to serve as a physical barrier).
      3. Visitation in Large Communal Indoor Spaces is currently open for: residents in Green Cohort for facilities that have met CMS, CDPH and PPHD criteria for indoor visitation as defined under Indoor Visitation for Facilities Meeting Specific Criteria in this guidance.
    3. Safety Guidelines for All Indoor Visitation (Communal Spaces and In-Room Visitation) Facilities that are cleared to allow indoor visitation in communal spaces or in-room must adhere to the following guidelines:
      1. Create dedicated visitation areas near the entrance to the facility (if possible i.e. pending design of building) where residents can meet with visitors in a sanitized, well-ventilated area.
      2. Facilities must disinfect rooms after each resident-visitor meeting.
      3. Set up the visitation area with a physical divider to help ensure physical distancing is maintained (e.g., positioning large tables 6 feet apart to serve as a physical barrier), and design the area with a one-way entrance and exit for both the resident and visitor. The use of clear Plexiglass dividers or curtains may be used to further reduce the risk of transmission if appropriate for the space.
      4. Visitors must be able to adhere to the core principles of COVID-19 infection prevention.
      5. Facility staff must be present to monitor infection control guidelines and ensure that core principles are followed.
      6. Facilities must limit the number of visitors per resident at one time and limit the total number of visitors in the facility at any given time, based on the size of the building and physical space.
      7. Visits are not to be scheduled for less than 30 minutes.
      8. Facilities must limit movement of visitors in the facility, regardless of vaccination status. For example, visitors must not walk around different halls of the facility. Visitors must go directly to and from the resident's room or designated visitation area.
      9. Visits for residents who share a room should not be conducted in the resident’s room.
        1. Preferably, conduct the visit in a separate indoor space or with the roommate not present in the room.
        2. For situations where a roommate is present and the health status of the resident prevents leaving the room, facilities must attempt to enable in-room visitation while adhering to the core principles of COVID-19 infection prevention, including the use of curtains or other barriers to reduce the risk of transmission.
    4. Safety Guidelines for Exceptions to In-Person Visitation Restrictions
      All visitors and personnel who qualify for exception to in-person visitation must:

      1. Conduct all in-person visits outdoors whenever practical.
      2. Be screened for COVID-19 signs and symptoms upon entry. Essential visits must be postponed if visitor screens positive (for symptoms and/or exposure to COVID-19) or is unwell.
        1. EMS workers responding to an urgent medical need do not have to be screened, as they are typically screened separately by their agency.
      3. Wear a surgical mask to protect others during the visit unless contraindicated, or a higher level of PPE. Use of mask is required. If the essential visitor is unable or unwilling to comply with these precautions, consider restricting their ability to enter the facility.
      4. Be restricted to the resident’s room or other location as necessitated by their visit.
      5. Perform hand hygiene before and after the visit at minimum.
      6. Be advised to self-monitor for signs and symptoms of respiratory infection for at least 14 days after exiting the facility and if symptoms occur, to self-isolate at home, contact their healthcare provider, and immediately notify the facility of the date(s) of their visit, the individuals they were in contact with, and the locations visited within the facility. The facility must immediately screen the individuals of reported contact and take all necessary actions infection control precautions based on findings.

III. Communal Dining and Group Activities

Communal Dining and Group Activities for Green Cohort

  1. Residents from the Green Cohort may engage in communal activities and communal dining while adhering to the core principles of COVID-19 infection prevention so long as:
    1. Adequate staffing: The facility must not be experiencing staff shortages; AND
    2. Supply of 30 days of Personal Protective Equipment (PPE) and disinfection supplies on hand: The facility must have adequate supplies of PPE for staff so that all staff may wear appropriate PPE when indicated and must have adequate essential cleaning and disinfection supplies; AND
    3. Access to adequate testing: The facility must maintain access to COVID-19 testing for all residents and staff by an established commercial laboratory; AND
    4. Approved COVID-19 Mitigation Plan: The facility must maintain regulatory compliance with CDPH guidance; AND
    5. Case status in the facility: There has been no new facility onset of COVID-19 cases in the last 14 days among residents; AND
      1. The facility is not currently conducting response testing; AND
      2. The facility has not more than 3 cases of acute illness compatible with COVID-19 symptoms in residents or staff with onset within a 72-hour period.
    6. Communal cohorting: The facility has defined groups of residents that can remain consistently cohorted for communal dining and group activities to minimize the number of people exposed if one or more of the residents is later identified as positive.
      1. Groups of no more than 10 residents are allowed.
      2. Facilities with vaccination rates of 70% or higher in staff AND 70% or higher in residents may forego communal cohorting.
  2. Communal Dining and Group Activities - General Guidelines:
    Communal dining and group activities are permitted for residents in the Green Cohort who are not symptomatic, close contacts, or exposed. Facilities must adhere to the following measures:

    1. Encourage communal activities to occur outdoors when feasible, especially when eating or drinking and face coverings will not be worn.
    2. If outdoor dining is not possible (e.g., due to weather conditions, etc.), fully vaccinated residents in the Green Cohort may eat in the same room without physical distancing. If any unvaccinated residents are dining in a communal area (e.g., dining room) all residents in the communal area must wear a face covering when not eating and unvaccinated residents must remain at least 6 feet from others (e.g., limited number of people at each table and with at least 6 feet between each person).
    3. When it is not possible to ensure all persons participating in an activity are fully vaccinated (e.g., in common areas where staff or residents may come and go), then all participants should follow all recommended infection prevention and control practices including physical distancing and wearing a well-fitting face mask.
    4. Facility adheres to universal source control
      1. All staff wearing surgical masks at all times.
      2. Residents wearing non-medical face coverings when possible.
    5. If less than 70% of the facility’s residents or staff are fully vaccinated, communal dining and group activities should be conducted in shifts of 10 or less to allow for 6 foot physical distancing.
      1. Shifts of residents should be kept together (e.g., same groups of residents dine together each night) and individual residents should be assigned to specific areas as often as possible to minimize exposure if a resident is later identified as positive.
      2. Use a sign-in sheet/roster of residents present during these activities to help with contact tracing if a resident is later identified as positive.
    6. Facility adheres to physical distancing.
      1. Unvaccinated and partially-vaccinated residents must maintain at least 6 feet distance from all other residents during all activities.
        1. Fully vaccinated residents are not required to maintain physical distancing from other fully vaccinated residents.
      2. All staff maintain at least 6 feet distance in break rooms and, as much as possible, during work activities.
      3. Activities should be done in shifts to allow for better physical distancing.
    7. Enhanced environmental disinfection.
      1. All communal, high touch surfaces must be disinfected after residents or staff vacate an area.
    8. Facilities may be able to offer a variety of activities while adhering to necessary precautions.
      1. For example, book clubs, crafts, movies, exercise, and bingo are all activities that can be facilitated with alterations to adhere to the guidelines for preventing transmission.
    9. If a new facility-onset case is identified among residents:
      1. Resident communal dining and group activities for any cohort, indoors and outdoors, must cease for at least 14 days.
      2. The facility must review their infection control and prevention practices to prevent future new infections.
      3. After there have been no new resident cases in the facility for 14 days, the facility may request permission from PPHD to resume communal dining and activities.

IV. New Admissions

New Admissions

  1. The facility remains closed to new admissions if there is evidence of possible or confirmed COVID-19 transmission including:
    1. The facility has 1 new COVID-19 facility-onset case in a resident; OR
    2. The facility has had 3 or more positive COVID-19 results among staff within the last 14 days; OR
    3. The facility has 3 or fewer cases of acute illness compatible with COVID-19 symptoms in residents or staff with onset within a 72-hour period.
  2. The facility must not admit new residents into a shared room if it would extend the existing occupant’s quarantine timeline in the Yellow Cohort.
    1. If the COVID-19 county positivity rate is greater than 10%, new admissions may only be admitted to private rooms.
  3. The facility will remain closed to new admissions until they have met all of the following CDPH and PPHD criteria:
    1. Cohorting requirements are implemented and ongoing; AND
    2. Facility-wide testing strategies and reporting are implemented and ongoing; AND
    3. Infection control measures are implemented and ongoing; AND
    4. The facility is not currently conducting response testing.
  4. PPHD also reserves the right to notify the facility that admissions are closed based on new CDPH or CMS guidelines, new research, or an ongoing investigation that suggests there is a possible active public health threat within the facility.
  5. NEW ADMISSIONS for confirmed COVID-19 residents:
    1. For facilities that are approved for new admission, the following limitation remains for new admission of residents with confirmed COVID-19 so long as they meet one of the two criteria below (source: LAC DPH interfacility transfer rules).
      1. 10 days have passed since symptoms first appeared or since date of first positive result AND no fever for 24 hours without the use of fever reducing medications AND symptoms have improved.
        1. Continue standard, contact, and droplet transmission-based precautions at the admitting facility.
        2. Transmission-based precautions must be continued for 20 days after admission. Resident must be placed in a room in the Red Cohort. The resident may be placed in a shared room with other confirmed COVID-19 patients.
      2. 20 days have passed since symptoms first appeared or since date of first positive viral test AND no fever for 24 hours without the use of fever reducing medications AND symptoms have improved.
        1. No transmission-based precautions required for transfer.
        2. The resident may be admitted directly to the Green Cohort.
        3. If greater than 90 days have passed since the initial positive test result, the resident must be admitted to the Yellow Cohort for observation quarantine, unless fully vaccinated.
  6. NEW ADMISSIONS for fully vaccinated residents:
    1. Fully vaccinated residents may be admitted directly to the Green Cohort and forego quarantine so long as:
      1. The facility is approved for new admissions.
      2. The resident is asymptomatic.
      3. The resident is not currently on isolation precautions based on a COVID-19 diagnosis in the last 20 days.
      4. The resident has not had close contact with a person with confirmed COVID-19 or resided in a facility with known COVID-19 transmission in the last 14 days.
      5. At least 70% of the admitting facility’s residents are fully vaccinated.

V. Re-Admissions

Re-admissions (from LAC DPH interfacility transfer rules)

  1. General Guidelines for Re-admissions
    1. Newly admitted and readmitted residents who are unvaccinated or partially-vaccinated and test negative must be placed in quarantine in the Yellow Cohort for 14 days, monitored for symptoms and signs of COVID-19, and retested at the end of quarantine.
      1. A positive test must initiate isolation in Red Cohort for 14 days from the positive test date if asymptomatic or 20 days from symptom onset if symptomatic.
      2. A negative post-quarantine result permits discharge to the Green Cohort provided criteria in Section VII. Corhorting under Guidance for Discharge from the Yellow Cohort section is met.
    2. Newly admitted and readmitted residents who have been previously positive within the last 90 days and completed isolation may be admitted directly to the Green Cohort.
      1. These residents will be excluded from admission and surveillance or response testing for 90 days from the initial positive test date so long as they remain asymptomatic.
      2. If the resident becomes symptomatic, they must be placed in the Yellow Cohort and tested according to quarantine for symptomatic residents.
    3. Newly admitted and readmitted residents who are fully vaccinated may be placed directly in the facility’s Green Cohort so long as they meet PPHD criteria as defined under NEW ADMISSIONS for fully vaccinated residents.
      1. These residents will be excluded from admission testing and are not required to participate in surveillance testing.
      2. If the resident becomes symptomatic, they must be placed in the Yellow Cohort and tested according to Quarantine for Symptomatic Residents.
  2. Rules for Re-admission of Residents with current Laboratory Confirmed COVID-19
    1. Previous residents may be returned to the facility from a higher level of care when clinically indicated.
    2. Continue standard, contact, and droplet transmission-based precautions at the admitting facility.
    3. Transmission-based precautions must be continued for 20 days after hospital admission.
    4. Resident must be placed in the Red Cohort designated to care for COVID-19 residents.
      1. The resident may be placed in a shared room with other confirmed COVID-19 residents.
    5. While facilities experiencing outbreaks are closed to new admissions, they are not closed to readmissions/returning cases.
    6. Admitting facility may not require a negative test result for COVID-19 as criteria for admission or readmission of hospitalized residents.
  3. Rules for Readmissions/Returning Residents without COVID-19
    1. No Clinical Concern for COVID-19
      1. If the patient was transferred out for non-infection related reason (e.g., cerebrovascular accident or fall) and had no fever or respiratory symptoms of infection, the patient may be returned to the facility and placed in the Yellow Cohort.
      2. If the resident was admitted for infectious syndrome not consistent with COVID-19 and another etiology is established (e.g., cellulitis, bacteremia) the resident may be returned to the facility and placed in the Yellow Cohort.
      3. Admitting facility may not require a negative test result for COVID-19 as criteria for admission or readmission of hospitalized residents with no clinical concern for COVID-19.
      4. Admitting facility must follow testing and cohorting instructions for admissions and readmissions as outlined in this guidance.
    2. Low Clinical Suspicion
      1. The resident may be transferred to an admitting facility if the resident was transferred for an infectious syndrome possibly consistent with COVID-19 (e.g., fever, shortness of breath, cough) and meets ALL of the following criteria:
        1. Low pre-test probability of COVID-19 (no known contact with a confirmed or suspect case, transferred from a facility not experiencing a COVID-19 outbreak); AND
        2. Alternative diagnosis is established and confirmed with microbiologic or virologic testing; AND
        3. Clinical improvement and no fever for 24 hours without the use of fever reducing medications; AND
        4. One negative COVID-19 test.
      2. If resident does not meet all four criteria above but tests negative for COVID-19, then follow Resident Investigated for Possible COVID-19 below.
      3. Skilled Nursing Facility (SNF): Admitting SNF may not require a negative test result for COVID-19 as criteria for admission or readmission of residents hospitalized with no clinical concern for COVID-19.
      4. Admitting facility must follow testing and cohorting instructions for admissions and readmissions as outlined in this guidance.
      5. If resident tests positive, follow facility mitigation rules for laboratory confirmed COVID-19 residents.
    3. Resident Investigated for Possible COVID-19
      1. If the resident was admitted for an infectious syndrome possibly consistent with COVID-19 (e.g., fever, malaise, cough) and there is an exposure risk for COVID-19 (e.g., contact with a confirmed or suspect case or transferred from a facility experiencing a COVID-19 outbreak), resident may be re-admitted if they meet the following criteria:
        1. Two negative COVID-19 tests administered at least 24 hours apart, AND
        2. Transmission-based precautions must be continued at the admitting facility until the resident has had no fever for 24 hours without the use of fever reducing medications AND there is clinical improvement of symptoms.
      2. Admitting facility must follow testing and cohorting instructions for admissions and readmissions as outlined in this guidance.
    4. Resident Originating from a Facility Experiencing a COVID-19 Outbreak
      1. If resident’s departure from the originating facility was less than 14 days prior, patient must be allowed to return to the originating facility.
      2. While admitting facilities experiencing outbreaks may be closed to new admissions, they are not closed to returning asymptomatic residents within the 14-day exposure period.
      3. If the resident’s departure from the originating facility was more than 14 days prior and the resident has remained asymptomatic, the resident should be transferred to a different facility, if their originating facility is still closed to admissions.
      4. Admitting facility must follow testing and cohorting instructions for the admissions and readmissions as outlined in this guidance.

VI. COVID-19 Testing

COVID-19 Testing

Recommendations for testing and cohorting in facilities based upon CDPH requirements outlined in recent CDPH All Facility Letters (AFLs) are as follows:

  • AFL 20-52 Coronavirus Disease 2019 (COVID-19) Mitigation Plan Implementation and Submission Requirements for Skilled Nursing Facilities (SNF) and Infection Control Guidance for Health Care Personnel (HCP) AFL
  • AFL 20-53 Coronavirus Disease 2019 (COVID-19) Mitigation Plan Recommendations for Testing of Health Care Personnel (HCP) and Residents at Skilled Nursing Facilities (SNF) AFL
    1. General Testing Requirements for LTCF in Pasadena
      1. Establish a relationship with a commercial lab to conduct COVID-19 PCR testing with turn-around time (TAT) of 48 hours or less.
        1. If the 48-hour TAT cannot be met, then the facility should document its efforts to obtain quick turnaround testing results including communication with the local and state health departments.
      2. COVID-19 Point of Care (POC) Antigen testing may be used to complement PCR testing per LA County Antigen Testing Guidance.
      3. Establish cohorting plan as part of CDPH-required COVID-19 mitigation plan.
      4. Report all staff and resident COVID-19 results daily to PPHD, including all staff and residents who are asymptomatic and test positive and all staff and residents who are symptomatic and test positive.
      5. Thorough documentation to demonstrate compliance with testing regulations in accordance with CDPH AFL 20-53, including submitting all test results to PPHD.
    2. Surveillance (Routine) Testing
      Surveillance testing includes baseline, routine (ongoing), as well as special circumstances for testing including upon admission, new onset of symptoms, and post-mortem.

      1. Baseline Testing. CDPH requires all facilities, regardless of outbreak status, to do one-time direct virus detection (i.e., PCR) testing of all residents and staff as part of surveillance testing.
      2. Surveillance testing of HCP and residents. Surveillance testing is initiated either when no cases were identified at baseline testing OR after no new cases are identified from 14 consecutive days of response testing. If any resident or staff tests positive, the facility must report the positive case to PPHD and initiate response testing as described in this guidance.
        1. Surveillance Testing of HCP
          1. Staff directly employed by the facility who are unvaccinated or partially-vaccinated must be routinely tested at least twice per week in accordance with the State Public Health Officer Order issued July 26, 2021.
          2. If the facility has 70% of residents or more fully vaccinated AND 70% of staff or more fully vaccinated, staff directly employed by the facility who are fully vaccinated and asymptomatic may discontinue participation in surveillance testing.
            1. Fully vaccinated staff who are asymptomatic must be routinely tested once per week if the facility does not meet this criteria.
        2. Surveillance testing of Regular Visitors
          1. All regular essential and general visitors who visit the facility at least once a week must be tested at the same frequency as facility staff according to vaccination status. All other infection prevention and control requirements including entry screening must be followed, regardless of negative test results and vaccination status.
          2. The absence of test results should not prevent essential and general visitation.
          3. Outside test results are acceptable if documentation of tested individual’s full name, date of birth, test date, and test result are provided by the administering lab on the lab report. Handwritten information is not valid.
          4. Same day onsite POC antigen testing of visitors is an additional safety measure that facilities may consider implementing prior to visiting the resident but is not required for entry. Please see local SNF antigen testing guidelines and follow Use of POC Ag tests for Screening-Only for Asymptomatic Staff.
        3. Surveillance Testing of Residents
          1. Unvaccinated and partially-vaccinated residents who reside in assisted living facilities or in congregate care settings must be routinely tested at least once per week.
          2. Unvaccinated and partially-vaccinated residents who reside in skilled nursing facilities are recommended to be tested once per week if they frequently leave the facility for other services/appointments.
          3. Fully-vaccinated residents who are asymptomatic may discontinue surveillance testing at this time.
          4. RESULTS: A positive test will initiate isolation for the resident in the Red Cohort. Please see the Cohorting section on appropriate isolation periods depending on the resident's clinical status.
        4. Surveillance testing on admission and readmission
          Newly admitted residents or readmissions who are unvaccinated or partially-vaccinated must be tested within 72 of hours admission. Asymptomatic residents who were previously positive within the last 90 days or who are fully vaccinated are exempt from this requirement. Facilities and residents must follow the transfer rules per LAC DPH. Lack of testing at discharge/transfer is not a reason to deny admission of a resident, nor is it a reason to forego testing upon admission.

          1. Newly admitted and readmitted unvaccinated or partially-vaccinated residents who test negative must quarantine in the Yellow Cohort for 14 days, be monitored for symptoms and signs of COVID-19, and retest on day 14 of quarantine.
          2. A negative post-quarantine result permits patient transfer to the Green Cohort. Please follow timeline and guidance for discharge from Yellow Cohort as described in Section VII. Cohorting.
          3. RESULTS: A positive test must initiate isolation for the resident in the Red Cohort. Please see the Cohorting section on appropriate isolation periods depending on the resident's clinical status.
        5. Surveillance Testing for Symptomatic Residents or HCP
          1. All HCP and residents with symptoms of COVID-19 must be tested with a PCR test as soon as possible.
          2. All symptomatic HCP must be immediately restricted from working. See Section IX. HCP Monitoring and Return to Work.
          3. All symptomatic residents should be presumed infectious pending test results and transferred immediately to a single room in the Yellow Cohort.
          4. Symptomatic residents who test negative require a second negative COVID-19 PCR test administered at least 24 hours later before they can transfer to the Green Cohort.
          5. If there is an alternative diagnosis for symptoms (i.e., UTI, cellulitis), one negative COVID-19 PCR test is sufficient to transfer the patient back to the Green Cohort.
          6. RESULTS: If any resident, staff, or essential support person tests positive, the facility must promptly initiate response testing.
        6. Surveillance Testing at Time of Death
          1. All deceased residents must be tested post-mortem if their most recent status was unknown or negative, regardless of vaccination status. Post-mortem testing is the responsibility of the facility. The CDC has provided guidance on post-mortem collection at https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-postmortem-specimens.html.
          2. RESULTS: If any post-mortem resident tests positive, the facility must promptly initiate response testing and report the positive result to PPHD.
    3. Response (Outbreak) Testing
      Response testing is required to identify the extent of a possible outbreak or exposure within a facility.

      1. If a single positive COVID-19 case is identified among either HCP or residents, the facility must immediately initiate comprehensive response testing to identify potential asymptomatic infections.
      2. The facility must conduct 100% testing for residents and staff every four days, for a minimum of three rounds of testing in a 14 day period (one incubation period), regardless of vaccination status. (AFL 20-53)
      3. The facility may optionally test 100% of residents and staff every three days, for a total of four rounds of testing in a 14-day period (one incubation period), regardless of vaccination status. (AFL 20-53)
      4. If testing capacity is limited, testing may be prioritized to first test the residents and staff in the same area (e.g., nursing station, floor) as the COVID-19 positive individual.
      5. Close contacts and exposed residents of confirmed COVID-19 cases must be quarantined in the Yellow Cohort, regardless of vaccination status.
        1. Residents who have been previously positive within the last 90 days do not need quarantine unless they are symptomatic.
      6. All residents and HCP who test negative must complete at least two additional rounds of testing within a 14 day period with no additional infections.
      7. After three complete rounds of testing with 100% negative results, PPHD will notify the facility that they may resume surveillance testing.
    4. Retesting 
      1. Staff or residents who previously tested positive and are asymptomatic should not be retested for 90 days after the date of symptom onset or date of the first positive test.
        1. Exception: A staff or resident who develops new symptoms less than 90 days after the initial positive test must be retested.
      2. Staff or residents who previously tested positive and are asymptomatic will return to the surveillance testing pool 90 days after the date of the initial positive test or date of symptom onset.
      3. Staff or residents who previously tested positive and test positive 90 days or more AFTER the initial positive test must be managed as a new infection; the person must be isolated in the Red Cohort and is exempt from testing for an additional 90 days.
    5. Testing Exemptions
      1. Staff Refusal:
        1. Staff who have signs or symptoms of COVID-19 and refuse testing are prohibited from entering the facility until return to work criteria are met and they have been approved to return by PPHD.
        2. If response testing has been initiated and a staff member refuses testing, the staff member must be restricted from working or entering the facility until the outbreak has been closed.
        3. The facility must follow CAL OSHA and LA County policies for asymptomatic staff during surveillance testing.
        4. Please notify PPHD of any test exemption requests for residents who decline or are unable to be tested.
      2. Resident Refusal:
        1. Residents or resident representatives may exercise their right to decline COVID-19 testing in accordance with the requirements under 42 CFR § 483.10(c)(6).
          1. When discussing testing with residents, staff should use person-centered approaches while explaining the importance of COVID-19 testing.
          2. Facilities must have procedures in place to address residents who refuse testing.
        2. Residents who have signs or symptoms of COVID-19 and refuse testing must be placed in the Yellow Cohort in a single room until the criteria for discontinuing transmission-based precautions have been met.
        3. If response testing has been initiated and an asymptomatic resident refuses testing, the facility should ensure the resident maintains at least 6 feet distance from other residents, wears a face covering, and practices effective hand hygiene until the outbreak has been closed, regardless of vaccination status.
        4. Please notify PPHD of any test exemption requests for residents who decline or are unable to be tested.
      3. Exemption Based on Compassionate Care:
        1. Please notify PPHD of any test exemption requests for residents for whom being tested would not be in line with compassionate care (i.e., during end-of-life care).

VII. Cohorting

Facilities must have three separate cohorting areas as described below and shown in Figure 1 below. The cohorting guidelines apply to all residents, regardless of vaccination status.

  1. Red Cohort (Isolation Area)
    The Red Cohort is only for residents who have laboratory-confirmed COVID-19. Residents may be admitted to the Green Cohort once they have completed the appropriate isolation period as follows:

    1. For symptomatic residents:
      1. At least 20 days have passed since symptoms first appeared; AND,
      2. At least 24 hours have passed since last fever without the use of fever reducing medications; AND,
      3. Improvement of symptoms (e.g., cough, shortness of breath).
    2. For asymptomatic residents with laboratory-confirmed COVID-19 without severe immunosuppressing conditions:
      1. At least 14 days have passed since the date of first positive COVID-19 diagnostic test without the development of symptoms of COVID-19.
      2. If the resident develops symptoms during this 14-day period, the isolation period must be restarted from the onset of symptoms per the symptomatic resident criteria outlined above.
    3. For asymptomatic residents with laboratory-confirmed COVID-19 with severely immunosuppressing conditions:
      1. At least 20 days have passed since the date of first positive COVID-19 diagnostic test without the development of symptoms of COVID-19.
      2. If the resident develops symptoms during this 20-day period, the isolation period must be restarted from the onset of symptoms per the symptomatic resident criteria outlined above.
      3. The following are considered severely immunosuppressing conditions: actively receiving chemotherapy for cancer, HIV with CD4 count <200, immunodeficiency disorder, prednisone dose of more than 20mg/day for more than 14 days, receipt of immunosuppressive medications (biologics, etc.) for treatment of autoimmune disease, or other form of immunosuppression as determined by the resident’s primary physician.
    4. Guidance for Care within the Red Cohort:
      1. Residents should be confined to a private room, if possible, within the Red Cohort.
      2. Keep the room door closed and post a sign stating that the door must be kept closed.
      3. If a resident in isolation must leave the room, for example, for medically necessary procedures, the resident must wear a facemask if possible.
      4. Facility HCP must assess residents in isolation frequently.
      5. Facility HCP must complete vital sign checks on all cases in isolation every shift at a minimum of 3 times per day or as needed depending on patient status. Vital sign checks include heart rate, blood pressure, oxygen saturation, and temperature.
      6. Limit the number of different facility HCP interacting with symptomatic resident(s) and attempt to assign the same facility HCP to care for the same resident as often as possible.
  2. Yellow Cohort (Quarantine for Exposed, Observation & Symptomatic Residents)
    1. The Yellow Cohort is for residents required to quarantine:
      1. Quarantine for Exposed Residents/Close Contacts:
        1. A close contact is anyone who has been within 6 feet of a person with confirmed COVID-19 for 15 minutes or longer (including roommates of a confirmed COVID-19 case) or who had unprotected direct contact with infectious secretions or excretions of a person with confirmed COVID-19 (e.g., was coughed or sneezed on or shared utensils or saliva), regardless of vaccination status.
          1. All residents exposed by close contact should be prioritized for private rooms.
          2. Residents who have tested positive within the last 90 days do not need to quarantine.
      2. Quarantine for Exposed by Proximity: In general, all residents on the unit or wing where a confirmed COVID-19 case was identified in a resident or HCP, unless previously positive within the last 90 days, are considered exposed by proximity and must remain in their current rooms unless sufficient private rooms are available.
        1. Avoid movement of residents that could lead to new exposures. For example, do not room an existing resident with a new resident on quarantine from admission.
        2. All residents exposed by proximity must remain in their current rooms unless sufficient private rooms are available. Signage indicating appropriate precautions must be placed outside of these residents’ rooms.
        3. All residents exposed by proximity must stay in quarantine for 14 days and complete testing as outlined in the Guidance for Discharge from the Yellow Cohort
      3. Quarantine for Observation:
        1. Newly admitted or re-admitted residents.
          1. New admissions and re-admissions that tested positive more than 90 days ago and are currently testing negative must be placed in the Yellow Cohort.
          2. New admissions and re-admissions who have tested positive within the last 90 days do not need to quarantine for observation and may be admitted directly to the Green Cohort.
          3. New admissions and re-admissions who are fully vaccinated and meet the criteria for direct admission to the Green Cohort may forego quarantine for observation.
        2. Residents who leave the facility frequently for outside appointments.
          1. Residents who leave the facility for greater than 24 hours and return should be managed similarly to new admissions.
          2. DIALYSIS PATIENTS: COVID-19-negative, asymptomatic residents who leave the facility regularly for dialysis may return to the Green Cohort and should be prioritized for weekly testing as described under COVID-19 Testing.
          3. Residents with indeterminate tests.
      4. Quarantine for Symptomatic Residents:
        1. Residents who have symptoms of COVID-19 pending test results including atypical symptoms.
          1. Symptomatic residents must be moved into the Yellow Cohort and have a PCR test administered within 24 hours of the onset of symptoms.
    2. Guidance for Care in Yellow Cohort:
      1. The facility must make reasonable efforts to place patients in the Yellow Cohort into private rooms.
      2. Private rooms should be prioritized for residents with typical COVID-19 symptoms (acute respiratory symptoms), close contacts, and those with indeterminate test results as they have a higher probability of infection.
        1. If private rooms are limited or unavailable, then symptomatic residents, especially residents with atypical symptoms, and their roommates should remain in their current rooms with appropriate transmission-based precautions as appropriate for the Yellow Cohort.
      3. If private rooms are not available for all current Yellow Cohort residents:
        1. The facility will be closed to new admissions.
        2. Available Yellow Cohort rooms must be prioritized for current residents who are exposed, symptomatic, or who are being readmitted.
        3. When a prior resident is returning to the facility as a readmission and no single-occupancy Yellow Cohort rooms are available, the resident may be placed in a shared Yellow Cohort room based on symptom status.
          1. In the circumstance of a shared Yellow Cohort room, the 14-day quarantine period will be extended to start on the admission date of the most recent patient admitted into the shared room.
        4. For shared rooms in the Yellow Cohort, strategies to reduce exposures between residents must be implemented:
          1. Residents with similar risk profiles should be placed in the same room (e.g., group low-risk admissions in the same room).
          2. Curtains should be placed between resident beds.
          3. Staff should change gowns and gloves and perform appropriate hand hygiene between contact with each separate resident in the shared room.
        5. Symptomatic residents must stay in their room with the door shut, regardless of COVID-19 test results.
        6. If a resident in isolation must leave the room, for example, for medically necessary procedures, the resident must wear a facemask if possible.
        7. Facility HCP must assess residents in quarantine frequently.
        8. Facility HCP must complete vital sign checks on all cases in quarantine every shift at a minimum of 3 times per day or as needed depending on patient status. Vital sign checks include heart rate, blood pressure, oxygen saturation, and temperature.
        9. Limit the number of different facility HCP interacting with symptomatic resident(s) and attempt to assign the same facility HCP to care for the same resident as often as possible.
      4. Keep the room door closed and post a sign stating that the door must be kept closed.
      5. Notify PPHD of all newly symptomatic residents daily.
    3. Guidance for Discharge from the Yellow Cohort:
      Residents may be discharged from the Yellow Cohort under the following circumstances:

      1. Transfer to Red Cohort: If the initial or subsequent test result (including an antigen result) is positive for COVID-19, the resident must immediately be moved to the Red Cohort.
      2. Discharge from Quarantine for Observation: Newly admitted and readmitted residents must quarantine in the Yellow Cohort for 14 days, unless previously positive within the last 90 days or fully vaccinated AND asymptomatic.
        1. These residents must be tested within 72 hours of admission/re-admission to the facility, and again on the 14th day post-admission.
        2. Once the facility receives the result of the day-14 PCR test, residents with a negative PCR result may be discharged to the Green Cohort.
      3. Discharge from Quarantine for Exposed – Close Contact: Residents exposed via confirmed close contact must stay in quarantine in the Yellow Cohort for 14 days, regardless of vaccination status, unless previously positive within the last 90 days.
        1. Residents must be tested on admission to the Yellow Cohort and again on the 14th day post-exposure to a confirmed close contact.
        2. Once the facility receives the result of the day-14 PCR test, residents with a negative PCR result may be discharged to the Green Cohort.
      4. Discharge from Quarantine for Exposed – Proximity:
        1. Residents exposed via proximity must stay in quarantine in the Yellow Cohort for 14 days from last potential exposure to an infectious person by proximity, regardless of vaccination status, unless previously positive within the last 90 days.
        2. Residents must be tested on admission to the Yellow Cohort and again on the 14th day post-exposure.
        3. Once the facility receives the result of the day-14 PCR test, residents with a negative PCR result may be discharged to the Green Cohort.
      5. Discharge from Quarantine for Symptoms:
        1. Residents with atypical symptoms of possible COVID-19 (e.g., delirium/confusion, change in functional status, change in oral intake, and new or worsening falls) can be returned to Green Cohort status if there is at least one negative PCR test.
        2. Symptomatic residents who are not tested (e.g., resident refusal) must remain in the Yellow Cohort, preferably in a single-occupancy room, for at least 20 days since symptom onset AND at least 24 hours since last fever without fever-reducing medications AND improvement of symptoms.
        3. Symptomatic residents must have two negative PCR tests at least 24 hours apart before they can return to the Green Cohort, unless an alternate diagnosis is made (e.g., URI, cellulitis), in which case a single negative PCR test is sufficient.
      6. Indeterminate or Invalid Results:
        1. Asymptomatic residents with indeterminate or invalid test results must remain in the Yellow Cohort until they either have a positive PCR test result OR two negative PCR results at least 24 hours apart.
            1. This does not apply to new admissions, readmissions, close contacts, or exposed residents.
  3. Green Cohort (Non-COVID-19 patient care area)
    The Green Cohort is reserved for asymptomatic residents who are not currently diagnosed with COVID-19. To reside in this area, the resident must have:

    1. Completed quarantine with negative initial and post-quarantine test results, OR
    2. Received clearance to discharge from isolation post-positive COVID-19 diagnosis and up to 90 days after the initial positive test result, OR
    3. Been fully vaccinated and met PPHD criteria for direct admission to the Green Cohort, OR
    4. Tested negative on baseline testing and remained asymptomatic with ongoing negative test results.
  4. Special Staffing Considerations in Cohort Areas
    1. Staff assigned to the Red Cohort should not care for patients in other cohorts if possible. If staff must care for residents in multiple cohorts, they must visit the Red Cohort last and must doff PPE and perform hand hygiene prior to moving between cohorts.
    2. Asymptomatic staff with current COVID-19 infection may be allowed to work in the Red Cohort with prior approval from PPHD. COVID-19 positive staff must be able to maintain separation from uninfected staff until they are no longer considered infectious (10 days after the date of collection of their initial positive test). Dedicated staff breakrooms and bathrooms must be established in the Red Cohort.
    3. All staff in the facility must adhere to physical distancing of at least 6 feet while in break rooms and must wear masks at all times while in the facility.

 

Figure 1. Cohorting
Figure 1. Cohorting

*Symptomatic residents under investigation can move from the Yellow Cohort to the Green Cohort with just 1 negative molecular assay test if an alternate diagnosis is made (e.g., URI, cellulitis).

VIII. Infection Prevention and Control

Infection Prevention and Control Considerations

This section outlines general and COVID-19 specific requirements and recommendations. For more information on infection control recommendations, visit https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html.

  1. Specific Considerations for Skilled Nursing Facilities:
      1. Skilled Nursing Facilities: CDPH guidance (AFL 20-52) requires that facilities employ a full-time, on-site infection preventionist to monitor compliance with infection control guidance.
      2. Skilled Nursing Facilities: 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 staff.
  2. Universal Source Control
    • Residents
      1. All residents must be provided a clean non-medical face covering daily.
      2. Surgical masks are required for any resident that is COVID-19-positive or suspected to be COVID-19 positive.
      3. All residents must wear the face covering/mask when outside their room, unless they have a contraindication. This includes residents who must regularly leave the facility for care (e.g., hemodialysis patients).
      4. Residents who cannot wear face coverings due to underlying cognitive or medical conditions must not be forcibly required to wear face coverings and should not be forcibly kept in their rooms. However, face coverings should be encouraged as often as possible.
      5. A face covering must not be placed on any individual who has trouble breathing, is unconscious, incapacitated, or otherwise unable to remove the face covering without assistance.
    • Staff
      1. All staff must wear a medical-grade surgical/procedure mask or respirator for universal source control at all times while they are in the facility. Cloth masks or cloth face coverings are not acceptable for use in an LTCF.
      2. Please see Cohort-Specific Transmission Based Precautions and PPE section for appropriate mask use for each cohort.
      3. N95 respirators must be used for aerosol generating procedures on residents with suspected or confirmed COVID-19.
      4. Extended use and reuse of masks and respirators must be based on principles set forth in prior CDC PPE optimization guidance: https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/face-masks.html#contingency-capacity.
  3. Hand Hygiene
      1. HCP and other staff members must perform hand hygiene before and after ALL resident encounters and must also perform hand hygiene at the beginning and end of their shifts, before and after eating, after using the restroom, any time that hands are visibly soiled, and at other appropriate times throughout the day.
      2. Make sure hand hygiene supplies, such as soap and water or alcohol-based hand sanitizer, are readily accessible in all resident care areas, including areas where HCP remove PPE.
      3. Sinks must be well-stocked with soap and paper towels. Hand sanitizer must be replaced as needed.
      4. Facilities must have a process for auditing HCP adherence to recommended hand hygiene practices.
      5. Ensure that there are alcohol-based hand sanitizer dispensers at the PPE donning and doffing areas.
  4. Respiratory Hygiene/Cough Etiquette
      1. Support hand and respiratory hygiene, as well as cough etiquette by residents and staff.
      2. Place hand sanitizer at facility entrances and encourage all residents and staff to use every time they enter the facility.
  5. Transmission-based Precautions and Personal Protective Equipment (PPE)
      1. HCP must follow transmission-based precautions for each cohort including standard precautions and wearing of appropriate PPE while providing resident care as detailed below in Figure 2. PPE in Each Cohort:
      2. General
        1. Facilities must regularly audit their HCP’s adherence to appropriate PPE use.
        2. Post appropriate Transmission-Based Precautions signage outside each resident room (e.g., from CDC).
        3. Post signage detailing the appropriate steps for donning and doffing PPE in donning and doffing areas: gov/acd/docs/CoVPPEPoster.pdf
        4. Facilities must follow CDC’s strategies to optimize the supply of PPE and equipment (https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html).
        5. If there are PPE shortages, the facility must make documented efforts to acquire more supplies and work with their assigned PHN at PPHD to identify potential alternative resources for PPE.
      3. Standard Precautions for All Resident Care
        1. Gloves must be changed between every resident
        2. Hand hygiene must be performed before donning and after doffing gloves. Please see above section on Hand Hygiene for more details.
        3. Respiratory hygiene/cough etiquette must be followed at all times including during resident
        4. Environmental cleaning recommendations must be followed where applicable before and after resident This includes properly disinfecting shared equipment, e.g., blood pressure cuffs and pulse oximeters before and after vital checks.
      4. Droplet Precautions
        1. In the Green Cohort, surgical masks may be worn for duration of the shift in place of N95 respirators.
        2. In the Yellow and Red Cohorts, N95 respirators must be worn. Please see N95 respirators section below.
        3. In the Yellow Cohort, eye protection, which is defined as a face shield or goggles, is recommended for close contact with residents (within 6 feet), especially if the resident cannot reliably wear a face covering.
        4. In the Red Cohort, eye protection is recommended to be worn for duration of shift.
        5. Eye protection may be reused if not soiled, as long as OHSA guidelines are followed and eye protection is intact and cleaned before donning and after doffing.
      5. Contact Precautions
        1. Gowns must be changed between residents in all cohorts if adequate supplies are available, even in multi-occupancy rooms.
        2. If there is a shortage of gowns, the same gown may be worn with multiple residents (extended use) in the Red Cohort as long as there are no other contact pathogens (C. difficile, CRE, Candida auris, etc.) that require changing between residents.
        3. If there is a shortage of gowns, gowns may be prioritized for resident care that may result in exposure to body fluids and/or high contact activity in the Yellow Cohort.
        4. The same gowns must never be worn for care of both COVID-19 positive and negative residents.
        5. Re-use of gowns is not allowed.
      6. N95 respirators
        1. In the Red Cohort, N95 respirators must be worn for duration of the shift.
        2. In the Yellow Cohort, N95 respirators must be worn when providing resident
        3. N95 respirators must be worn for all aerosol generating procedures (suction, ventilation, CPR, nebulizer treatments, etc.) for all cohorts including the Green Cohort.
        4. N95 respirators with an exhaust valve do not provide source control and must not be used in any LTCF or healthcare settings.
        5. Initial and annual N95 respiratory fit testing is required for all staff per California Division of Occupational Safety and Health (Cal-OSHA).
        6. Cal-OSHA no longer allows for re-use of N95 respirators over multiple days, but still allows for extended use with multiple residents in the same shift/day.
          1. Staff members should throw away N95 respirators after doffing.
        7. If there is a shortage of N95 respirators, facilities should make efforts to acquire more supplies including documented communication with PPHD. If the facility is still experiencing a shortage despite these efforts, facilities could consider re-use of N95 respirators and must document their reasoning in a written risk assessment.
      7. Cleaning Staff
        1. Cleaning staff must wear the same PPE as required by the cohort they are working in.
      8. Kitchen/Dietary Staff
        1. Kitchen/Dietary staff must wear a surgical mask or N95 and gloves while in the kitchen and the same PPE as required by the cohort they are working in if entering a resident’s
      9. Donning and doffing areas for PPE must be clearly defined.
        1. The doffing area for employees working with COVID-19 suspected or confirmed residents must be physically separate from the doffing area for those working with COVID-19 negative residents.
        2. Post signage on the appropriate steps for donning and doffing PPE in donning and doffing areas: http://publichealth.lacounty.gov/acd/docs/CoVPPEPoster.pdf.
      10. Post PPE Signage
        1. Post signage on the door or wall outside of each resident’s room that clearly describes the type of precautions needed and required PPE.
  6. Environmental cleaning
    In addition to CDC guidelines, the recommendations below are referenced from the CDPH AFL for Environmental Infection Control for the Coronavirus Disease 2019 (COVID-19).

      1. Facilities must have a plan to ensure proper cleaning and disinfection of environmental surfaces (including high touch surfaces such as light switches, bed rails, bedside tables, etc.) and equipment in the resident room.
      2. High touch surfaces must be cleaned at least every 2 hours, 24 hours a day, 7 days a week. A log must be kept of all high touch surface cleanings.
      3. 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).
      4. Ensure shared or non-dedicated equipment is cleaned and disinfected after each use according to the manufacturer’s recommendations.
      5. Ensure 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 are 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
      6. 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
Figure 2. PPE in Each Cohort
Figure 2. PPE in Each Cohort

IX. HCP Monitoring and Return to Work

Healthcare Personnel (HCP) Monitoring and Return to Work Monitoring

  1. Monitoring
    1. All HCP must self-monitor for possible symptoms of COVID-19 (i.e., elevated temperature above 100.0⁰ F, cough, shortness of breath) once daily prior to coming to work.
    2. If HCP have symptoms (e.g., fever, cough, shortness of breath), they must contact the facility immediately to arrange for medical evaluation and/or testing as soon as possible.
    3. Symptomatic HCP must be tested for COVID-19 as soon as possible via PCR, regardless of vaccination status.
    4. Facility-designated staff should screen for symptoms of COVID-19 and perform temperature checks of all HCP prior to the start of their shifts.
    5. Identify staff who can monitor sick staff with daily “check-ins” using telephone calls, emails, and texts.
    6. Asymptomatic HCP who test positive for COVID-19 must stay home from work, regardless of vaccination status. PPHD may waive this restriction in situations of severe staffing shortages, provided COVID-19 staff are only assigned to work with residents in the Red Cohort.
    7. Refer to the Los Angeles County Department of Public Health (LAC DPH) Guidance for Monitoring Healthcare Personnel for more detailed information including management of possible workplace exposures.
  2. Return to Work
    1. Symptomatic HCP with mild to moderate illness who are not severely immunocompromised may return to work when the following conditions are met:
      1. At least 10 days* have passed since symptoms first appeared; AND
      2. At least 24 hours have passed since last fever without the use of fever-reducing medications and improvement in symptoms (e.g., cough, shortness of breath); AND
      3. HCP who test positive for COVID-19 cannot enter the facility until permission to return to is provided by PPHD. HCP must complete the Pasadena Return to Work Form and receive approval from PPHD prior to return to work in a long-term care facility: https://healthforms.cityofpasadena.net/v/WorkClearanceForm. It is the employee’s responsibility to provide PPHD Return to Work approval to the facility administrator prior to returning to work at the facility.
    2. Asymptomatic HCP with laboratory-confirmed COVID-19 who are not severely immunocompromised should be excluded from work for 10 days after the date of their first positive COVID-19 lab result, as long as they have not developed symptoms since their positive result.
      1. If the HCP is severely immunocompromised, then they should be excluded from work for at least 20 days after the date of their first positive COVID-19 lab result. In the case of severe staff shortage, asymptomatic staff may be permitted to work with COVID-19 positive residents in the Red Cohort
        1. For current definitions of COVID-19 illness severity and severely immunocompromised see CDC Return to Work for Healthcare Personnel with SARS-CoV-2 Infection
      2. HCP who test positive for COVID-19 cannot enter the facility until permission to return to is provided by PPHD. HCP must complete the Pasadena Return to Work Form and receive approval from PPHD prior to return to work in a long-term care facility: https://healthforms.cityofpasadena.net/v/WorkClearanceForm. It is the employee’s responsibility to provide PPHD Return to Work approval to the facility administrator prior to returning to work at the facility.
    3. After returning to work HCP should:
      1. Self-monitor for symptoms and seek re-evaluation from occupational health if symptoms recur or worsen.
      2. Be sent home if new onset of symptoms occurs and retested for COVID-19.
      3. Adhere to hand hygiene, respiratory hygiene, and cough etiquette (e.g., cover nose and mouth when coughing or sneezing, dispose of tissues in waste receptacles and then perform hand hygiene).
      4. Be restricted from contact with severely immunocompromised residents (e.g., transplant, hematology-oncology) until 20 days after illness onset.
      5. See the CDC Criteria for Return to Work for Healthcare Personnel with SARS-CoV-2 Infection and the LAC DPH Guidance for Monitoring Healthcare Personnel for more information.

X. Inter-Facility Transfers

Inter-facility Transfers

  1. Facilities are required to follow transfer rules as listed on the LAC DPH website (http://publichealth.lacounty.gov/acd/NCorona2019/InterfacilityTransferRules.htm).
  2. Transfer of Residents to a Hospital
    1. No prior permission is required to transfer a resident to a hospital when a higher level of care is warranted.
    2. A Healthcare Facility Transfer Form must be completed by the LTCF and given to the admitting hospital: http://publichealth.lacounty.gov/acd/docs/facilitytransferform.pdf.
  3. Discharge of Residents from a Hospital
    1. Facilities cannot deny the readmission of a resident after hospitalization, regardless of the resident’s COVID-19 status, unless otherwise directed by PPHD.
  4. Home Discharge Rules for Residents with Laboratory Confirmed COVID-19
    1. At least 10 days have passed since symptom onset AND no fever for at least 24 hours without the use of fever reducing medications AND symptoms have improved:
      1. No restrictions: resident is considered non-infectious for the purpose of discharge.
    2. Less than 10 days since symptom onset, still febrile, and/or no improvement in symptoms:
      1. Provide home isolation instructions.
      2. If the resident lives with others, advise household members that are not fully vaccinated that they will need to quarantine for 10 days after the last close contact with this resident. Provide home quarantine instructions.
      3. Transport home by private conveyance or non-medical transport. Avoid public transportation and rideshare/taxi.
        1. Resident should wear a surgical mask.
        2. The driver should wear a surgical mask; an isolation gown is optional, if available.
        3. Resident and driver should maintain a 6 foot distance at all times.
        4. Vehicle should be disinfected with approved disinfectant (e.g., disinfectant wipes) after transport and not used/aired out for a minimum of 2 hours.
  5. A resident in quarantine, isolation, or during a facility outbreak may be discharged home IF:
    1. The facility has completed a home assessment and approves the discharge.
      1. The family/legal caregivers/household members are able to follow the guidance on home quarantine or isolation instruction until the end of the resident's incubation or infectious period.
      2. The family/legal caregivers/household members are able to commit to implementing home quarantine for 14 days after their last contact with the resident, while the resident was symptomatic, or within the infectious period.

XI. Death Reporting

Death Reporting
PPHD must be notified of all deaths regardless of COVID-19 status. The facility must complete and submit a death report to PPHD.

  1. Form for COVID-19 positive associated deaths: http://publichealth.lacounty.gov/acd/Diseases/EpiForms/COVID19DeathSaveable.pdf
  2. Form for all other facility deaths: https://cdss.ca.gov/cdssweb/entres/forms/English/LIC624A.PDF
  3. CDC guidelines for attesting to cause of death due to COVID-19 are available at: https://www.cdc.gov/nchs/data/nvss/vsrg/vsrg03-508.pdf
  4. All deceased residents must be tested for COVID-19 post-mortem if their previous status was unknown or negative, regardless of vaccination status. Post-mortem testing is the responsibility of the facility. The CDC has provided guidance on post-mortem collection at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-postmortem-specimens.html.

XII. Resources

Resources

  1. Pasadena Public Health Department Resources
    1. COVID-19 information: https://www.cityofpasadena.net/covid-19/
    2. Social Engagement Strategy: https://www.cityofpasadena.net/public-health/wp-content/uploads/sites/32/PPHD-OMB-Joint-Strategy-for-Engagement.pdf
  2. Los Angeles County Department of Public Health Resources
    1. COVID-19 information: http://publichealth.lacounty.gov/media/Coronavirus/
    2. COVID-19 information for health professionals: http://publichealth.lacounty.gov/acd/ncorona2019/
    3. Los Angeles Health Alert Network (LAHAN): Priority communications are emailed to health care professionals through LAHAN. Topics include local or national disease outbreaks and emerging health risks. Register to receive critical information at: http://publichealth.lacounty.gov/lahan/
    4. Los Angeles County Department of Mental Health Access Center 24/7 Helpline (800) 854-7771
  3. Centers for Disease Control and Prevention (CDC) Resources
    1. COVID-19 information: https://www.cdc.gov/coronavirus/2019-ncov/index.html
    2. Information for Healthcare Professionals: https://www.cdc.gov/coronavirus/2019-ncov/hcp/index.html
    3. Healthcare Infection Prevention and Control FAQs: https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html
    4. Interim Infection Prevention and Control Recommendations for Healthcare Personnel During Coronavirus Disease 2019 (COVID-19) Pandemic: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html
    5. CDC Facilities COVID-19 Screening Form, revised 6/11/2021: https://www.cdc.gov/screening/paper-version.pdf
    6. Optimizing Supply of PPE and Other Equipment during Shortages: https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html
    7. Preparing for COVID-19 in Nursing Homes: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html
  4. Other Reliable Sources of COVID-19 Information
    1. California Department of Public Health https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/Immunization/nCOV2019.aspx
    2. CMS Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in nursing homes (Revised) https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and/guidance-infection-control-and-prevention-coronavirus-disease-2019-covid-19-nursing-homes-revised
    3. CMS COVID-19 Long-Term Care Facility Guidance April 2, 2020 https://www.cms.gov/files/document/4220-covid-19-long-term-care-facility-guidance.pdf

Appendix 2: Sample Letter

Appendix 2: Sample Letter

 

SAMPLE

Letter Head

 

Date

This is a notification that this facility has had one or more confirmed cases of COVID-19. We want to assure you that we are working closely with the health department and licensing.

No visitors are allowed at this time, except for certain care situations, such as end of life.

We are asking all of our employees to monitor their health carefully. If you experience symptoms of COVID-19, we ask that you contact the Human Resources Manager.  Symptoms may include flu-like conditions such as sore throat, dry cough and fever.  Other less frequent symptoms may include nausea or diarrhea. All health care personnel are to initiate temperature and symptom check prior to shift. Ill healthcare personnel will be sent home.

All HCP are reminded to practice social distancing when in break rooms or common areas.

There is additional information about COVID-19 at the CDC website: https://www.cdc.gov/coronavirus/2019-ncov/index.html.  If you should have symptoms, please seek medical advice regarding whether or not you need to be tested for COVID-19.

We care about your health and look forward to answering any questions or concerns that you may have.  Please continue to practice all safety practices that we have formerly discussed.

Sincerely,

(Your name/contact information)