Coronavirus Disease 2019 (COVID-19) Mitigation Plan Implementation and Submission Requirements for Skilled Nursing Facilities (SNF) and Infection Control Guidance for Health Care Personnel (HCP)

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AFL 20-52 From the California Department of Public Health

May 11, 2020

TO: Skilled Nursing Facilities

SUBJECT: Coronavirus Disease 2019 (COVID-19) Mitigation Plan Implementation and Submission Requirements for Skilled Nursing Facilities (SNF) and Infection Control Guidance for Health Care Personnel (HCP)

AUTHORITY: Title 22 of the California Code of Regulations section 72573 (c)

All Facilities Letter (AFL) Summary

This AFL advises SNFs of the requirement to submit a facility specific COVID-19 mitigation plan with specified elements to the California Department of Public Health (CDPH) within 21 calendar days and provides updated infection control guidance for HCP.

Facility Mitigation Plans

Due to the higher risk of severe illness and death from COVID-19 among elderly persons and those with chronic medical conditions, CDPH is requiring all SNFs to expand their existing infection control policies to include the development and implementation of a CDPH approved COVID-19 mitigation plan. SNFs must submit a mitigation plan to CDPH within 21 calendar days. Failure to implement an approved COVID-19 mitigation plan may result in an immediate jeopardy. The mitigation plan must include the following six elements:

  1. Testing and Cohorting. The SNF will develop a plan in conjunction with CDPH and their local health department (LHD) for regular testing of residents and staff, including how test results will be used to inform resident and HCP cohorting.
  2. Infection Prevention and Control. The SNF must have a full-time, dedicated Infection Preventionist (IP). This can be achieved by more than one staff member sharing this role, but a plan must be in place for infection prevention quality control. CDPH’s Healthcare-Associated Infections Program has developed training materials for SNF IP staff. The SNF must ensure HCPs receive infection prevention and control training and can work with the department to develop a reasonable implementation timeline and plan to bring on the necessary IP staff.
  3. Personal Protective Equipment (PPE). The SNF must have a plan for adequate provision of PPE, including types that will be kept in stock, duration the stock is expected to last and information on established contracts or relationships with vendors for replenishing stock.
  4. Staffing Shortages. The SNF must have policies in place to address HCP shortages, including contingency and crisis capacity strategies.
  5. Designation of Space. The SNF must have policies in place for dedicated spaces within the facility to ensure separation of infected patients and for eliminating movement of HCP among those spaces to minimize transmission risk. In the event the facility cannot designate space, they are to communicate the limitation to their local public health department and CDPH Licensing district office.    
  6. Communication. A designated staff member has been assigned responsibility for daily communications with staff, residents, and their families regarding the status and impact of COVID-19 in the facility.

Mitigation Plan Visit

Each facility will receive a visit from CDPH to validate its certification at least every six to eight weeks. If CDPH determines that facility is not implementing its approved mitigation plan and identifies unsafe practices that have or are likely to cause harm to patients, CDPH may take enforcement action including calling an immediate jeopardy situation which may result in a civil penalty. 


Polymerase Chain Reaction (PCR) testing for COVID-19 infection is becoming more readily available at hospitals, academic, commercial, and public health laboratories across California. Governor Newsom and the Testing Task Force are committed to rapidly expanding the availability of testing across California, ensuring that more Californians get tested. Counties and facilities should refer to AFL 20-44.1 for guidance on expanded access to testing when prioritizing COVID-19 testing for SNF staff and residents. If necessary, CDPH can assist facilities with acquiring access to testing. 

Face Coverings, Masks and Respirators

To account for the role of asymptomatic and pre-symptomatic transmission, CDC’s infection control guidance recommends source control for everyone entering a healthcare facility (including, HCP, patients, and limited visitors), regardless of symptoms. Cloth face coverings may be worn in the facility by patients and the limited number of allowable visitors but should not be considered PPE for HCP because their capability to protect HCP is unknown and they should not be worn instead of a respirator or facemask during the provision of patient care.

HCP should continue to wear their respirator or facemask (implementing extended use) while in the healthcare facility instead of intermittently switching back to their cloth face covering, possibly causing self-contamination. HCP should remove their respirator or facemask and put on their cloth face covering when leaving the facility at the end of their shift. Previous guidance on the optimization of PPE and implementation of extended use can be found in AFL 20-36.1 and AFL 20-39.

Visitors and patients should be wearing their own cloth face covering upon arrival to the facility per CDC recommendations to the general public. If they are not, they should be offered a facemask or cloth face covering, as supplies allow, and instructed to wear it while in the facility.

This recommendation does not change CDC’s guidance for HCP to use N95 or equivalent respirators when providing care for patients with suspected or known COVID-19 infection.

Facilities that do not have sufficient supplies of N95s or equivalent respirators should prioritize their use for activities and procedures that pose high risks of generating infectious aerosols, using facemasks for care that does not involve those activities or procedures. Facilities should continue to purchase supplies through their normal supply chain as availability is improving. Once the adequate availability of supplies is reestablished, N95s and equivalent respirators use should resume for all HCP caring for these patients.

Contingency and Crisis Strategies to Address Staffing Shortages

The Centers for Disease Control and Prevention (CDC) released guidance on mitigating HCP staffing shortages for healthcare facilities experiencing staffing shortages due to HCP exposures, illness, or need to care for family members at home. This guidance includes contingency and crisis capacity strategies that healthcare systems and facilities can consider in coordination with their local health departments (LHD).

SNFs should plan for implementing contingency capacity strategies when anticipating staffing shortages, including, but not limited to, the following:

  • Determining the minimum number of staff needed to provide a safe work environment and patient care.
  • Identifying additional HCP to work in the facility pursuant to state emergency waivers or changes in licensing or certification requirements.
  • Contacting the Medical Heath Coordination Center call-in line for immediate staffing needs. All facilities must report directly to the coordination center before proceeding to evacuation.
  • SNF will provide CDPH District Office with list of available positions they are hiring for and CDPH may assist in connecting with available health care workers in the area.
  • CDPH will work with SNFs to address social factors that might prevent HCP from reporting to work such as transportation or housing if HCP live with vulnerable individuals and provide the SNF with any available solutions for the geographic area.
  • Developing plans to allow asymptomatic HCP who have had an unprotected exposure to COVID-19 to continue to work under specified conditions.

Resident Transfers

Facilities should also 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. Facilities should refer to AFL 20-25.2 for a toolkit for management of exposures and recognized cases in SNFs.

SNFs should submit proposed COVID-19 mitigation plans to their Licensing and Certification Program District Office. SNFs may submit any questions about infection prevention and control of COVID-19 to the CDPH Healthcare-Associated Infections Program via email at or

An administrator or other appropriate representative, who physically works in the SNF, must submit a scanned copy of the mitigation plan and attestation.


Original signed by Heidi W. Steinecker

Heidi W. Steinecker
Deputy Director