Movement of Patients/Residents in the Healthcare Continuum During Seasonal Surges and the Coronavirus Disease 2019 (COVID-19) Pandemic

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AFL 20-87.1 From the California Department of Public Health

November 15, 2021

TO: Skilled Nursing Facilities
General Acute Care Hospitals

SUBJECT: Movement of Patients/Residents in the Healthcare Continuum During Seasonal Surges and the Coronavirus Disease 2019 (COVID-19) Pandemic
(This AFL supersedes AFL 20-87)

All Facilities Letter (AFL) Summary

  • This AFL provides guidance for admission and readmission of skilled nursing facility (SNF) residents during seasonal hospital surges and the COVID-19 pandemic.
  • This AFL provides guidance on working with local public health departments (LHD) and hospital discharge planners to ensure appropriate placement of resident following hospital discharge.
  • This AFL revision includes updated guidance based on residents’ vaccination status.


As transmissible variants of the SARS-CoV-2 virus circulate in California, COVID-19 incidents continue, with the vast majority of cases occurring in unvaccinated individuals. Despite the availability of safe and highly effective COVID-19 vaccines, many individuals remain unvaccinated and are at high risk of acquiring COVID-19 and exposing SNF residents and health care personnel (HCP).

In an ongoing effort to ensure resident safety and to minimize the spread of COVID-19 among vulnerable individuals, the California Department of Public Health (CDPH) is revising this AFL to include updated guidance from the Centers for Disease Control and Prevention (CDC) on vaccination. This includes considerations for SARS-CoV-2 testing and quarantine of new SNF admissions and readmissions during an outbreak. CDPH is providing this guidance to SNFs and general acute care hospitals to support safe, appropriate, and timely access to SNF care following acute hospitalization.

Seasonal Surges During the COVID-19 Pandemic

As we move into the influenza season with the co-occurrence of COVID-19, anticipated surges in hospital admissions and emergency department (ED) visits can affect hospital capacity when SNFs do not accept new admissions or readmissions of residents from hospitals. This barrier to hospital discharges will lead to SNF residents remaining in the acute care hospital for longer than medically necessary. At the same time, SNFs must be operationally prepared to safely and appropriately accept admissions or readmissions in relation to acceptable staffing levels, adequate supply of personal protective equipment (PPE), appropriate separate zones within the facility, and following applicable testing strategies. Hospitals should proactively communicate with SNFs early to facilitate transfers. SNFs should work collaboratively with hospital discharge planners and LHD to facilitate the safe and appropriate placement of SNF residents. SNFs should be prepared to provide care safely without putting existing residents at risk during the COVID-19 pandemic and upcoming influenza season. Additionally, facilities that experience critical staffing shortages may refer to AFL 21-08.5 Guidance on Quarantine for Health Care Personnel (HCP) Exposed to SARS-CoV-2 and Return to Work for HCP with COVID-19. Facilities experiencing urgent staffing needs may also request resources through their local Medical Health Operational Area Coordinator using the process described in AFL 20-46.3

Testing and Quarantine for Newly Admitted and Readmitted Residents

The CDC has updated testing and quarantine guidance for newly admitted and readmitted residents, based on their vaccination status.

  • Testing and quarantine is no longer required for newly admitted and readmitted residents if they are fully vaccinated (i.e., ≥2 weeks following receipt of the second dose in a 2-dose series, or ≥2 weeks following receipt of one dose of a single-dose vaccine) and have not had prolonged close contact (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 14 days.
  • Regardless of vaccination status, residents who have prolonged close contact (within 6 feet for a cumulative total of 15 minutes or more over a 24-hour period) with someone with SARS-CoV-2 infection while outside the facility should quarantine in the yellow-observation area for 14 days and be tested immediately, at 5-7 days after exposure, and again prior to return to their usual room in green-unexposed/recovered area.
  • Testing is still recommended for unvaccinated or partially vaccinated newly admitted residents prior to admission, including transfers from hospitals or other healthcare facilities.  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. Two negative tests are not required prior to transfer. 
  • Unvaccinated or partially vaccinated residents newly admitted from the hospital should be quarantined in single rooms or a separate observation area (“yellow-observation”) for 14 days and then retested. If negative, the resident can be released from quarantine.
  • SNFs may consider acute care hospital days as part of the quarantine observation period for unvaccinated or partially vaccinated new admissions as long as the following criteria are met:
    • SNF is in regular communication with their LHD and/or the hospital infection preventionist and/or occupational health program, and there is no suspected or confirmed COVID-19 transmission among patients or staff at the hospital.
    • In general, an acute care hospital stay is not considered an exposure unless that hospital is having a suspected or confirmed outbreak.
  • Testing and 14-day quarantine are recommended for unvaccinated or partially vaccinated residents readmitted after hospitalization or who leave the SNF for more than 24 hours, as well as for residents who leave the SNF for ambulatory care (e.g., ED, outpatient procedures, dialysis, or other clinic visits) when there is suspected or confirmed COVID-19 transmission at the outside facility.
  • Testing is recommended for unvaccinated or partially vaccinated resident who leave the SNF for less than 24 hours and are readmitted. Residents should be tested 5-7 days after their return.
  • 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.
  • 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.

Procedures for the Duration of Isolation of Residents

Residents who test positive and are symptomatic 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 timeframe from symptoms onset could be extended up 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 who test positive and are asymptomatic throughout their infection should be isolated for at least 10 days following the date of their positive test.

COVID-19 Recovered Residents

CDC recommends against the use of the test-based strategy (two tests 24 hours apart) to discontinue isolation and transmission-based precautions for SARS-CoV-2 positive individuals, except under special circumstances. Facilities should use the symptoms or time-based strategy for discontinuing isolation and transmission-based precautions for SARS-CoV-2 positive individuals. COVID-19 recovered individuals who have met criteria for discontinuation of isolation and transmission-based precautions and:

  • Are within 90 days of a positive test can be admitted to the green “recovered” area of a SNF
  • More than 90 days have passed since their prior positive test should be admitted to the “yellow” observation area of the SNF for 14 days since the date of their last potential new exposure

Facilities may refer to the following for additional guidance on resident placement and cohorting based on COVID-19 and influenza status:

Limitations on New Admissions during an Outbreak

Many LHDs require SNFs to close to new admissions during an outbreak until transmission is contained; for COVID-19 outbreaks, containment is generally evidenced by two sequentially negative rounds of response testing among residents over 14 days, and for influenza, containment is generally evidenced by no new cases for one week.  However, demonstration of containment should not be the sole basis for determining closures to new admissions. Particularly during hospital surges, LHD should consider the following factors to allow flexibility for SNFs to continue admitting new residents before outbreak containment is demonstrated:

  • SNF has implemented outbreak control measures, as appropriate, such as response testing, cohorting, dedicated staff for the COVID-19 positive zone with no crossover, transmission-based precautions, and chemoprophylaxis (for influenza, assuming adequate availability).
  • SNF has no staffing shortage or operational problems (e.g., administrator or director of nursing out sick). SNF must have a trained infection preventionist. Long term staffing plans should be documented.
  • SNF has adequate PPE, staff from all shifts have access to N95 respirator fit testing and all staff have been fit-tested to the respirator model(s) currently available for use in the facility, and access to adequate hand hygiene and environmental cleaning supplies.
  • SNF has a well-demarcated “yellow” COVID-19 observation area (unit or wing) for new admissions.

Request for Admission/Transfer Review or Guidance

CDPH requests that hospitals or SNFs that encounter difficulty in transitioning new or returning residents from an acute care hospital to a SNF based on their COVID-19 status or COVID-19-related admission hold, contact the LHD, or the healthcare associated infections program of CDPH for review of the admission decision and suggestions for next steps. 

LHDs and their acute hospital and SNF partners are encouraged to proactively communicate on issues relating to SNF access, and the implications for regional capacity and surge planning, and to collaborate on development and dissemination of policies most appropriate for their specific county. 


SNFs may submit any questions about infection prevention and control of COVID-19 to the CDPH Healthcare-Associated Infections Program via email at or

If you have any questions about this AFL, please contact your local district office.


Original signed by Cassie Dunham

Cassie Dunham
Acting Deputy Director