Long-Term Care Facilities

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A new respiratory disease – coronavirus disease 2019 (COVID-19) – is spreading globally and there is community spread in the United States, including in Arizona. Long-term care facilities should assume COVID-19 is in their community and restrict all non-essential visitors to their facilities.

Overview with details:

Prevent the introduction of respiratory germs INTO your facility:

Ill visitors and healthcare personnel (HCP) are the most likely sources of introduction of COVID-19 into a facility. MCDPH and CDC recommends aggressive visitor restrictions and enforcing sick leave policies for ill staff, even before COVID-19 is identified in a community or facility.

  • Restrict all visitation except for certain compassionate care situations, such as end of life situations.
    • Decisions about visitation during an end of life situation should be made on a case by case basis, which should include careful screening of the visitor for fever or respiratory symptoms. Those with symptoms should not be permitted to enter the facility.
  • Restrict all volunteers and non-essential HCP, including non-essential healthcare personnel (e.g., barbers, consultants).
  • Cancel all group activities and communal dining.
  • Implement active screening of residents and healthcare workers for fever and respiratory symptoms.
  • Ensure sick leave policies allow employees to stay home if they have symptoms of respiratory infection.

Prevent the spread of respiratory germs WITHIN your facility:

Employee-specific guidance

  • Develop a system to regularly monitor all employees for fever and any respiratory symptoms. (For example, employees could be expected to monitor their temperature and any symptoms twice a day or before working a shift.)
  • Reinforce that employees should not report to work when ill.
  • Per CMS Guidance released on April 2, “For the duration of the state of emergency in [Arizona], all LTCF personnel should wear a face mask while they are in the facility.”
  • Per CMS Guidance released on April 2, “When possible, all long-term care facility residents, whether they have COVID-19 symptoms or not, should cover their noses and mouths when staff are in their room. Residents can use tissues for this. They could also use cloth, non-medical masks when those are available. Residents should not use medical face masks unless they are COVID-19-positive or assumed to be COVID-19-positive.”
  • Identify dedicated employees to care for COVID-19 patients and provide infection control training.
    • Guidance on implementing recommended infection prevention practices is available in CDC’s free online course — The Nursing Home Infection Preventionist Training — which includes resources and checklists for facilities and employees to use.
  • Provide the right supplies to ensure easy and correct use of PPE.
    • Post signs on the door or wall outside of the resident room that clearly describe the type of precautions needed and required PPE.
    • Make PPE, including facemasks, eye protection, gowns, and gloves, available immediately outside of the resident room.
    • Position a trash can near the exit inside any resident room to make it easy for employees to discard PPE.
  • Make sure that EPA-registered, hospital-grade disinfectants are available to allow for frequent cleaning of high-touch surfaces and shared resident care equipment.
    • Refer to the EPA list for EPA-registered disinfectants that have qualified under EPA’s emerging viral pathogens program for use against SARS-CoV-2.

Resident-specific guidance

  • Monitor residents for fever or respiratory symptoms.
  • Restrict residents with fever or acute respiratory symptoms to their room. If they must leave the room for medically necessary procedures or appointments, have them wear a facemask (if tolerated).
  • Implement the correct precautions for residents with respiratory infection.
    • For care of residents with an undiagnosed respiratory infection use Standard, Contact, and Droplet Precautions with eye protection unless a suspected diagnosis requires Airborne Precautions (e.g., tuberculosis).
  • Encourage good hand and respiratory hygiene, as well as cough etiquette by residents, visitors, and employees.
    • Ensure employees clean their hands according to CDC guidelines, including before and after contact with residents, after contact with contaminated surfaces or equipment, and after removing personal protective equipment (PPE).
    • Put alcohol-based hand rub in every resident room (ideally both inside and outside of the room).
    • Make sure tissues are available and any sink is well-stocked with soap and paper towels for hand washing.

Prevent the spread of respiratory germs BETWEEN facilities:

  • Notify facilities prior to transferring a resident with an acute respiratory illness, including suspected or confirmed COVID-19, to a higher level of care.
  • Report any possible COVID-19 illness in residents and employees to the local health department.
  • HCP who work in multiple locations may pose higher risk and should be asked about exposure to facilities with recognized COVID-19 cases.
    • Consider encouraging staff to work at only one facility.
  • When transmission in the community is identified, nursing homes and assisted living facilities may face staffing shortages. Facilities should develop (or review existing) plans to mitigate staffing shortages.

Evaluate and Manage Residents with Symptoms of Respiratory Infection

  • Ask residents to report if they feel feverish or have symptoms of respiratory infection.
  • Actively monitor all residents upon admission and at least daily for fever and respiratory symptoms.
    • If a resident has fever or respiratory symptoms, implement recommended infection control practices.
    • In general, when caring for residents with undiagnosed respiratory infection, use Standard, Contact, and Droplet Precautions with eye protection unless the suspected diagnosis requires Airborne Precautions (e.g., tuberculosis). This includes restricting residents with respiratory infection to their rooms. If they leave the room, residents should wear a facemask.
  • The health department should be notified about residents with severe respiratory infection, or a cluster (e.g., ≥3 residents or healthcare personnel with new-onset respiratory symptoms over 72 hours) of people with respiratory infections.

If a resident with COVID-19 is diagnosed in my facility

  • Facilities should notify the health department immediately and follow CDC recommendations for PPE.
  • Facilities should implement universal use of facemask for healthcare personnel while in the facility.
  • Healthcare personnel should wear all recommended PPE (gown, gloves, eye protection, face mask) for the care of all residents, regardless of presence of symptoms. Implement protocols for extended use of eye protection and facemasks.
  • Encourage residents to remain in their room and restrict movement except for medically necessary purposes.
    • If residents leave their room, residents should wear a facemask, perform hand hygiene, limit their movement in the facility, and perform social distancing (stay at least 6 feet away from others).
  • Room sharing (“cohorting”) might be necessary if there are multiple residents with known or suspected COVID-19 in the facility. As roommates of symptomatic residents might already be exposed, it is generally not recommended to separate them in this scenario.
  • If possible, designate a ward or section of the facility for COVID-19 patients with dedicated staff.
  • Implement protocols for having dedicated healthcare personnel caring for cohorted residents with COVID-19.

If employees develop any symptoms consistent with COVID-19 (fever or respiratory symptoms) they must:

  • Cease contact with residents.
  • Put on a facemask immediately (if not already wearing).
  • Notify their supervisor or occupational health services prior to leaving work.

If you are concerned a resident could have COVID-19:

What to do if employees have had a known exposure to COVID-19:

  • Allow asymptomatic employees to continue to work after consultation with their occupational health program. Use your monitoring system to ensure exposed employees are monitored daily for the 14 days after the last exposure.
  • If the long-term care facility has a sufficient supply, healthcare personnel who were not wearing recommended PPE during the COVID-19 exposure could be asked to wear a facemask while at work for the 14 days after the exposure.

For Further Guidance

Recordings of MCDPH Webinars for Long-Term Care Facilities (Register to join live every Tuesday):