AFL 20-67 From the California Department of Public Health
August 20, 2020
TO: Skilled Nursing Facilities
SUBJECT: Emergency Resident Transfers during the Coronavirus Disease 2019 (COVID-19) Pandemic
AUTHORITY: Title 22 California Code of Regulations (CCR) sections 72519, 72551, and 72553
Title 42 Code of Federal Regulations section 483.73
All Facilities Letter (AFL) Summary
This AFL provides guidance to skilled nursing facilities (SNFs) for evacuating and transferring residents in emergency situations during the COVID-19 pandemic.
Facilities must be prepared for natural disasters and emergencies such as wildfires, floods, earthquakes, and widespread serious illnesses. To keep residents and staff safe in emergency situations during the COVID-19 pandemic, the California Department of Public Health (CDPH) recommends all SNFs review and modify, as needed, their emergency plans to ensure COVID-19 infection control measures are addressed.
State and federal regulations require SNFs to develop and maintain an emergency preparedness plan that must be reviewed and updated at least annually. Components of the emergency plan and related policies and procedures include, but are not limited to, the following:
- Emergency transfer of residents who can be moved to other health facilities, including arrangements for safe and efficient transportation and transfer information
- Written agreements with other health facilities to receive residents in the event of limitation or cessation of operations to maintain the continuity of services to residents
- Emergency discharge of residents who can be safely discharged to the community
- Providing emergency care to incoming residents from other health facilities
- A system to track the location of on-duty staff and sheltered residents in the facility’s care during and after an emergency
- A system of medical documentation that preserves resident information, protects confidentiality of resident information, and secures and maintains the availability of records
Note: This is not an all-inclusive list of the emergency plan requirements. Please refer to state and federal regulations for more information.
Emergency Transfer Recommendations
In preparation for emergency situations during the COVID-19 pandemic, CDPH recommends facilities:
- Be aware and engage in regional planning efforts to transfer residents with COVID-19 to designated healthcare facilities, isolation sites, or alternate care sites with adequate staffing and personal protective equipment (PPE) supplies.
- Establish relationships with multiple healthcare facilities that may receive emergency transfer of residents.
- Ensure transfer agreements with other healthcare facilities are current.
- Review the emergency plan and modify, if needed, to include infection control measures for COVID-19, including communication of:
- The facility’s COVID-19 status, specifically:
- Whether there are current confirmed cases of COVID-19 among residents; and
- Whether there is ongoing COVID-19 transmission (newly identified COVID-19 positive residents or staff during the preceding 14 days)
- Each resident’s COVID-19 status, specifically:
- COVID-19 positive;
- COVID-19 exposed undergoing monitoring and serial testing;
- New admission undergoing 14-day observation; and
- COVID-19 negative with no known exposure
- Any residents with COVID-19 tests pending
- The facility’s COVID-19 status, specifically:
- Review emergency communication plan and ensure all contact information is current.
- Provide emergency preparedness training to staff and ensure staff are knowledgeable of emergency procedures.
When transferring evacuated residents during an emergency, residents in the same cohort group should be transported in the same vehicle; however; if this is not feasible, facilities should prioritize transporting COVID-19 positive residents in a separate vehicle. All residents should wear PPE (e.g. facemask) for source control wherever possible during transport. Transferring facilities must also ensure all residents’ medications, medical records, etc. are transferred.
For facilities receiving emergency transfer of evacuated resident(s), CDPH recommends facilities:
- Communicate with the transferring facility regarding space and staff availability (including availability of a designated COVID-19 area, staffing, and PPE), transportation, medical records, transfer information, medications, etc.
- If your facility does not have adequate space/staff to accept emergency transfer of residents, the transferring facility should escalate to local/state authorities. Coordination with local/state emergency authorities may include temporary relocation to an alternate care site or fairground until a more permanent placement can be found.
- Designate areas to receive evacuated resident(s).
- Ensure evacuated residents are wearing PPE (e.g. facemask) provided by the transferring facility.
- Ensure all residents’ medications, medical records, etc. are transferred.
- Cohort residents by COVID-19 status:
- COVID-19 negative with no known exposure and/or COVID-19 recovered (green area)
- COVID-19 exposed undergoing monitoring and serial testing (yellow-exposed area)
- New admission undergoing 14-day observation (yellow-observation area)
- COVID-19 positive (red area)
- Place residents in designated spaces according to COVID-19 status:
- Green area: rooms or units that do not include confirmed or suspected COVID-19 cases, but may include COVID-19 recovered individuals
- Yellow areas (separate exposed and observation areas): single-occupancy rooms or multi-occupancy room with 6 ft, or as far as possible, between beds and curtains closed
- Red area: single-occupancy rooms, or multi-occupancy room with other confirmed COVID-19 cases
- Symptomatic residents who have not yet been confirmed with a positive COVID-19 test should be prioritized for single-occupancy rooms
Facilities may refer to the Emergency Resident Transfers during COVID-19 (PDF) for a flowchart on receiving and cohorting evacuated resident(s).
Evacuated Facility Staff
Evacuated facility staff who have tested negative for COVID-19 may work in another facility to support relocated residents during an emergency if they are screened for symptoms and implement source control (e.g. facemask) at all times in the other facility. If facility staff become positive after the emergency and worked in the other facility during the two weeks prior or since the positive result, the other facility must be notified.
CDPH encourages facilities to sign-up with their respective county emergency medical services agency and/or local department of public health emergency communications system. Facilities should also notify CDPH if there is a change in a facility’s designated emergency contact.
If you have any questions about infection prevention and control of COVID-19, please contact the CDPH Healthcare-Associated Infections Program at HAIProgram@cdph.ca.gov or email@example.com.
If you have any questions about emergency plans or emergency transfer of residents, please contact your local district office.
Original signed by Heidi W. Steinecker
Heidi W. Steinecker
Emergency Resident Transfers during COVID-19 (PDF)
 Pursuant to AFL 20-52, COVID-19 mitigation plans must include policies in place for dedicated spaces within the facility to ensure separation of infected patients and for eliminating movement of healthcare personnel among those spaces to minimize transmission risk.