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 From the California Department of Public Health

May 22, 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)

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 a recommendation for baseline, surveillance and response-driven testing of SNF residents and HCP to prevent spread of infection in the facility. 

​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) that includes:

  • Baseline testing for all SNF residents and HCP for any facility that does not currently have a positive case
  • Testing residents prior to admission or readmission, including transfers from hospitals or other healthcare facilities.  If the hospital does not test the patient, the SNF must test and quarantine upon admission.
  • Residents admitted from the hospital should be tested prior to admission and if they test negative, should be quarantined[1] for 14 days and then retested.  If negative, the resident can be released from quarantine.
  • Testing of symptomatic or exposed residents
  • An arrangement with laboratories to process tests. The test used should be able to detect SARS-CoV-2 virus (e.g., polymerase chain reaction (PCR)) with greater than 95 percent sensitivity, greater than 90 percent specificity, 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.
  • 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 treated as positive).
  • 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 3 days (72 hours) have passed since recovery, defined as a resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms (e.g., cough, shortness of breath); AND
      • at least 10 days have passed since symptoms first appeared.
    • 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 3 days (72 hours) have passed since recovery, defined as a resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms (e.g., cough, shortness of breath); AND
      • at least 10 days have passed since symptoms first appeared.
  • Surveillance testing:
  • In facilities without any positive COVID-19 cases: implement testing of 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 initial testing should be performed every 7 days until no new cases are identified in two sequential rounds of testing; the facility may then resume their regular surveillance testing schedule for HCP. Once a resident tests positive, no additional testing is needed for that resident.

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.

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 in two sequential rounds of testing; the facility may then resume their regular surveillance testing schedule. If testing capacity is not sufficient to serially retest all HCP, consider 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.

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 Steinecker 

Heidi W. Steinecker
Deputy Director

[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

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