AFL 22-13 From the California Department of Public Health
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 20-53.6)
All Facilities Letter (AFL) Summary
- This AFL incorporates updated recommendations from the California Department of Public Health (CDPH) for SNFs conducting diagnostic screening testing of SNF HCP and response testing of SNF residents and HCP to prevent spread of COVID-19 in the facility informed by CDC recommendations and Centers for Medicare and Medicaid Services requirements.
- This AFL includes updated CDC guidance related to quarantine and outbreak investigations.
- This AFL revision incorporates the January, 25 2022 amended Public Health Order requiring SNF HCP to receive boosters and complete their primary series and booster dose by March 1, 2022, unless exempt. This revision also updates the testing requirements to require twice weekly COVID-19 testing for unvaccinated exempt HCP and booster-eligible HCP who have not yet received their booster.
- CDPH continues to recommend that all HCP in SNFs (including those that have completed their primary series and booster dose) undergo at least twice weekly screening testing wherever feasible.
Updated Testing Guidance Based Upon COVID-19 Vaccination and Boosters
Routine SARS-CoV-2 diagnostic screening testing of SNF HCP, and response testing of SNF residents and HCP remain essential to protect the vulnerable SNF population. The purpose of this AFL revision is provide updated testing recommendations for SNF residents and HCP, and quarantine recommendations for residents, in the context of COVID-19 vaccination and boosters based on updated CDC guidance.
Additionally, in accordance with the Public Health Officer Order – Health Care Work Vaccine Requirement amended January 25, 2022, CDPH is requiring HCP to receive boosters, if eligible, and have completed their primary series by March 1, 2022, unless exempt. Unvaccinated exempt HCP and booster-eligible HCP who have not yet received their booster must undergo twice weekly COVID-19 testing. In addition, vaccinated workers that defer their booster dose based on documented previous infection in the last 90 days do not have to test during those 90 days, but must self-monitor for symptoms and continue to follow all other infection control requirements, including masking, as stated in the July 26 Order. Such workers must resume testing immediately after the 90 days if they are booster eligible but have not yet received their booster dose.
CDPH continues to recommend that all HCP in SNFs (including those that are fully vaccinated and boosted) undergo at least twice weekly screening testing wherever feasible.
In addition to the guidance provided below, facilities must comply with requirements set forth in the July 26, 2021 Public Health Order. For information on these requirements, please see AFL 21-28.1.
Routine Diagnostic Screening Testing of HCP
CDPH is requiring twice weekly COVID-19 testing for unvaccinated exempt HCP and booster-eligible HCP who have not yet received their booster in long-term care settings. SNFs must understand that:
- Testing should continue to be performed for HCP with signs or symptoms consistent with COVID-19, regardless of their vaccination status.
- Testing should continue to be performed for HCP with higher-risk exposures to SARS-CoV-2 (i.e., as part of response testing);
Testing and Quarantine for Newly Admitted and Readmitted Residents
CDC has updated testing and quarantine guidance for newly admitted and readmitted residents, based on their vaccination and booster status.
- Newly admitted residents and residents who have left the facility for >24 hours, regardless of vaccination status, should have a series of two viral tests for SARS-COV-2 infection; immediately upon admission and, if negative, again 5-7 days after their admission.
- Testing is still recommended prior to admission for residents who are unvaccinated, or who have completed their primary series and are booster eligible but not yet boosted, including transfers from hospitals or other healthcare facilities. SNFs may not require a negative test result prior to accepting a new admission, and should be prepared to isolate or quarantine new admissions as needed if suspected infection or exposure.
- Quarantine is not required for newly admitted and readmitted residents who are boosted, or have completed their primary series but are not yet booster eligible, or have recovered from SARS-CoV-2 infection in the prior 90 days and have not had high-risk contact (within close proximity, e.g. within 6 feet, for a cumulative total of 15 minutes or more over a 24-hour period) with someone with SARS-CoV-2 infection within the prior 10 days.
- Newly admitted residents and residents who have left the facility for >24 hours who are unvaccinated, or who have completed their primary series and are booster eligible but not yet boosted, should be quarantined in single rooms or a separate observation area (“yellow-observation”) for at least 7 days from the date of admission or last potential exposure until results are known for testing obtained within 5-7 days after their admission.
- Testing and quarantine are not required for hospitalized residents who tested positive for COVID-19 and met criteria for discontinuation of isolation and precautions prior to SNF admission or readmission and are within 90 days of their infection.
- SNFs should consider periodic (for example, weekly) diagnostic screening testing for unvaccinated and partially vaccinated residents who regularly leave the SNF for dialysis; in the absence of suspected or confirmed COVID-19 transmission at the dialysis center, residents who leave the facility for dialysis do not need to be quarantined in a “yellow-observation” or “yellow-exposed” area.
Diagnostic Testing for Symptomatic Individuals
Residents or HCP with signs or symptoms potentially consistent with COVID-19 should be tested immediately to identify current infection, regardless of their vaccination status; SNFs should not delay testing of symptomatic individuals until scheduled diagnostic screening or response-driven testing.
Updated CDC guidance continues to recommend immediate investigation as a potential outbreak when one (or more) COVID-19 positive individuals (resident or HCP) is identified in a facility.
In SNFs where ≥90% of residents and ≥90% of HCP who are boosted or have completed their primary series but are not yet booster eligible, and their LHD determines that contact tracing is feasible, the facility should perform contact tracing within the facility to identify any HCP who have had a higher-risk exposure or residents who may have had high-risk contact (within close proximity/6 feet for a cumulative total of 15 minutes over 24 hours) with the individual with SARS-CoV-2 infection:
- All HCP who have had a higher-risk exposure and residents who have had close contacts, regardless of vaccination status, should be tested promptly (but not earlier than 2 days after the exposure) and, if negative, again 5–7 days after the exposure.
- Residents who are unvaccinated, or who have completed their primary series and are booster eligible but not yet boosted and have had close contact with someone with SARS-CoV-2 infection should be placed in quarantine (“yellow-exposed” status) for at least 7 days after their exposure, even if viral testing is negative.
- Residents who are boosted, or have completed their primary series but are not yet booster eligible, and are close contacts should wear source control but do not need to be quarantined, restricted to their room, or cared for by HCP using the full personal protective equipment (PPE) recommended for the care of a resident with COVID-19.
- Refer to AFL 21-08.8 for guidance about work restriction for HCP who have higher-risk exposures.
- Quarantine and testing are not generally recommended for people who have had SARS-CoV-2 infection in the last 90 days if they remain asymptomatic.
If testing of close contacts reveals additional HCP or residents with SARS-CoV-2 infection, contact tracing should be continued to identify residents with close contact or HCP with higher-risk exposures to the newly identified individual(s) with SARS-CoV-2 infection. A facility-wide or group-level (e.g., unit, floor, or other specific area(s) of the facility) approach should be considered if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission.
In SNFs with <90% of residents and <90% of HCP who are boosted or have completed their primary series but are not yet booster eligible, or the facility or LHD determine that contact tracing is not feasible, serial retesting of all residents and HCP who test negative upon the prior round of testing (regardless of their vaccination status) should be performed every 3-7 days until no new cases are identified among residents in sequential rounds of testing over 14 days; the facility may then resume their previous routine diagnostic screening testing schedule for HCP.
Place residents into three separate cohorts based on the test results, regardless of their vaccination status:
- Positive result, for the duration of the resident’s isolation period (“red” area);
- Negative result but exposed (“yellow-exposed” area) until no new cases are identified among residents in sequential rounds of testing over 14 days; in general, all residents on the unit or wing where a case was identified in a resident or HCP are considered exposed and should remain in their current rooms unless sufficient private rooms are available.
- Negative result without known exposure and recovered residents who have completed their isolation period (“green” area).
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. SNFs that currently do not have any positive cases and do not have a current need for a red area should remain prepared to quickly reestablish the red area and provide care for, and accept admission of, COVID-19 positive residents.
If available, private rooms should be prioritized for residents with symptoms consistent with COVID-19, while testing is pending; if no private room is available, these residents should remain in their current rooms.
In general, testing is not necessary for asymptomatic residents or HCP who have recovered from SARS-CoV-2 infection in the prior 90 days; however, if testing is performed on these people, an antigen test instead of a molecular test (e.g., PCR) is recommended. This is because some people may remain positive on molecular (e.g., PCR) testing but not be infectious during this period. For residents or HCP who develop new symptoms consistent with COVID-19 during the 90 days after their prior infection, if an alternative etiology cannot be identified, then retesting can be considered in consultation with the medical director, infectious disease or infection control experts. Quarantine, isolation and transmission-based precautions may also be considered during this evaluation based on consultation with the medical director or an infection control expert, especially in the event symptoms develop within 14 days after close contact with an infected person.
Refer to AFL 21-08.8 for guidance about work restriction for HCP with exposures and for HCP who test positive.
Procedures for the Duration of Isolation of Residents Who Test Positive:
Residents Who Test Positive for COVID-19
- Residents who test positive and are symptomatic with mild to moderate illness should be isolated (regardless of their vaccination status) 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 duration of isolation could be extended to up to 20 days for individuals who had critical illness (e.g., required intensive care) and beyond 20 days for individuals who are moderately to severely immunocompromised (e.g., currently receiving chemotherapy, or recent organ transplant); use of a test-based strategy and (if available) consultation with an infectious disease specialist is recommended to determine when Transmission-based precautions could be discontinued for these individuals.
- Residents who test positive and are asymptomatic throughout their infection should be isolated for 10 days following the date of their positive test.
Reporting Test Results
Facilities conductin tests under a Clinical Laboratory Improvement Amendments of 1988 (CLIA) certificate of waiver are subject to regulations that require laboratories to report data for all testing completed, for each individual tested. CDPH has updated the requirements for reporting non-positive COVID-19 antigen results.
During focused infection control surveys, surveyors will be monitoring whether the facility is complying with the CLIA laboratory reporting requirements and reporting any concerns to the CMS Division of Clinical Laboratory Improvement and Quality. In addition to reporting in accordance with CLIA requirements, facilities must continue to report COVID-19 information to the CDC’s National Healthcare Safety Network, in accordance with 42 CFR section 483.80(g)(1)–(2). SNFs must demonstrate their compliance with testing requirements by documenting the following information:
- For symptomatic residents and staff, document the date(s) and time(s) of the identification of signs or symptoms, when testing was conducted, when results were obtained, and the actions the facility took based on the results.
- Upon identification of a new COVID-19 case in the facility (i.e., outbreak), document the date the case was identified, the date that all other residents and staff are tested, the dates that staff and residents who tested negative are retested, and the results of all tests.
- Document the facility’s procedures for addressing residents and staff that refuse testing or are unable to be tested, and document any staff or residents who refused or were unable to be tested and how the facility addressed those cases.
- When necessary, such as in emergencies due to testing supply shortages, document that the facility contacted state and local health departments to assist in testing efforts, such as obtaining testing supplies or processing test results.
- When a 48-hour turnaround time for testing cannot be met due to testing supply shortages, the facility should document its efforts to obtain quick turnaround test results with the identified laboratory or laboratories and contact to the local and state health department.
SNFs have submitted proposed COVID-19 testing plans to their local Licensing and Certification Program District Office. Although CDPH is no longer conducting separate mitigation surveys, SNFs should continue use of the strategies developed as part of their SNF Mitigation plans and integrate them into their infection control and emergency preparedness plans. As testing and mitigation strategies change based on updated CDC or CMS guidance, updated plans and policies and procedures will need to be revised. CDPH will be conducting State Monitoring Infection Control Mitigation Surveys which will look at some of the components of the prior SNF Mitigation Surveys and additional requirements associated with recently issued Public Health Orders.
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 PPE, 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.
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.
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 firstname.lastname@example.org.
Original signed by Cassie Dunham
- CDPH Updated Testing Guidance
- CalREDIE Manual Lab Reporting Module (PDF)
- CMS QSO 20-38 (PDF)
- CDC Duration of Isolation and Precautions for Adults with COVID-19
- CDC Criteria for Return to Work for Healthcare Personnel with SARS-CoV-2 Infection (Interim Guidance)
- AFL 20-52 COVID-19 Mitigation Plan Implementation and Submission Requirements for SNFs and Infection Control Guidance for HCP
- Lab Resources for Testing
- Department of Managed Health Care COVID-19 webpage
- CDC Nursing Homes Testing Recommendations
- CDC Long-Term Care Facility Wide Testing
- Nursing Home Preparing for COVID-19
- CDC Guidance on Mitigating Staffing Shortages
- CDPH Guidance on the Use of Antigen Tests for Diagnosis of Acute COVID-19
- Public Health Order – Health Care Worker Protections in High-Risk Settings
- Public Health Order – Health Care Worker Vaccine Requirement
 People are considered to have completed their primary series for COVID-19: after they have received the second dose in a 2-dose series (Pfizer-BioNTech or Moderna or vaccine authorized by the World Health Organization), or after they have received a single-dose vaccine (Johnson and Johnson [J&J]/Janssen).
 CDC Defines quarantine as separate and restrict the movement of people who were exposed to a contagious disease to see if they become sick. CDC Quarantine and Isolation
 According to CDC, screening testing is performed to identify persons who may be contagious so that measures can be taken to prevent further transmission, for example in a congregate living setting such as a skilled nursing facility. This was referred to as surveillance testing in prior versions of this AFL. The terminology change aligns with new CDC testing guidance.