Guidance for Limiting the Transmission of COVID-19 in Long-Term Care Facilities

Please note that this information has been superseded by a more recent item and is only retained here for reference.

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AFL 20-22.4 From the California Department of Public Health

August 25, 2020

TO: Long-Term Care Facilities
SUBJECT: Guidance for Limiting the Transmission of COVID-19 in Long-Term Care Facilities
(This AFL supersedes guidance provided in AFL 20-22.3)

All Facilities Letter (AFL) Summary

  • This AFL notifies long-term care (LTC) facilities of Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) guidance for improving their infection control and prevention practices to prevent the transmission of Coronavirus Disease 2019 (COVID-19), including revised guidance for visitation.
  • This AFL authorizes LTC facilities to temporarily modify their facility’s visitation policies in accordance with CMS and CDC COVID-19 guidance when necessary to protect the health and safety of residents, staff, and the public.
  • This AFL updates visitation guidance to require facilities to permit ombudsman to enter regardless of whether or not there is a COVID-19 outbreak.

Exception to Visitation Restrictions
The following are exceptions to a facility’s visitation restrictions:

  • Healthcare workers: Facilities should follow CDC guidelines for restricting access to healthcare workers. Healthcare workers, including those from the local county public health offices, should be permitted to come into the facility if they meet the CDC guidelines for healthcare workers.
  • Surveyors: CMS and CDPH are constantly evaluating their surveyors to ensure they do not pose a transmission risk when entering the facility. Any surveyor entering the facility are subject to screening for fever and COVID-19 symptoms and must wear appropriate PPE.
  • Ombudsman: Facilities must permit ombudsman in the facility. Any ombudsman representative entering the facility is subject to screening for fever and COVID-19 symptoms and must wear appropriate PPE.
  • Nursing students: Students obtaining their clinical experience as part of an approved nurse assistant, vocational nurse or registered nurse training program should be permitted to come into the facility if they meet the CDC guidelines for healthcare workers.
  • End of life visitation: For permitted visitors for end of life situations, those individuals:
    • Must be screened for COVID-19 symptoms
    • Must wear a surgical facemask while in the building
    • Restrict their visit to the resident’s room or other location designated by the facility
    • Should be reminded by the facility to frequently perform hand hygiene
  • Legal matters: Visitors must be permitted 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. Any visitor entering the facility is subject to screening for fever and COVID-19 symptoms and must wear appropriate PPE. 

Resuming Other Visitation
To resume visitation, facilities should refer to the “Recommended Nursing Home Phased Reopening for States” attachment in QSO 20-30 (PDF) and work with their local health department in determining the general community’s current reopening phase. Due to the elevated risk COVID-19 poses to SNF residents, CMS recommends that facility reopening should lag behind the general community by 14 days. Facilities experiencing an outbreak (i.e. one or more confirmed positive cases) should not resume visitation.

Facilities that meet the following conditions shall allow residents to designate one visitor per resident for inside facility visitation:

  • Case conditions in the community – There is a decline in the number of new cases, hospitalizations or deaths in the community.
  • Case status in the facility – Absence of any new COVID-19 cases in the facility for 14 days, either residents or staff.
  • Adequate staffing – No staffing shortages and the facility is not using a COVID-19 staffing waiver. 
  • Access to adequate testing – The facility has a testing plan in place in compliance with AFL-20-53.
  • An approved COVID-19 Mitigation Plan- The facility must maintain good regulatory compliance for safety.

Facilities unable to meet the conditions specified above may not resume in room facility visitation, but they shall provide outdoor and other visitation options, including but not limited to:

  • Allow scheduled visits on the facility premises where there is 6-feet or more physical distancing, and both residents and visitors where facial coverings with staff monitoring infection control guidelines. (i.e. large communal spaces, outdoor visits, drive-by visits or visit through a person’s window).
  • Offering alternative means of communication for people who would otherwise visit, such as virtual communications (phone, video-communication, etc.).
  • Creating/increasing listserv communication to update families, such as advising not to visit.
  • Assigning staff as primary contact to families for inbound calls and conduct regular outbound calls to keep families up to date.
  • Offering a phone line with a voice recording updated at set times (i.e. daily) with the facility’s general operating status, such as when it is safe to resume visits.

Visitation Guidance

  1. For all visitations, facilities should make efforts to allow for safe visitation for residents and loved ones.
    • Ensure visitor screening for fever and COVID-19 symptoms
    • Visitors and residents should have facial coverings (cloth masks or surgical face masks)
    • Staff should monitor to physical distancing is practiced with no hand-shaking, hugging, and remaining six feet apart.
    • If possible (i.e. pending design of building), creating dedicated visiting areas near the entrance to the facility where residents can meet with visitors in a sanitized environment. Facilities should disinfect rooms after each resident-visitor meeting.  
  2. Advise visitors, and any individuals who entered the facility (e.g., hospice staff), to monitor for signs and symptoms of respiratory infection for at least 14 days after exiting the facility. If symptoms occur, advise them to self-isolate at home, contact their healthcare provider, and immediately notify the facility of the date they were in the facility, the individuals they were in contact with, and the locations within the facility they visited. Facilities should immediately screen the individuals of reported contact, and take all necessary actions based on findings.
  3. For medically necessary trips away from the facility, the resident must wear a cloth face covering or a surgical facemask and the facility must share the resident’s COVID-19 status with the transportation service and entity with whom the resident has the appointment.
  4. All staff must wear appropriate PPE when they are interacting with residents, to the extent PPE is available and consistent with CDC guidance on optimization of PPE. Staff should wear cloth face covering if surgical facemask is not indicated.  
  5. Once baseline testing is complete implement either surveillance or response driven testing based on the conditions at the facility in accordance with
  6. Have dedicated space in the facility for cohorting and managing care for residents with COVID-19; plan to manage new/readmission with an unknown COVID-19 status and residents who develop symptoms.

Additional Guidance
The following are additional CMS guidance to prevent the spread of COVID-19. This guidance is subject to revision by CMS at any time. 

  1. Cancel communal dining and all group activities, such as internal and external group activities. For COVID-19 negative or asymptomatic residents, communal dining should be limited, but residents may eat in the same room with social distancing (limited number of people at tables and spaced by at least 6 feet).
  2. Remind residents to practice social distancing and perform frequent hand hygiene. Residents must wear cloth face covering or facemasks as mandated in CDPH’s Guidance for the Use of Face Coverings (PDF).
  3. Facilities should identify staff that work at multiple facilities (e.g., agency staff, regional or corporate staff, etc.) and actively screen and restrict them appropriately to ensure they do not place individuals in the facility at risk for COVID-19.
  4. Facilities should review and revise how they interact with vendors and receiving supplies, agency staff, EMS personnel and equipment, transportation providers, and other non-health care providers (e.g., food delivery, etc.), and take necessary actions to prevent any potential transmission. 

CDPH understands the importance of maintaining contact with family and friends to LTC residents. If you have any questions about this AFL, please contact your local district office.


Original signed by Heidi W. Steinecker

Heidi W. Steinecker
Deputy Director