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

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AFL 20-53.2 From the California Department of Public Health 

July 31, 2020

TO: Skilled Nursing Facilities

SUBJECT: Coronavirus Disease 2019 (COVID-19) Mitigation Plan Recommendations for Testing of Health Care Personnel (HCP) and Residents at Skilled Nursing Facilities (SNF) (This AFL supersedes AFL 20-53.1)

All Facilities Letter (AFL) Summary

  • This AFL provides recommendations from the California Department of Public Health (CDPH) for SNFs developing COVID-19 Mitigation Plans. This includes recommendations for baseline, surveillance and response-driven testing of SNF residents and HCP to prevent spread of infection in the facility.
  • This AFL updates testing guidelines, isolation guidelines, and HCP return to work criteria to reflect recent changes to the Centers for Disease Control and Prevention (CDC) guidance.
  • The AFL also highlights the Department of Health and Human Services recent announcement of the Point of Care (POC) rapid response-testing instrument to bolster each SNF’s ability to prevent the spread of COVID-19 and increase testing options.

General Testing Guidance
SNFs have been severely impacted by COVID-19, with outbreaks causing high morbidity and mortality. The vulnerable nature of the SNF population combined with the inherent risks of congregate living in a healthcare setting requires aggressive efforts to limit COVID-19 exposure and to prevent the spread of COVID-19 within SNFs.

Establishing a plan for baseline, surveillance, and response-driven testing of SNF residents and HCP is necessary to protect the vulnerable SNF population.

CDPH recommends SNFs include testing strategies informed by the Centers for Disease Control and Prevention (CDC) recommendations in their COVID-19 Mitigation plans (announced in AFL 20-52). This plan should be developed in conjunction with CDPH and their local health department (LHD) and include:

  • Baseline testing for all SNF residents and HCP for any facility that does not currently have a positive case.
  • Testing newly admitted residents prior to admission, including transfers from hospitals or other healthcare facilities. If the hospital does not test the patient, the SNF must test and quarantine upon admission. Results for asymptomatic patients tested in the hospital do not have to be available prior to SNF transfer. SNFs may not require a negative test result prior to accepting a new admission. If tested at the hospital, two negative tests are not required prior to transfer. 
  • Residents newly admitted from the hospital should be tested prior to admission and should be quarantined [1] for 14 days and then retested.  If negative, the resident can be released from quarantine. SNF may consider acute care hospital days as part of the quarantine observation period from the date of last potential exposure for new admissions as long as the following criteria are met:
    • SNF is in regular communication with their local health department (LHD) and/or the hospital infection preventionist and occupational health program, and there is no suspected or confirmed COVID-19 transmission among patients or staff at the hospital
    • SNF has verified (via the LHD or hospital) that the hospital is testing all patients upon admission and has designated COVID-19 unit(s) with dedicated staff and minimal cross-over
  • Testing and quarantine are not required for residents readmitted after hospitalization, or who leave the SNF for ambulatory care (e.g., emergency department or clinic) visits unless there is suspected or confirmed COVID-19 transmission at the outside facility, or for hospitalized residents that tested positive for COVID-19 and met criteria for discontinuation of isolation and precautions prior to SNF admission or readmission.
  • SNFs should consider periodic surveillance testing and cohorting for residents that regularly leave the SNF for dialysis, as well as surveillance testing for residents following hospitalization or ED visits.
  • Testing of symptomatic or exposed residents
  • An arrangement with laboratories to process tests. The test used should be an authorized nucleic acid or antigen detection assay for SARS-CoV-2 virus used as recommended for testing in nursing homes by CDC, with results obtained rapidly (e.g., within 48 hours). Antibody test results should not be used to diagnose someone with an active SARS-CoV-2 (the virus that causes COVID-19) infection. The Department of Health and Human Services recently announced that it will begin providing nursing homes with a Point of Care (POC) rapid response testing instrument to bolster each facility’s ability to prevent the spread of COVID-19.
  • A procedure for addressing residents or staff that decline or are unable to be tested (e.g., symptomatic resident refusing testing in a facility with positive COVID-19 cases should be managed with transmission-based precautions).
  • Plans for use and follow-up of test results, including:
  • How results will be explained to the resident or HCP
  • How to communicate information about any positive cases of residents or HCP in the facility to family members or responsible parties
  • How results (positive or negative) will be tracked for residents and HCP at the facility, and methods for communication of facility results with the local health department
  • How results will be used to guide implementation of infection control measures, resident placement, and HCP and resident cohorting
  • How results will be communicated to ensure appropriate management when residents are transferred to other congregate settings
  • Plans for serial retesting of residents and HCP who test negative and are still within 14 days of their last exposure to a positive resident or HCP in the facility
  • Plans to address potential staffing shortages if positive HCP are excluded from work 

SNFs must understand that testing does not replace or preclude other infection prevention and control interventions, including monitoring all HCP and residents for signs and symptoms of COVID-19, universal masking by HCP and residents for source control, use of recommended personal protective equipment, and environmental cleaning and disinfection. When testing is performed, a negative test only indicates an individual did not have detectable infection at the time of testing; individuals might have SARS-CoV-2 infection that is still in the incubation period or could have ongoing or future exposures that lead to infection.  

Baseline and Surveillance Testing of SNF Residents and HCP
Baseline and surveillance testing are critical steps to avoid outbreaks and protect vulnerable populations. 

  • Conduct baseline testing for all SNF residents and HCP for any facility that does not currently have a positive case
    • Residents that test positive and are symptomatic should be isolated until the following conditions are met:
      • At least 10 days have passed since symptom onset; AND
    • At least 24 hours have passed since resolution of fever without the use of fever-reducing medications; AND
    • Any other symptoms have improved
      NOTE: The timeframe from symptom onset could be extended to 20 days for individuals who are severely immunocompromised (e.g., currently receiving chemotherapy, or recent organ transplant), or who had critical illness (e.g., required intensive care).
  • Residents that test positive and are asymptomatic should be isolated for 10 days from the date of their positive test, as long as they have not subsequently developed symptoms, in which case the symptoms-based criteria for discontinuing isolation should be applied.  

    HCP who test positive and are asymptomatic can continue to work as long as they are only caring for residents with confirmed COVID-19, preferably in a cohort setting, and maintain separation from other HCP as much as possible (for example, use a separate breakroom and restroom) and wear a facemask for source control at all times while in the facility. Asymptomatic positive HCP may not care for residents who have not tested COVID-19 positive until at least 10 days from the date of their positive test.
  • HCP who test positive and are symptomatic should be excluded from work. They may return to work after the following conditions are met:
    • At least 10 days have passed since symptom onset; AND
    • At least 24 hours have passed since resolution of fever without the use of fever-reducing medications; AND
    • Any other symptoms have improved
      NOTE: The timeframe from symptom onset could be extended to 20 days for individuals who are severely immunocompromised (e.g., currently receiving chemotherapy, or recent organ transplant), or who had critical illness (e.g., required intensive care).
  • For residents or HCP previously diagnosed with COVID-19 who remain asymptomatic after recovery, retesting is not recommended within 3 months after the date of symptom onset for the initial COVID-19 infection or date of positive test for asymptomatic individuals. In addition, quarantine is not necessary in the event of close contact with an infected person.
  • Surveillance testing:
  • In facilities without any positive COVID-19 cases: implement testing of approximately 25 percent of all HCP every 7 days including staff from multiple shifts and facility locations. The testing plan should ensure that 100 percent of facility staff are tested each month.
    NOTE: State and local leaders may adjust the frequency of HCP testing based on community spread data and prevalence of the virus in the community.
  • In facilities with a positive COVID-19 case, implement response-driven testing as described, below.  

Response-driven Testing of Residents
As soon as possible after one (or more) COVID-19 positive individuals (resident or HCP) is identified in a facility, serial retesting of all residents who test negative upon the prior round of testing should be performed every 7 days until no new cases are identified among residents in two sequential rounds of testing; the facility may then resume their regular surveillance testing schedule for HCP.  If testing capacity is not sufficient to serially retest all residents, prioritize testing of residents on the same unit(s) where COVID-19 positive residents or HCP were identified.

Place residents into three separate cohorts based on the test results, accordingly:

  • Positive result
  • Negative result but exposed within the last 14 days
  • Negative result without known exposure within the last 14 days

The COVID-19 positive cohort should be housed in a separate area (building, unit or wing) of the facility and have dedicated HCP who do not provide care for residents in other cohorts and should have separate break rooms and restrooms if possible.

Additional testing considerations may include more frequent regular testing of residents who frequently leave the facility for dialysis or other services.

Facilities should follow CDC guidance to determine when a resident who tests positive should be included in subsequent facility-wide response testing (e.g., in response to a new outbreak). Residents who had a positive viral test in the past 3 months and are now asymptomatic do not need to be retested as part of facility-wide testing; testing should be considered again (e.g., in response to an exposure) only if it is 3 months after the date of onset of the prior infection.  For residents who develop new symptoms consistent with COVID-19 during the 3 months after the date of initial symptom onset, if an alternative etiology cannot be identified, then retesting can be considered in consultation with infectious disease or infection control experts. Quarantine, isolation and transmission based precautions, may also be considered during this evaluation based on consultation with an infection control expert, especially in the event symptoms develop within 14 days after close contact with an infected person.

Response-driven Testing of Healthcare Personnel
As soon as possible after one (or more) COVID-19 positive individuals (resident or HCP) is identified in a facility, serial retesting of all HCP should be performed every 7 days until no new cases are identified among residents in two sequential rounds of testing; the facility may then resume their regular surveillance testing schedule for HCP. If testing capacity is not sufficient to serially retest all HCP, prioritize testing HCP who worked on the unit with COVID-19 positive residents or are known to work at other healthcare facilities with cases of COVID-19.

In general, HCP with COVID-19 should be excluded from work. If staffing shortages result, facilities may allow asymptomatic HCP with suspected or confirmed COVID-19 (who are well enough to work) to provide direct care only for residents with confirmed COVID-19 following CDC Guidance on Mitigating Staffing Shortages, preferably in a cohort setting and maintain separation from other HCP as much as possible (for example, use a separate breakroom and restroom) and wear a facemask for source control at all times while in the facility.

HCP who had a positive viral test in the past 3 months and are now asymptomatic do not need to be retested as part of facility-wide testing; testing should be considered again (e.g., in response to an exposure) only if it is 3 months after the date of onset of the prior infection. For HCP who develop new symptoms consistent with COVID-19 during the 3 months after the date of initial symptom onset, if an alternative etiology cannot be identified, then retesting can be considered in consultation with infectious disease or infection control experts.

SNFs should submit proposed COVID-19 testing plans to their local Licensing and Certification Program District Office. An administrator or other appropriate representative, who physically works in the SNF, must submit a scanned copy of the mitigation plan and attestation.

SNFs may submit any questions about infection prevention and control of COVID-19 to the CDPH Healthcare-Associated Infections Program via email at HAIProgram@cdph.ca.gov or novelvirus@cdph.ca.gov.

If you have any questions about this AFL, please contact the CDPH Healthcare-Associated Infections Program via email at HAIProgram@cdph.ca.gov.

If you have any questions about state testing prioritization plans, please contact the Testing Taskforce at testing_taskforce@state.ca.gov.

Sincerely,

Original signed by Heidi W. Steinecker

Heidi W. Steinecker
Deputy Director

Footnotes:

[1] CDC Defines quarantine as separate and restrict the movement of people who were exposed to a contagious disease to see if they become sick. https://www.cdc.gov/quarantine/index.html

Resources:

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