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This manual is only intended for use by staff from the Los Angeles County Department of Public Health.

Please check this webpage to view the current guidance: http://publichealth.lacounty.gov/acd/ncorona2019/b73covid/SNF/index.htm

REPORTING PROCEDURES

Outbreak Definitions: Under Title 17, Section 2500, California Code of Regulations all suspected outbreaks are reportable.

Definition of Outbreak:

1. At least one or more laboratory confirmed case (symptomatic or asymptomatic) of COVID-19 in a SNF resident who has resided in the facility for at least 14 days

a. If newly admitted residents who are admitted to the YELLOW quarantine cohort test positive for COVID-19, this is not considered an outbreak as it was acquired outside the SNF.

b. Facilities should test PUI/Suspect cases (cases with symptoms of possible COVID) immediately.

NOTE: a positive case of COVID-19 in a healthcare provider (HCP) should prompt response testing in the SNF but is not considered an outbreak until there are identified cases among residents.

EPIDEMIOLOGIC DATA FOR OUTBREAKS a. Establish a case definition (i.e., fever [measured or reported] and either cough, sore throat,

or stuffy nose): include pertinent clinical symptoms and laboratory data. b. Confirm etiology of outbreak using laboratory data. c. Create a line list and contact information following the COVID-19 line list template above. d. Maintain surveillance for new cases until no new cases for at least 2 weeks. e. Create an epi-curve, by week of symptom onset or positive test result (see CDC Quick

Learn Lesson: Create an Epi Curve for guidance). Only put those that meet the case definition on the epi-curve. Recommend listing case totals by increments of 7 days (1 week).

CONTROL OF CASE, CONTACTS & CARRIERS Case Single confirmed COVID-19 RESIDENT case in a SNF

1. Immediately transfer COVID positive resident to the RED (COVID positive) cohort.

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2. Identify any close contacts or exposures to the COVID positive resident and place them in the YELLOW (mixed quarantine) cohort for 14 days, regardless of vaccination status. Residents who are considered exposed due to being in the same unit/wing as a case do not need to be moved. Please see “Cohorting” section for further details.

3. If the resident testing positive was in the YELLOW (mixed quarantine) cohort because of recent admission within the past 14 days, this should not be opened as an outbreak and outbreak measures may not be necessary for the SNF.

o However, the facility should still immediately start response testing for all residents and all staff for at least 14 days until no further cases are identified without officially opening an outbreak. This is because positive residents recently admitted/re-admitted may have acquired the infection at the facility or prior to the facility.

o Note: this does not apply to dialysis residents who are not new admissions and who test positive as the infection could have been acquired at either the SNF or the dialysis center, and warrants opening an outbreak.

4. If a resident from the GREEN (Non-COVID-19) cohort tests positive, this suggests transmission within the SNF and warrants opening an outbreak in the facility and the facility should initiate an outbreak response.

Confirmed COVID-19 HCP case in a SNF

1. If a HCP is identified as positive either as result of being symptomatic or due to routine testing of asymptomatic staff, the HCP should be excluded from work if symptomatic, but may continue to work only with COVID positive patients if there is a staffing shortage in the facility. While CDC does allow asymptomatic COVID positive staff to work with COVID negative patients under certain circumstances, this should be done only after approval from the Area Medical Director (AMD) or designee.

2. Positive COVID test results in a HCP should trigger response testing as described above, but does not meet the outbreak definition

3. New admissions and re-admissions to SNFs should follow the inter-facility transfer rules including during outbreaks.

NOTE: Any HCP who has not recently worked at the facility and tested positive should be linked to the outbreak under the following circumstances:

• For symptomatic staff, if they have been on facility premises starting 2 days prior to symptom onset or specimen collection date, whichever is earlier, through the isolation period

• For asymptomatic staff, if they have been on facility premises starting 2 days prior to specimen collection date through the isolation period

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CONTACTS Contacts are defined as below:

a. All residents on the same unit or wing where a case was identified in a resident or HCP b. All HCPs who worked on the same unit or wing where a case was identified in a resident or

HCP c. Any person who has been within 6 feet of a person with lab-confirmed COVID-19 for a

cumulative total of ≥15 minutes within a 24 hour period without consistent use of all appropriate PPE

d. Any person who had 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)

Healthcare Personnel (HCP):

Facility to identify all close contact HCP (includes clinical and ancillary staff), and determine risk status using the guide outlined in LAC DPH Guidance for Monitoring Healthcare Personnel and a companion guidance, CDC Criteria for Return to Work for Healthcare Personnel with Confirmed or Suspected COVID-19 (Interim Guidance).

Document the contacts on the COVID-19 Line List template (see Report Forms section) and submit it to DPH as requested by DPH

Visitors:

For the most up to date guidance on visitation in SNFs, please see Communal Dining, Group Activities, and Visitation section. Facility to identify and instruct any visitors that may have been a close contact to a confirmed case and who were not fully vaccinated at the time of the visit to self-quarantine and self-monitor for symptoms for 14 days after last exposure.

GUIDELINES FOR PREVENTING AND MANAGING COVID-19 IN SKILLED NURSING FACILITIES These guidelines outline actions that Skilled Nursing Facilities (SNFs) should take to help prevent and manage COVID-19, based on the current status of and trends in community transmission in LA County.

Definition of Fully Vaccinated:

For the purposes of this guidance, per CDC, fully vaccinated refers to individuals who are:

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• ≥2 weeks following receipt of the second dose in a 2-dose series (e.g. Moderna or Pfizer), OR

• ≥2 weeks following receipt of one dose of a single-dose vaccine (e.g. Johnson & Johnson’s Janssen).

COVID-19 Prevention - General and Administrative Practices

1. Offer COVID-19 vaccination to all residents and staff (including new residents and staff) a. Continue to improve vaccination rates for staff and residents including re-offering

the vaccine to persons who initially decline. Please see Best Practices for Improving Vaccination in SNFs for more strategies.

b. Follow COVID-19 Immunization Guidance for SNFs. 2. Conduct entry screening

a. All persons, regardless of vaccination status, should be screened for signs and symptoms of COVID-19 infection, including a temperature check. Additionally, all persons who are not fully vaccinated should be screened for any recent travel in the past 14 days. Persons requiring symptom and travel screening includes facility staff, essential visitors, and general visitors. Symptoms include but are not limited to the following: fever, chills, cough, shortness of breath, new loss of taste or smell, muscle or body aches, headache, sore throat, congestion or runny nose, nausea or vomiting, diarrhea, or not feeling well.

i. Anyone with fever or signs or symptoms of COVID-19 infection is prohibited from entry.

ii. Anyone who is not fully vaccinated reporting recent travel in the past 14 days is prohibited from entry.

b. All visitors (general and essential) must be screened prior to entry for any history of close contact to a COVID-19 case within the past 14 days. See SNF Visitation Guidance for definitions of essential visitors and general visitors.

i. Anyone reporting recent close contact exposure is prohibited from entry, regardless of vaccination status.

c. An exception to entry screening: Emergency Medical Service (EMS) workers responding to an urgent medical need. They do not have to be screened, as they are typically screened separately.

3. Conduct symptom and temperature screening for all staff and residents a. All staff should be checked for symptoms and fever at least once per shift, including

at the beginning of shifts (see Healthcare Personnel Monitoring section below.) b. All asymptomatic residents should be assessed for symptoms and have their

temperature checked at least every 24 hours, with closer monitoring recommended for symptomatic residents under investigation and residents with confirmed COVID-19.

c. Records should be kept of these staff and resident symptom and temperature checks.

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4. Reinforce physical distancing, hand hygiene, and universal source control. a. Residents should remain in their room as much as possible and should be

encouraged to wear a mask if they leave. Remind residents to practice physical distancing and perform frequent hand hygiene. Residents who have underlying cognitive conditions should not be forcibly kept in their rooms nor forced to wear a mask.

5. Support good workforce health. a. Non-punitive sick leave policies to support staff to stay home when sick or when

caring for sick household members. Make sure staff are aware of the non-punitive sick leave policy.

6. Enhanced environmental disinfection with EPA-approved healthcare disinfectants should be performed on high touch surfaces (e.g., bed rails, doorknobs, handrails, etc.).

7. Facilities must demonstrate that they have contracted with suppliers to order a 2-week supply of PPE and other infection prevention and control supplies

a. PPE and other infection prevention and control supplies (e.g., surgical masks, respirators, gowns, gloves, goggles, hand hygiene supplies) that would be used for both HCP protection and source control for infected patients (e.g., facemask on the patient) should be readily accessible for use.

b. Follow CDC’s Guidance on Strategies to Optimize the Supply of PPE and Equipment in the setting of shortages at cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html.

Communal Dining, Group Activities, and Visitation The purpose of these visitation guidelines is to help each facility develop a resident-centered visitation policy that balances the need to protect staff and residents from COVID-19 transmission with the need to provide timely care that optimizes residents’ physical and psychological health in alignment with state and federal requirements.

The following recommendations for communal dining, group activities, and visitation are based upon the most recent CDPH All Facility Letter (AFL) and CMS Quality Safety & Oversight memo (QSO):

• CDPH AFL 20-22.6: Guidance for Limiting the Transmission of COVID-19 in Long-Term Care Facilities

• CMS QSO 20-39-NH-revised: Nursing Home Visitation – COVID-19

Criteria for Communal Dining, Group Activities, and General Visitation For facilities to allow any gathering, facilities must meet these baseline CMS criteria:

• Adequate staffing: The facility must not be experiencing staff shortages; AND

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• Supply of 14 days of Personal Protective Equipment (PPE) and disinfection supplies on hand: The facility must have adequate supplies of PPE1for staff, such that all staff wear all appropriate PPE when indicated, and must have adequate essential cleaning and disinfection supplies; AND

• Access to adequate testing: The facility must maintain access to COVID-19 testing for all residents and staff by an established commercial laboratory; AND

• Approved COVID-19 Mitigation Plan: The facility must maintain regulatory compliance with CDPH guidance; AND

1Per CMS Guidance, contingency PPE capacity strategy is allowable, such as CDC’s guidance Optimizing Supply of PPE and Other Equipment during Shortages. However, facilities’ crisis capacity PPE strategy does not constitute adequate access to PPE.

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

Communal Dining and Group Activities

Communal dining and group activities are only* permitted for residents in the Green Cohort provided the facility meets the baseline criteria. Communal activities are permitted outdoors and may be permitted indoors depending on a variety of factors including resident vaccination status, county tier, and outbreak status in the facility.

* Residents who are in the Yellow Cohort because they are not fully vaccinated and have frequent appointments outside the facility (e.g., dialysis) may also participate in communal dining and group activities as long as they are not in quarantine, there is no outbreak in the facility, and the county is in Red, Orange, or Yellow tier.

See Figure 1 Schematic of visitation and communal dining/group activities

Facility should adhere to the following measures for all communal dining and group activities:

1. Universal source control a. All staff should wear appropriate medical-grade surgical/procedure mask or

respirator at all times while they are in the facility b. Residents, regardless of vaccination status, should wear non-medical masks as

described below 2. Physical distancing

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a. All residents, regardless of vaccination status, must keep at least 6 feet apart during all activities.

b. All staff must keep 6 feet apart in break rooms and, as much as possible, during work activities.

c. Activities should be done in shifts to allow better physical distancing. i. These shifts of residents should be kept together (i.e., same group of

residents dine together consistently) and individual residents should be assigned to specific areas as much as possible to attempt to minimize exposure should a resident later test positive for COVID-19.

ii. Use a sign-in sheet/roster of residents present during these activities will help with contact tracing should a resident later test positive for COVID-19.

3. Enhanced environmental disinfection. a. All communal, high touch surfaces should be disinfected after residents or staff

vacate an area. 4. Location of communal dining and group activities

1. The facility should prioritize outdoor settings for communal dining and group activities, if practical.

2. Fully vaccinated residents can participate in indoor communal dining and group activities regardless of county tier status when there is no outbreak at the facility.

3. Partially and unvaccinated residents can participate in indoor communal dining and group activities when the county tier is in Red, Orange, and Yellow when there is no outbreak at the facility. Partially and unvaccinated residents can participate in indoor communal dining and group activities when the county is in the Purple tier ONLY if the facility’s resident vaccination coverage is > 75% when there is no outbreak.

5. Refer to CDPH AFL 20-86 (COVID-19 Infection Control Recommendations during Holiday Celebrations) for further guidance on group activities and communal dining during the holidays.

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

1. Outdoor communal dining and group activities can continue. 2. Fully vaccinated residents can continue to participate in indoor communal dining and

group activities when the county is in Red, Orange, or Yellow tier. If an indoor location is used, avoid poorly ventilated and/or fully enclosed spaces. Increase ventilation by opening windows and doors to the extent that is safe and feasible based on the weather. If the county is in Purple tier, all indoor communal activities for fully vaccinated persons must cease.

3. Non fully vaccinated residents must cease participation in indoor communal activities for at least 14 days after the last known case of COVID is confirmed.

4. The facility should review their infection control and prevention practices to prevent future new infections.

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5. After there have been no new resident cases in the facility for 14 days and the Self-Assessment and Attestation have been submitted, resident indoor communal dining and activities that had ceased may resume.

Visitation

HCP and essential visitors are exempted from visitation restrictions. General visitors are limited to only* residents in the Green Cohort .

*Residents who are in the Yellow Cohort because they are not fully vaccinated and have frequent appointments outside the facility (e.g., dialysis) may also receive general visitors as long as they are not in quarantine, there is no outbreak in the facility, and the county is in Red, Orange, or Yellow tier.

1. Healthcare personnel (HCP) are facility staff directly employed by the facility and are exceptions to visitation restrictions.

2. Essential visitors are exceptions to visitation restrictions and should be permitted visitation regardless of facility’s outbreak status or COVID-19 status of the resident receiving the visitation. Based on CDPH AFL 20-22.6, essential visitors are defined as:

a. HCP not directly employed by the facility including consultants, contractors, trainees in the facility’s nurse aide training programs or from affiliated academic institutions, and local county public health staff.

b. Surveyors c. Compassionate care visitors including visitors for:

End-of-life situations Residents experiencing weight loss, dehydration, failure to thrive,

psychological distress, functional decline, or struggling with a change in environment. The determination of who may benefit from in-person visitation should be made by an interdisciplinary team that includes the resident and/or designated representative.

d. Caregivers or essential support persons for patients with physical, intellectual, and/or developmental disabilities and patients with cognitive impairments; CDPH recommends that one essential support person be allowed to be present with the patient. The determination of who is the caregiver/essential support person should involve the resident and/or designated representative.

e. Ombudsman representatives f. Protection & advocacy representatives g. 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

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h. Individuals authorized by federal disability rights laws including qualified interpreters when assistance is not available by onsite staff or video remote interpretation.

3. General visitors: General visitors are defined as visitors who do not fall under the definition of HCP or Essential Visitors. This was previously known as “Non-essential visitors.”

a. General visits should be scheduled in advance, when possible. b. General visitation is only permitted for residents in Green Cohort and residents of

the Yellow Cohort who have frequent medical appointments as mentioned above. c. General visitation is permitted outdoors regardless of a facility’s outbreak status,

resident’s vaccination status, and County tier. d. Indoor and in-room general visitation in the facility is subject to outbreak status of

the facility, the resident’s vaccination status, and County tier.

Fully vaccinated residents in the Green Cohort may receive indoor and in-room visitors unless there is an outbreak in the facility AND the County is in Purple tier.

Not fully vaccinated residents in the Green Cohort (and the specific residents in Yellow Cohort with frequent outside medical appointments) may receive indoor visitation when the county is the Red, Orange, or Yellow tier. In addition, indoor visitation is permitted if the county is in Purple tier and the facility’s current resident vaccination coverage is >75%. Only outdoor general visitation is permitted when there is an outbreak or if the facility’s current resident vaccination coverage is lower than 75% AND the county is in Purple tier.

See Figure 1 Schematic of visitation and communal dining/group activities 4. Resident Rights: Facilities may not restrict visitation without a reasonable clinical or safety

cause, consistent with resident rights in the federal regulation Title 42 CFR section 483.10(f)(4)(v), as stated in CDPH AFL 20-22.5 and CMS QSO 20-39-NH. Furthermore, residents or their designated representative when the resident does not have capacity, should be involved and have their preferences prioritized in the determination of essential visitors (e.g. caregivers/essential support persons, compassionate care visitors). Failure to facilitate residents’ visitation rights, without adequate reason related to clinical necessity or resident safety, would constitute a potential violation of this federal regulation, and the facility would be subject to citation and enforcement actions.

5. Place of Visitation a. Outdoor visitation is preferred for all visitation whenever practical due to lower risk

of transmission from increased space and airflow. b. Large indoor spaces that allow for ≥ 6 ft physical distancing with good ventilation

can be offered as an alternative when outdoor visitation is not possible (e.g.

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inclement weather, poor air quality, inability to move resident outside). Essential visitation may be conducted in large indoor spaces even during an outbreak.

c. In-room visitation i. Essential visits may be conducted in-room when visitation outdoors and in

large indoor spaces are not practical. ii. Per CMS, for essential visitation where there is a roommate and the health

status of the resident prevents leaving the room, facilities should attempt to conduct in-room visitation with the roommate(s) not present in the room when possible. In addition, any in-room visitation must adhere to core principles of infection prevention and control.

iii. For general visitation, please refer to section 3d above 6. All visitors, essential and general, must adhere to the following measures or the facility

may remove them from facility premises and/or restrict their entry. Visitors should be screened on entry as described above. If a visitor screens positive for COVID-19 symptoms and/or close contact to COVID-19, regardless of vaccination status, their visit must be postponed until after appropriate isolation or quarantine periods are completed.

. Visitors should document in a visitor log their name, contact information, and locations within the facility premises they are visiting in order to assist with contact tracing if needed.

a. Visitor testing For indoor and in-room visitation when the county is in Purple tier,

visitors must provide proof of a negative viral test (POC antigen or PCR) on a sample taken within 2 days prior to the visit, regardless of the visitor’s or resident’s vaccination status.

For indoor and in-room visitation when the county is in Red, Orange, and Yellow tiers, testing of visitors, regardless of visitor’s vaccination status, within 2 days prior to the visit can be considered as an additional safety measure for residents who are not fully vaccinated.

The absence of test results should not prevent essential visitation. Outside test results are acceptable if documentation of test date and

test result can be provided. If same day on site point of care antigen testing is utilized, please

follow local SNF antigen testing guidelines, referring to the section Use of POC Ag tests for Screening-Only for asymptomatic staff.

b. Visitors, essential and general, who regularly enter the facility should be encouraged to seek COVID-19 vaccination through the resources available in their community.

c. Visitors must wear face masks appropriate for the cohort of the resident they are visiting regardless of indoor or outdoor setting (medical grade surgical

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mask/procedure mask or higher). Residents should also be encouraged to wear masks if possible.

d. Visitors should don and doff appropriate PPE according to instruction by facility staff.

e. Visitors should perform hand hygiene before and after the visit at minimum. f. Visitors should maintain physical distancing of 6 feet or more. If 6 feet of distance

is not possible, a clear plastic divider may be used. g. Fully vaccinated visitors may have brief, limited physical contact with fully

vaccinated residents (e.g., a brief hug, hand holding, assisting with feeding or grooming). Otherwise, direct physical contact between an essential visitor and the resident can be considered on a case by case basis (e.g. compassionate care visitation) with a pre-determined plan that involves adequate infection prevention and control practices, e.g. wearing full PPE, minimizing total cumulative time of direct physical contact. Visitors must avoid direct physical contact with staff and other residents they are not visiting.

h. Staff should monitor the visit to make sure infection control guidelines are followed (e.g., safe distancing, face coverings, no physical contact) to assure a safe visitation for both residents and loved ones.

i. All visitors should be instructed to notify the facility if they develop COVID-19 signs and symptoms and/or have a positive test within 14 days of visiting the facility. Facilities should take all necessary actions including infection control precautions based on findings.

7. Facilities should establish the following to support in-person visitation: . 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).

a. Facilities should consider scheduling visits for a specified length of time to help ensure all residents are able to receive visitors; facilities can consider shorter indoor visits and longer outdoor visits.

b. Facilities should limit movement of visitors within the facility to encourage visitors to go directly to and from the resident’s room or designated visitation area.

c. Facilities should disinfect rooms and designated visiting areas after each resident-visitor meeting.

d. Facilities are encouraged to consider implementation of physical barriers, e.g. clear plastic dividers, in visitation areas to further reduce risk of transmission

e. Facilities are encouraged to regularly communicate visitation guidelines and expectations with residents, family, caregivers, designated decision makers, etc. Facilities are also recommended to provide visitation instructions to visitors prior to their scheduled visits and/or on entry to facility.

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f. Facilities should place clear signage for visitors in relevant languages throughout the facility regarding education on COVID-19 signs and symptoms, infection control precautions including hand hygiene and universal masking, specified entries/exits and routes to designated areas, etc.

g. Facilities could consider providing infection prevention and control education for visitors who are regularly visiting (more than one in-person visit every 7 days).

8. Facilities should continue to support other visitation options. . Continue to offer alternative means of communication for people who would

otherwise visit, such as virtual communications (phone, video-communication, etc.).

a. Create a communication outlet (email listserv, website, call-in number with recording, etc.) to provide updated communication with families.

b. Assign staff as primary contact to families for inbound calls and conduct regular outbound calls to keep families up to date.

Figure 1. Schematic of visitation and communal dining/group activities

Printable version (PDF)

B73 Communal Dining, Group Activities, and Visitation FAQs

1. Are residents who have roommates allowed to receive essential visitation in-room eg, for compassionate care and end of life visitation?

o Answer: In general, in-room visitation is discouraged where there is a roommate. However, based on CMS guidance (CMS QSO 20-39-NH), for essential visitation

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situations including for compassionate care/end of life visits where there is a roommate and the health status of the resident prevents leaving the room, facilities should attempt to enable in-room visitation while adhering to core principles of infection prevention (see Visitation and Infection Prevention and Control Considerations sections).

2. Some patients require close monitoring during feeding, must they eat in their rooms? o Answer: Residents who may be prone to aspiration or who cannot feed themselves

may eat outside their rooms if staffing is insufficient to support one-to-one feeding. If residents eat outside their rooms, then social (physical) distancing of six feet or more should be maintained and other precautions mentioned in “Communal Dining” should be followed.

COVID-19 Testing Below are recommendations for testing and cohorting in SNFs based upon California Department of Public Health (CDPH) requirements outlined in recent CDPH AFLs:

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

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

NOTE: COVID-19 testing requirements and interpretation of viral test results do not change after a resident or staff has received COVID-19 vaccination. Please also refer to the COVID-19 Immunization Guidance for Skilled Nursing Facilities for current information on vaccination guidelines in SNFs.

General requirements

1. Establish a relationship with a commercial lab to do rapid PCR testing with a turn-around time (TAT) of 48 hours or less for COVID-19. Refer to LAC DPH's Laboratory Information to find a lab providing COVID-19 PCR testing. If the 48-hour TAT cannot be met, then the facility should document its efforts to obtain quick turnaround testing results including communication with the local and state health departments.

2. COVID-19 Antigen point of care testing may be used to complement PCR testing per LA County Antigen Testing Guidance.

3. Establish cohorting plan as part of CDPH-required COVID-19 mitigation plan. 4. Report weekly to Public Health the number of staff and residents tested each week for

COVID-19, the number who are asymptomatic and test positive, and the number who are symptomatic and test positive, as per the May 26, 2020 Board of Supervisors Motion.

5. Thorough documentation to demonstrate compliance with testing regulations in accordance with CDPH AFL 20-53.3.

Testing of symptomatic residents or staff.

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1. Every staff member or resident with symptoms of COVID-19 should be tested as soon as possible, regardless of vaccination status. Be aware that older adults may have atypical symptoms of COVID-19 infection including but not limited to delirium (or confusion), change in functional status, change in oral intake, and new or worsening falls with or without fever or more typical symptoms.

2. All symptomatic residents should be presumed infectious pending test results and should be in quarantine in a private room in the Yellow Cohort, if possible, with priority given to residents with typical COVID-19 symptoms (acute respiratory symptoms). However, if a private room is unavailable, then the symptomatic resident and their roommates should remain in their current rooms with appropriate transmission-based precautions as appropriate for the Yellow Cohort.

3. During the influenza season, residents with acute respiratory symptoms should also be tested for influenza as per LAC DPH's guidance on management of influenza in context of COVID-19 in SNFs.

4. Any staff or resident testing positive for COVID-19 should then prompt response testing (see below).

5. All symptomatic staff must be immediately restricted from working (see Healthcare Personnel Monitoring and Return to Work sections below).

Response testing. If a single positive COVID-19 case is identified among either staff or residents, the SNF must conduct comprehensive testing of all residents and staff to identify potential asymptomatic infections. All residents should be tested once weekly and all staff should be tested at the same frequency as routine staff testing. If testing capacity is limited, testing may be prioritized for the residents and staff in the same area (e.g., nursing station, floor, etc.) as the COVID-19 positive individual. Any close contacts and exposed residents of confirmed COVID-19 cases will need to be quarantined accordingly in the Yellow Cohort (see below). All residents and staff who test negative will need to be included in response testing until there are at least 2 weeks with no additional infections identified. After 2 weeks of negative testing for residents, the facility could restart routine testing for residents as outlined below, in consultation with local Public Health.

Routine testing of staff and residents. Routine testing is initiated when either no cases were identified at baseline testing OR after no new cases are identified from two sequential weeks of response testing. If any resident or staff tests positive, the SNF must report the positive case to LAC DPH and proceed with outbreak/response testing as described above.

1. All staff directly employed by the facility must be routinely tested at a frequency based on community test positivity rates (see Table 1).

2. The facility should monitor Los Angeles County's testing positivity rate every week to determine staff testing frequency. The county testing positivity rate can be located on the CDPH Blueprint for a Safer Economy

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webpage: https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/COVID-19/COVID19CountyMonitoringOverview.aspx

Table 1: Routine Testing Intervals Vary by Community COVID-19 Activity Level

Community COVID-19 Activity County Test Positivity Rate in the Past Week Minimum Testing Frequenc Low <10% Once a week High >10% Twice a week

a. As soon as the LA County test positivity rate reaches ≥10%, the facility should increase the frequency of staff testing to twice a week.

b. The LA County test positivity rate should remain <10% for at least two consecutive weeks before decreasing the frequency of routine staff testing to once a week.

3. In addition, all regular visitors (essential and general) who visit the facility at least once a week or more, should be tested at the same frequency as facility staff, regardless of vaccination status. All other infection prevention and control requirements, including entry screening must be followed, regardless of negative test results.

a. The absence of test results should not prevent essential visitation. b. Outside test results are acceptable if documentation of test date and test result can

be provided. c. Same day on site point of care antigen testing could be utilized for visitors

following local SNF antigen testing guidelines, referring to the section Use of POC Ag tests for Screening-Only for asymptomatic staff.

4. Residents: a. SNFs must test a random sample of 10% of non-fully vaccinated residents weekly

Retesting Previously Positive Staff/Residents

1. Staff or residents who previously tested positive and are asymptomatic should not be retested for 90 days since the date of symptom onset or date of the first positive test.

a. Exception: A staff or resident who develops new symptoms ≤ 90 days of the initial positive test should be retested.

2. Staff or residents who previously tested positive and are asymptomatic will be back in the routine testing pool after 90 days of the date of previously positive test or date of symptom onset.

3. Staff or residents who previously tested positive who re-test positive 90 days or more AFTER the first infection should be managed as a new infection; the person should be isolated and would be exempt from testing for another 90 days.

Figure 2. Testing Schematic

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Refusal of Testing

1. Staff: The following restrictions only apply to staff directly employed by the facility. a. 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. b. If outbreak testing has been triggered and a staff member refuses testing, the staff

member should be restricted from entering the facility until the outbreak has been closed.

c. For asymptomatic staff during routine testing, the facility should establish policies and procedures to address refusal in this situation.

2. Residents: a. Residents (or resident representatives) may exercise their right to decline COVID-19

testing in accordance with the requirements under 42 CFR § 483.10(c)(6). In discussing testing with residents, staff should use person-centered approaches when explaining the importance of testing for COVID-19. Facilities must have procedures in place to address residents who refuse testing.

b. Residents who have signs or symptoms of COVID-19 and refuse testing must be placed in the Yellow quarantine cohort, preferably in a single room, until the criteria for discontinuing transmission-based precautions have been met.

c. If outbreak testing has been triggered and an asymptomatic resident refuses testing, the facility should ensure the resident maintains appropriate > 6 feet

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distance from other residents, wears a mask, and practices effective hand hygiene until the outbreak has been closed.

B73 Testing FAQs 1. Do DPH staff also have to get tested as part of the facility staff testing requirement?

o Answer: No. Neither CMS nor CDPH testing requirements include DPH staff. Please see updated testing guidance on regular visitors who enter the facility more than once per week (under "Routine testing of staff and residents."

2. When can targeted testing be considered? o Answer: Targeted testing can be considered in selected scenarios only when a

facility’s testing capacity is limited in consultation with ACDC. 3. We have staff who work only 2 consecutive days every week; do they also need to be

tested twice per week? Also, in general, what is the minimum time frame that should occur between tests?

o Answer: Ideally, per CDPH, results from prior test should be available by the time the next test takes place. We realize that many laboratory’s TAT may not support this, so the recommendation is for a minimum of 48 hours between testing. All facility staff should get tested twice weekly, and this can be achieved by testing at an outside testing site as long as the facility receives appropriate documentation from the staff.

4. If a recently positive resident has finished isolation, still <90 days of prior infection, and asymptomatic is then exposed by being a close contact (e.g. roommate of a positive case) or by being in the same unit/wing where a positive case in either staff or resident was identified, do they still need to be quarantined and tested?

o Answer: Yes, they should still need to be quarantined for 14 days on Yellow Cohort status with appropriate transmission-based precautions signage (N95 respirator, eye protection, gown, glove, hand hygiene) and closer monitoring of symptoms and vital signs including oxygen saturation, but does not need to be tested. If the resident at any point becomes symptomatic, they should be treated as any other symptomatic resident and be tested in the Yellow Cohort.

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

1. Green Cohort: This cohort is reserved for residents who do not have COVID-19. To be in this cohort, residents must have either completed quarantine, cleared isolation, have tested negative and remained asymptomatic after last negative testing, or they are fully vaccinated as per below:

o Fully vaccinated residents who frequently leave the facility for medical appointments (e.g. dialysis residents)

o Fully vaccinated residents who leave for non-medical reasons o Fully vaccinated newly admitted or re-admitted residents.

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2. Red Cohort (Isolation Area). This area is only for patients who have laboratory-confirmed COVID-19 with or without symptoms, regardless of vaccination status. Patients may be transferred to the Green Cohort once they have completed the appropriate isolation period as follows:

a. For symptomatic residents: At least 20 days have passed since symptoms first appeared; and, At least 24 hours have passed since last fever without the use of antipyretic

medications and Improvement in symptoms (e.g., cough, shortness of breath).

b. For asymptomatic residents without severe immunosuppressing conditions with laboratory-confirmed COVID-19: At least 14 days have passed since the date of first positive COVID-19

diagnostic test without the development of symptoms of COVID-19. If they develop symptoms during this 14-day period, the isolation period

should be restarted from the onset of symptoms per the symptomatic resident criteria outlined above.

c. For asymptomatic residents with severely immunosuppressing conditions: At least 20 days from the date of first positive COVID-19 diagnostic test

without the development of symptoms of COVID-19. If they develop symptoms during this 20-day period, the isolation period

should be restarted from the onset of symptoms per the symptomatic resident criteria outlined above.

The following are considered severely immunosuppressing conditions: actively receiving chemotherapy for cancer, HIV with CD4 count <200, immunodeficiency disorder, prednisone dose >20mg/day for more than 14 days, receipt of immunosuppressive medications (biologics, etc.) for treatment of autoimmune disease, or other form of immunosuppression as determined by the patient’s primary physician.

3. Yellow Cohort (Mixed quarantine & symptomatic cohort) . This cohort is for the following residents:

Regardless of vaccination status Close contacts to a known COVID-19 case Residents who have symptoms of COVID-19 pending test results including

atypical symptoms. Residents with indeterminate test results All residents on the unit or wing where a case was identified in a resident or

HCP. All exposed residents can remain in their current rooms unless sufficient private rooms are available. Signage indicating appropriate precautions should be placed outside of these residents’ rooms.

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Unvaccinated or partially vaccinated

Newly admitted or re-admitted residents. Those who frequently leave the facility for medical appointments (e.g.

dialysis residents) should be grouped together in the Yellow Cohort. Those who leave the facility for a non-medical reason should be placed in

the Yellow Cohort upon return to the facility; exceptions can be made on a case-by-case basis. Please see CDPH AFL 20-86for further guidance on “COVID-19 Infection Control Recommendations during Holiday Celebrations,” including factors to consider in determining the risk of exposure to COVID-19.

a. Private rooms should be prioritized for residents with typical COVID-19 symptoms (acute respiratory symptoms), close contacts, and those with indeterminate test results as they have a higher probability of infection. However, if private rooms are limited or unavailable, then symptomatic residents, especially residents with atypical symptoms, and their roommates should remain in their current rooms with appropriate transmission-based precautions as appropriate for the Yellow Cohort.

b. For multi-occupancy rooms, strategies to reduce exposures between residents should be implemented: Residents with similar risk profiles should be placed in the same room (e.g., group low risk admissions in the same room). Curtains should be placed between resident beds. Staff should change gowns and gloves with appropriate hand hygiene between each patient contact in the same room.

Residents may leave the Yellow Cohort under these circumstances:

c. If their test result is positive for COVID-19, they should be moved into the Red Cohort.

d. Newly admitted and readmitted patients must stay in quarantine in the Yellow Cohort for 14 days from the date of admission at the SNF.

e. Close contacts and exposed residents to confirmed cases must stay in quarantine in the Yellow Cohort for 14 days. They should be tested on admission and again at the end of quarantine. Negative post-quarantine result permits the residents to be transferred to the Green Cohort.

f. Residents with COVID-19 symptoms should remain in the Yellow Cohort until either: One negative PCR test AND at least 10 days have passed AND at least 24

hours since last fever without fever-reducing medication AND improvement in symptoms (preferred). or

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Two negative PCR tests at least 24 hours apart AND improvement in symptoms AND at least 24 hours since last fever without fever-reducing medication.

g. 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.

h. Symptomatic residents who are not tested (e.g. resident refusal) should remain in the Yellow Cohort preferably in a single-occupancy room for at least 20 days since symptom onset AND at least 24 hours since last fever without fever-reducing medication AND improvement of symptoms.

i. Asymptomatic residents with indeterminate test results should remain in the Yellow Cohort until they either have a positive PCR test or they have 2 negative PCR tests at least 24 hours apart. This does not apply to new admissions, readmissions, close contacts, or exposed residents.

Figure 3. Cohorting

Special staffing considerations in cohort areas

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1. Staff assigned to the Red Cohort should not care for patients in other cohorts if possible. If staff must care for residents in multiple cohorts, they should visit the Red Cohort last and should doff PPE and perform hand hygiene prior to moving between cohorts.

2. With prior approval from Public Health, asymptomatic staff with lab-confirmed COVID-19 infection may be allowed to work in the Red Cohort. They will need to be able to keep separated from uninfected staff. This includes having dedicated breakrooms and bathrooms until they are no longer considered infectious (10 days after the date of collection of their initial positive test).

3. All staff in the facility should adhere to physical distancing of at least 6 feet while in break rooms and should wear masks while in the facility.

B73 Cohorting FAQs 1. Can asymptomatic, non-exposed, cleared residents be transferred between buildings on

the same facility premise without first going to the yellow zone as a new admission? o Answer: Yes, only if there is no ongoing outbreak in either building and if county

positivity rates are below 10%. “Premises” include, without limitation, the buildings, grounds, facilities, driveways, parking areas, and public spaces within the legal boundaries of the Facility.

2. Can a facility have more than one Yellow Cohort? o Answer:

It is preferred to have one physical Yellow Cohort. However, if a facility has layout restraints, Yellow and Green Cohorts can be treated as functional cohorts. For example, a facility could cohort their dialysis residents in a physically different area of the facility than their main Yellow Cohort but must have all the same Yellow Cohort requirements including transmission-based precautions.

Additionally, multiple Yellow Cohorts may naturally be created due to entire units/wings being considered exposed as described under “Yellow Cohort”, and based on CDPH AFL 20-74, which recommends managing these exposed residents in place, and not moving them all to one Yellow Cohort.

Regardless of configuration of Yellow and Green Cohorts, all resident rooms must always have clear signage indicating appropriate transmission-based precautions and corresponding required PPE for entry.

3. Are floor-to-ceiling partitions a written requirement or best practice for cohorting? o Answer: No, floor-to-ceiling partitions has not been written guidance on the

federal, state, or local levels in terms of COVID-19 infection prevention & control. They do not serve an infection control role as SARS-CoV-2 is not a true airborne transmissible disease. Sometimes, facilities may consider the use of physical barriers to discourage staff movement in and out of the Red Cohort, but they do not need to be floor-to-ceiling partitions. If floor-to-ceiling partitions are considered, they should be implemented in consultation with facility engineers and OSHPD for approval as they could impact the facility’s air balance and air flow.

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4. How soon can Red Cohort staff start working in the Yellow Cohort or Green Cohort? o Answer: As long as staff is following all infection prevention and control practices

including wearing appropriate PPE with correct donning and doffing, then they can start working in a different cohort/zone on a different day in a different shift. The staff should wear clean clothes for the different cohort.

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

General Considerations

1. California Department of Public Health (https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/AFL-20-52.aspx) guidance requires that facilities employ a full-time, on-site infection preventionist who will monitor compliance with infection control guidance.

2. CDPH also requires SNFs to have a CDPH-approved COVID-19-specific mitigation plan and to provide infection prevention and control training and updated infection control guidance to its HCP.

Universal Source Control

Patients/Residents

1. All patients/residents must be provided a clean mask daily. 2. Medical-grade surgical/procedure masks are required for any resident that is COVID-19-

positive or assumed to be COVID-19-positive. 3. All residents must wear a mask when outside their room, unless they have a

contraindication. This includes patients who must regularly leave the facility for care (e.g. hemodialysis patients).

4. Residents who due to underlying cognitive or medical conditions cannot wear a mask should not be forcibly required to wear one (and should not be forcibly kept in their rooms). However, masks should be encouraged as much as possible.

5. A mask should not be placed on anyone who has trouble breathing, or is unconscious, incapacitated, or otherwise unable to remove it without assistance.

6. Face shields with a drape may be offered to residents who are not able to wear masks. Staff

1. All HCP should wear a medical-grade surgical/procedure mask or respirator for universal source control at all times while they are in the facility.

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2. Please see Cohort-Specific Transmission Based Precautions and PPE section for appropriate mask use for each cohort.

Hand Hygiene (HH)

1. Healthcare personnel (HCP) and other staff members should perform HH before and after ALL patient encounters and should also use HH at the beginning of their shifts, before and after eating, after using the restroom, and at other times throughout the day.

2. Make sure HH supplies, such as soap and water or alcohol-based hand sanitizer, are readily accessible in all patient care areas, including areas where HCP remove PPE.

3. Sinks need to be well-stocked with soap and paper towels. Hand sanitizers should be replaced as needed.

4. Facilities should have a process for auditing adherence to recommended HH practices by the HCP.

5. Ensure that there are alcohol-based hand sanitizer dispensers at the PPE donning and doffing areas.

Respiratory Hygiene/Cough Etiquette:

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

every time they enter your facility. Transmission Based Precautions and Personal Protective Equipment (PPE)

HCP should follow transmission- based precautions for each cohort including standard precautions and wearing of appropriate PPE while providing patient care as detailed below.

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Figure 4. PPE in Each Cohort

1. General

a. Facilities must regularly audit their HCP’s adherence to appropriate PPE use. b. Post appropriate Transmission-Based Precautions signage outside of each resident

room: https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html#anchor_1564058318

c. Post signage on the appropriate steps for donning and doffing PPE in donning and doffing areas: lacounty.gov/acd/docs/CoVPPEPoster.pdf

d. Facilities should follow CDC’s strategies to optimize the supply of PPE and equipment (https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html).

e. If there are PPE shortages, the facility should make and document efforts to acquire more supply and can consider contacting Public Health’s PPE Coordinator by email for inquiries about PPE supplies: DPHPPECoordinator@ph.lacounty.gov

2. Standard Precautions for All Patient Care a. Gloves should be changed between every patient encounter. b. Hand hygiene should be performed before donning and after doffing gloves.

Please see above section on Hand Hygiene (HH) for more details. c. Respiratory hygiene/cough etiquette must be followed at all times including during

patient care. d. Environmental cleaning recommendations should be followed where applicable

before and after patient care. This includes properly disinfecting shared equipment, e.g., blood pressure cuffs and pulse oximeters before and after vital checks.

3. Droplet Precautions

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a. In the Green Cohort, surgical masks alone may be worn for duration of the shift in place of N95 respirators.

b. In the Yellow and Red Cohorts, N95 respirators should be worn. Please see N95 respirators section below.

c. In Yellow and Green Cohorts, eye protection, which is defined as a face shield or goggles, is recommended for close contact with patients (within 6ft), especially if the patient cannot reliably wear a face covering.

d. In the Red Cohort, eye protection is recommended to be worn for duration of shift. 4. Contact Precautions

a. Gowns should be changed between patients in all cohorts if adequate supplies are available, even in multi-occupancy rooms.

b. If there is a shortage of gowns, the same gown may be worn with multiple residents (extended use) in the Red Cohort as long as there are no other contact pathogens (difficile, CRE, Candida auris, etc.) that require changing between residents.

c. If there is a shortage of gowns, gowns may be prioritized for patient care that may result in exposure to body fluids and/or high contact activity in the Yellow Cohort.

d. The same gowns should never be worn for care of both COVID-19 positive and negative patients.

e. Re-use (over multiple days) of gowns is not allowed. 5. N95 respirators

a. In the Red Cohort, N95 respirator use should be worn for duration of the shift. b. In the Yellow Cohort, N95 respirator should be worn when providing for patient

care (within 6 ft). c. N95 respirators should be worn for all aerosol generating procedures (suction,

ventilation, CPR, nebulizer treatments, etc.) for all cohorts including the Green Cohort if the facility has an active outbreak.

d. N95 respirators with an exhaust valve do not provide source control and should not be used in healthcare settings.

e. Initial and annual N95 respiratory fit testing is required for all staff per California Division of Occupational Safety and Health (Cal-OSHA).

f. Cal-OSHA no longer allows for re-use (over multiple days) of N95 respirators, but still allows for extended use (with multiple residents in the same shift/day).

g. If there is a shortage of N95 respirators, facilities should make efforts to acquire more supply including documented communication with Public Health (see contact information above). If, despite these efforts, the facility is still experiencing a shortage, facilities could consider re-use of N95 respirators and must document their reasoning in a written risk assessment.

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Environmental cleaning:

In addition to CDC guidelines, the recommendations below are referenced from the California Department of Public Health AFL for Environmental Infection Control for the Coronavirus Disease 2019 (COVID-19).

1. Facilities must have a plan to ensure proper cleaning and disinfection of environmental surfaces (including high touch surfaces such as light switches, bed rails, bedside tables, etc.) and equipment in the patient room.

2. All staff with cleaning responsibilities must understand the contact time for the cleaning and disinfection products used in the facility (check containers for specific guidelines).

3. Ensure shared or non-dedicated equipment is cleaned and disinfected after use according to the manufacturer’s recommendations.

4. Routine cleaning and disinfection procedures (e.g., using cleaners and water to pre-clean surfaces prior to applying an EPA-registered, hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product’s label) are appropriate for COVID-19 in healthcare settings.

a. For a list of EPA-registered disinfectants that have qualified for use against SARS-CoV-2 (the COVID-19 pathogen) go to: https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2

5. Set a protocol to terminally clean rooms after a patient is discharged from the facility. If a known COVID-19 resident is discharged or transferred, staff should refrain from entering the room until sufficient time has elapsed for enough air exchanges to take place (more information on air exchanges at https://www.cdc.gov/infectioncontrol/guidelines/environmental/appendix/air.html#tableb6)

B73 Infection Prevention and Control FAQs 1. Can gowns be worn in the common areas, e.g. hallways, nursing stations, break rooms,

etc., including in the Red Zone? o Answer: No, that is no longer the recommendation since CDPH AFL 20-74 was

released on September 22, 2020 and as stated above under “Contact Precautions”. Extended use of gowns (using the same gown with more than one resident) is no longer allowed unless the facility is experiencing a shortage of gowns, for which extended use of gowns could be acceptable only in the Red Cohort and not for residents with known MDRO’s. Thus, gowns should be donned and doffed at resident room borders with each resident care encounter even in multi-occupancy rooms. Since gowns are doffed before exiting resident rooms, there should be no gown use in common areas, e.g. hallways, nursing stations, break rooms, etc. Similarly, gowns and gloves should not be donned upon entering the Red Cohort. If extended use of gowns is practiced including for Red Cohort residents, the facility should document the gown shortage and attempts to attain more gowns.

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2. Are there best practices for staff working at multiple facilities? o Answer: There is no written guidance on this. It would be recommended to change

into new clothes/scrubs for the next facility. 3. Are there special recommendations for facilities with memory care units or dementia,

behavioral, or psychiatric residents? o Answer: CDPH has a “COVID-19 and Memory Care Units Reference Sheet.”

Additionally, the concept of micro-cohorting, i.e. sub-dividing ambulatory dementia residents into smaller groups where they’re allowed to ambulate in the hallway of a small section of a unit/wing to mitigate the spread of the virus can be a consideration. Finally, we strongly encourage the facility to engage the resident’s family, designated representative, primary physician, medical director, and/or interdisciplinary team (IDT) in encouraging compliance with infection prevention recommendations (universal masking, staying in resident rooms) in creative ways that respects residents rights while protecting others.

4. What are the recommendations for residents taking showers? o Facility should establish and follow a written standardized protocol for bathing &

showering residents to include: i. In-room sponge baths are encouraged for residents in quarantine in Yellow

Cohort and isolation in Red Cohort. ii. For Yellow & Red Cohort residents who still need to shower, they should use

in-room/private showers (if available). If private showers are not available, then communal shower rooms should be dedicated for cohorts of the same COVID-19 status/risk category. Red Cohort residents should never use the same communal shower area or equipment (e.g. shower benches/chairs) with non-COVID-19 residents.

iii. If a resident is able to shower independently, they should continue to do so. iv. For Yellow & Red Cohort residents for whom showering is deemed necessary

and also needs assistance, please consider the following recommendations: • Assisting HCP must be able to wear and maintain safe use of all

recommended PPE while assisting residents with personal hygiene • Caution N95 respirators could slip off more easily when wet. • Wear water-proof PPE e.g. gowns, booties, face shields, shower cap,

etc. • Proper donning & doffing of PPE including hand hygiene should be

strictly adhered to • Utilize DME’s like shower chairs/benches, grab bars, etc. for residents

to support themselves as much as possible so that direct contact between resident and HCP can be minimized

• Only the minimum number of HCP needed to assist with bathing should be in the communal shower room at any moment

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• Attempt to bathe/shower resident with resident facing away from HCP as much as possible

• Encourage resident to wear a face mask and/or face shield as much as possible, especially when resident is facing HCP

• Educate residents from talking loudly or singing during shower process (potentially aerosolizing)

v. Showering should be spaced out to allow proper cleaning and disinfection of bathroom surfaces with EPA-approved healthcare-grade disinfectant between each use that is clearly documented, e.g. cleaning log.

• Most facilities have 2-4 air exchanges per hour and it takes about 2-3 hours to clear out particles that are suspended in the air. Hence it would be prudent when shared showers are used (not recommend particularly during an OB), to space out use by 3 hours while cleaning and disinfecting the areas (EVS staff to use full PPE including N-95 masks).

o Please also involve HVAC service providers/consultants to evaluate for possible improvements to the exhaust system/fan to increase exhausted air from the shower room.

Healthcare Personnel Monitoring and Return to Work Monitoring

1. 1. All HCP should be checked for symptoms and fever at least once per shift, including at the beginning of shifts.

2. If HCP have symptoms, they should stay home from work and contact the health care facility (HCF) immediately to arrange for medical evaluation and/or testing as soon as possible.

3. HCF should inquire about symptoms of COVID and do temperature checks of all HCP prior to the start of working their shifts AND at the end of the shift.

4. Identify staff who can monitor sick staff with daily “check-ins” using telephone calls, emails, and texts.

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

Return to Work for Symptomatic HCP and for HCP with Confirmed COVID-19

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Facilities are required to follow relevant sections in the LAC DPH Guidance for Monitoring Health Care Personnel.

Inter-facility Transfers Facilities are required to follow transfer rules as listed on the LAC DPH website (http://publichealth.lacounty.gov/acd/NCorona2019/InterfacilityTransferRules.htm).

OUTBREAK RESPONSE MEASURES 1. Once an outbreak has been identified, facilities should immediately implement the

following measures. a. Immediately initiate standard, contact, droplet precautions, plus N95 respiratory

use and eye protection for all suspect or confirmed residents with fever and/or respiratory symptoms.

b. Increase environmental cleaning throughout the facility to 3 times a day (if possible) with emphasis on high touch surfaces particularly in the unit where the resident was located.

c. If you have not already done so, ensure that you are using an approved cleaning agent: List N: Disinfectants for Use Against SARS-CoV-2.

2. Discontinue indoor group activities and communal dining for relevant residents depending on vaccination status and county tier status (please see Communal Dining, Group Activities, & Visitation section). For residents where indoor communal dining is not permitted, serve meals in resident rooms. For residents where indoor communal dining and group activities are still permitted, keep the same groups together to decrease the risk of exposure. All communal dining and group activities that must still be continued should adhere to social distancing and universal source control when possible.

3. For any transfers out of the building, notify EMS and the receiving facility of possible exposures.

4. Consider discharge of any patients that can be cared for in the home setting. 5. Restrict visitors as per Visitation section. 6. Continue to monitor all residents for fever and respiratory symptoms (i.e. cough, sore

throat, shortness of breath) until 14-day after the last COVID-19 case has recovered. 7. Lab testing of symptomatic residents should be done through a commercial lab, if

possible. 8. Response testing should be done as described in testing section above. 9. If the facility is not able to do testing on their own, they will be placed in a prioritization

scheme by ACDC. Testing requests to ACDC will not be honored unless the Area Medical Director (AMD) believes there is an urgent need for testing outside of the priority.

10. Hold new admissions of patients without COVID-19 to units where ongoing transmission of COVID may be occurring. If the SNF has separate floors or buildings that do not have evidence of COVID transmission after response testing, AMD may elect to resume new

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admissions to the facility. Facilities should continue to re-admit returning residents. Please refer to Interfacility Transfer Rules for most up to date guidance.

11. Implement a line listing of all HCP, residents, and visitors with symptoms. 12. Notify all HCPs who were exposed to the resident within 48 hours before the onset of

symptoms regarding the potential for exposure and instruct them to self-monitor for fever and respiratory symptoms twice a day for 14 days. Refer to LAC DPH Guidance for Monitoring Healthcare Personnel regarding restriction from work depending on vaccination status (http://publichealth.lacounty.gov/acd/ncorona2019/healthfacilities/HCPMonitoring/ ).

13. Monitor all HCP (regardless of contact with a case) for fever, cough, and shortness of breath. Symptomatic HCP may not work, regardless of vaccination status.

14. Instruct the facility to notify District Public Health Nurse (DPHN) assigned to the facility immediately if any resident or staff report fever or respiratory symptoms.

15. Notify DPHN immediately if any HCP contact tests positive for COVID-19. 16. For symptomatic HCPs, ensure they are not working and recommend the following:

a. Testing should be performed through the SNF testing plan. If the SNF is unable to perform testing, testing through the PHL may be arranged if approved by the AMD.

b. Instruct the facility to notify DPHN to arrange for testing. 17. Check all HCPs for fever (>100.0° F) and respiratory symptoms at least at the beginning of

the shift. For confirmed HCP cases who are symptomatic, ensure the HCP self-isolates for at least 10 days have passed since symptoms first appeared AND at least 24 hours have passed since last fever without the use of fever-reducing medications AND symptoms (e.g., cough, short of breath) have improved. HCP with high risk exposures (exposure to high-hazard aerosol-generating procedure without mask or eye protection) to COVID-19 should be excluded from work for 14 days. HCP can return to work after 14 days if they have never had symptoms. Refer to LAC DPH Guidance for Monitoring Healthcare Personnel and a companion guidance, CDC Criteria for Return to Work for Healthcare Personnel with Confirmed or Suspected COVID-19 (Interim Guidance).

For asymptomatic confirmed HCW cases, Refer to LAC DPH Guidance for Monitoring Healthcare Personnel.

Special situations for long-term care facilities to consider

1. Residents who have possible symptoms of COVID-19 should be transferred to the YELLOW (mixed quarantine) cohort immediately and tested. They should be placed in single rooms if possible, or cohorted together until testing is performed.

2. Residents who test positive should be transferred to the RED (COVID-19 positive) cohort. 3. Symptomatic residents may be moved back into the GREEN (Non-COVID-19) cohort if

they meet either of the two criteria listed in "Yellow Cohort" under "Cohorting" section. Residents who test negative for COVID-19 should be tested for influenza and other

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respiratory pathogens as per LAC DPH's guidance on management of influenza in context of COVID-19 in SNFs.

4. Any positive COVID-19 PCR tests of residents in the GREEN cohort should trigger response testing of the residents and HCP of the facility, should be identified as an outbreak and should warrant outbreak response measures.

5. For partially vaccinated and unvaccinated residents receiving dialysis outside of the facility, notify their dialysis center and request that they be dialyzed in “isolation.” Dialysis residents should be placed in the Yellow Cohort.

6. Consider substituting metered dose inhalers for nebulizers to reduce the risk of aerosolization.

ADMISSIONS AND READMISSIONS TO SNFs DURING AN OUTBREAK 1. In an outbreak situation, admission of new residents (new admissions) and returning

residents (readmissions) should be permitted unless closure is approved by the AMD. 2. The decision to close admissions, in collaboration with HFID, should be recommended

based upon a number of factors. Consider closing the facility to admissions if the following are concerns:

a. Immediate jeopardy for infection prevention & control concerns by licensing b. Concerning rates of adverse outcomes including hospitalizations and deaths c. Evidence of concerning viral transmission based on response testing of residents d. Inability to cohort residents per protocol

i. Inability to effectively quarantine new admissions and readmissions ii. Inability to effectively dedicate COVID and non-COVID areas in the facility

e. Lack of effective infection control practices as evidenced by a virtual or on-site infection control visit

f. Inadequate supply of PPE g. Staffing shortages reported

CLOSURE CRITERIA Outbreak can be closed once closure criteria is met:

1. Two consecutive weeks of response testing in residents have been negative; OR 2. 14 days from the last onset of a symptomatic case if response testing is not being

performed based upon the assessment of the AMD; OR 3. Upon the discretion of the AMD or MD designee. 4. Prior to closure, all the following documents must be completed:

a. PHN uploads all documents into IRIS and completes all required documents in IRIS per protocol.

b. PHNS reviews and forwards to AMD. c. PHN or PHNS can close COVID-19 outbreak in IRIS after approval by AMD or AMD

delegated physician. Closure letter will be signed by AMD or AMD delegate and placed in IRIS under the filing cabinet.

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Exceptions to routine closure:

1. If the facility becomes a COVID-designated facility upon approval by ACDC, outbreak can be closed after consultation with AMD.

2. If baseline/mass testing is delayed and is done in a facility after the facility meets other closure criteria, the outbreak may be closed and any asymptomatic positive cases found during baseline/mass testing should be isolated, but the outbreak should not be re-opened unless there are additional symptomatic or confirmed cases in residents.

GUIDELINES FOR OPENING A NEW OUTBREAK AFTER CLOSURE For facilities that are conducting response driven testing

1. The outbreak cannot be closed until two weeks of testing are completed, demonstrating no additional transmission.

2. If a single new case in a resident who has not tested positive in the past 90 days is identified after two weeks of negative testing, the facility should be opened as a new outbreak.

o Once the NEW outbreak has been opened under a NEW outbreak number, PHN can manage the facility with the following abbreviated procedures:

i. Contact the facility to reinforce infection control recommendations. ii. Determine if there are any infection control barriers or deficiencies with

cohorting, staffing, PPE, etc. iii. Ensure facility is able to conduct response testing. iv. Monitor site for new cases weekly until investigation can be closed. v. Documentation to include the epi form, line list, and clearance letter. The

notification letter and HOO are optional upon the discretion of the MD assigned to the investigation.

o NOTE: A facility with a single case can accept new admissions if there are no infection control barriers/challenges, if the facility is able to properly cohort residents, if the facility has an adequate quarantine area to receive the residents, and is compliant with response testing requirements.

o If >2 cases are identified at the facility or if the facility admits to substantial infection control barriers or deficiencies, then consider managing the OB with standard OB procedures, including daily check-ins and onsite/virtual visits as appropriate.

DEATH REPORTING DPHN must be notified of a death and the facilities will need to complete and submit a death report form to ACDC.