AFL 21-28.1 From the California Department of Public Health
TO: Skilled Nursing Facilities
SUBJECT: Coronavirus Disease 2019 (COVID-19) Testing, Vaccination Verification and Personal Protective Equipment for Health Care Personnel (HCP) at Skilled Nursing Facilities (SNF)
(This AFL supersedes AFL 21-28)
All Facilities Letter (AFL) Summary
This AFL requires SARS-CoV-2 diagnostic screening testing for healthcare personnel (HCP) in SNFs.
- The Public Health Order issued July 26, 2021 related to unvaccinated workers in high risk setting becomes effective August 9, 2021.
- This AFL requires SNFs to develop and implement processes for verifying the vaccination status of all HCP and for obtaining and tracking documentation of results of SARS-CoV-2 diagnostic screening testing from HCP who are unvaccinated or incompletely vaccinated and includes additional PPE requirements. These requirements are effective August 9th and should begin as soon as reasonably possible, with full compliance no later than August 23, 2021.
- This AFL revision notifies all facilities of the December 22, 2021 Public Health Order and requires HCP to be up to date with vaccinations and receive boosters by February 1, 2022, unless exempt. This revision also requires at least twice weekly COVID-19 testing for all HCP for unvaccinated exempt HCP and booster-eligible HCP who have not yet received their booster in long-term care settings. Facilities must begin testing of all booster-eligible HCP who have not yet received their booster by December 27, 2021 and be in full compliance by January 7, 2022.
- The California Department of Public Health (CDPH) strongly recommends that all HCP in SNFs (including those that are fully vaccinated and boosted) undergo at least twice weekly screening testing.
Coinciding with increasing circulation of more transmissible variants of the SARS-CoV-2 virus, COVID-19 cases are rising rapidly with the majority of cases occurring in unvaccinated individuals. The recent emergence of the Omicron variant further emphasizes the importance of vaccination, boosters, and prevention efforts, including testing and masking, needed to continue protecting against COVID-19. Early data also suggest the increased transmissibility of the Omicron variant is two to four times as infectious as the Delta variant. Recent evidence also shows that among healthcare workers, vaccine effectiveness against COVID-19 infection is also decreasing over time.
In an ongoing effort to ensure resident safety, and to minimize the spread of COVID-19 among vulnerable individuals, CDPH is requiring SNFs to develop and implement processes for verifying the vaccination status of all HCP, and for obtaining and tracking documentation of twice-weekly SARS-CoV-2 diagnostic screening testing of all unvaccinated exempt HCP and booster-eligible HCP who have not yet received their booster.
In accordance with Public Health Officer Order – Health Care Worker Vaccine Requirement issued December 22, 2021, CDPH is requiring HCP to be up to date with vaccinations and receive boosters by February 1, 2022, unless exempt. Additionally, all unvaccinated exempt HCP and booster-eligible HCP who have not yet received their booster must be tested for COVID-19 at least twice weekly. Facilities must begin testing of all booster-eligible HCP who have not yet received their booster by December 27, 2021 and be in full compliance by January 7, 2022.
CDPH strongly recommends that all SNF HCP (including those that are fully vaccinated and boosted) undergo at least twice weekly screening testing.
Options for Providing Proof of Vaccination:
Per the CDPH Guidance for Vaccine Records Guidelines & Standards, only the following modes may be used as proof of vaccination:
- COVID-19 Vaccination Record Card (issued by the Department of Health and Human Services Centers for Disease Control & Prevention or WHO Yellow Card) which includes name of person vaccinated, type of vaccine provided, and date last dose administered); OR
- a photo of a Vaccination Record Card as a separate document; OR
- a photo of the client’s Vaccination Record Card stored on a phone or electronic device; OR
- documentation of COVID-19 vaccination from a healthcare provider; OR
- digital record that includes a QR code that when scanned by a SMART Health Card reader displays to the reader client name, date of birth, vaccine dates and vaccine type; OR
- documentation of vaccination from other contracted employers who follow these vaccination guidelines and standards.
HCP may access their digital vaccination record by using the Digital COVID-19 Vaccine Record website.
In the absence of knowledge to the contrary, an employer may accept the documentation presented as valid. Facilities must have a plan in place for tracking verified worker vaccination status. Documentation of the verification must be kept on file at the facility and made available upon request by CDPH or the local public health department.
Updated Routine Diagnostic Screening Testing of Unvaccinated Exempt or Booster Eligible HCP
- HCP who are unvaccinated exempt or booster-eligible HCP who have not yet received their booster must undergo at least twice-weekly SARS-CoV-2 diagnostic screening testing.
- HCP who are unvaccinated exempt or booster-eligible HCP who have not yet received their booster that work no more than one shift per week must undergo weekly SARS-CoV-2 diagnostic screening testing, and the testing should occur within 48 hours before their shift
- HCP who are unvaccinated exempt or booster-eligible HCP who have not yet received their booster that work less often than weekly must undergo SARS-CoV-2 diagnostic screening testing, and the testing should occur within 48 hours before each shift
- HCP who are unvaccinated exempt or booster-eligible HCP who have not yet received their booster that do not work in areas where care is provided to patients, or to which patients do not have access for any purpose, must undergo weekly SARS-CoV-2 diagnostic screening testing
SNFs can provide antigen testing or polymerase chain reaction (PCR) testing to HCP. HCP may choose to use antigen or PCR tests provided by the SNF to satisfy this requirement. HCP that are unvaccinated or incompletely vaccinated shall be tested at the cadence specified above with either PCR testing or antigen testing. Any PCR (molecular) or antigen test used must either have Emergency Use Authorization by the U.S. Food and Drug Administration or be operating per the Laboratory Developed Test requirements by the U.S. Centers for Medicare and Medicaid Services.
HCP that are unvaccinated or incompletely vaccinated must observe all other infection control requirements, including masking, and are not exempted from the testing requirement even if they have a medical contraindication to vaccination, since they are still potentially able to spread the illness. Previous history of COVID-19 from which the individual recovered more than 90 days earlier or a previous positive antibody test for COVID-19 does not waive this requirement. HCP with COVID-19 should be excluded from work for the duration of their isolation period. SNFs should follow CDC Guidance on Mitigating Staffing Shortages, and CDC Return to Work guidance to determine when HCP may return to work.
For additional information about response testing, diagnostic testing of symptomatic HCP, diagnostic screening testing of asymptomatic fully vaccinated HCP, testing for patients, plans for use of test results, and procedures for work exclusion please refer to AFL 20-53.6.
Employers who conduct workplace diagnostic screening testing should have a plan in place for tracking test results, conducting workplace contact tracing and response testing, and reporting results to public health departments. There are IT platforms available that can facilitate these processes for employers. Employers should also consult CDPH/CDC guidance on workplace screening testing for additional cohort specific considerations. Testing is not a substitute for other COVID-19 prevention measures, such as vaccination, mask wearing, physical distancing, improved ventilation, hand hygiene and cleaning and disinfection.
Health care facilities should continue to implement strategies to increase, maintain, and track vaccination coverage among HCP as high as possible, including verifying vaccination status of new hires, and offering education, listening sessions, counseling, and vaccination at every opportunity, even to those HCP who have previously refused.
Additional Personal Protective Equipment and Masking for Unvaccinated HCP
The Aerosol Transmissible Disease (ATD) Standard (Title 8 of the California Code of Regulations section 5199) requires all employees working in an area or residence where a suspected or confirmed COVID-19 case is present to use National Institute for Occupational Safety and Health (NIOSH) approved respirators. An N95 is the minimum protection permitted for these employees. A higher level of respiratory protection is required for certain medical procedures. Health facilities are covered by the ATD Standard.
The COVID-19 Emergency Temporary Standard (ETS) (Title 8, sections 3205 – 3205.4) requires employers to provide NIOSH approved respirators, such as N95s, upon request to employees who are unvaccinated or incompletely vaccinated and who are working indoors or in vehicles with more than one person.
Pursuant to the July 26, 2021 Public Health Order, all facilities identified in the Order must strictly adhere to current CDPH Masking Guidance. To the extent they are already applicable, facilities must also continue to adhere to Cal/OSHA’s standards for Aerosol Transmissible Diseases (ATD) and Emergency Temporary Standards (ETS).
In addition to respirators required under Title 8 of the California Code of Regulations, facilities must provide respirators to all unvaccinated or workers who work in indoor work settings where (1) care is provided to patients or residents, or (2) to which patients or residents have access for any purpose. Workers are strongly encouraged to wear respirators in all such settings. The facility must provide the respirators at no cost, and workers must be instructed how to properly wear the respirator and how to perform a seal check according to the manufacturer’s instructions, if this has not already occurred.
If you have any questions about this AFL, please contact the CDPH Healthcare-Associated Infections Program via email at HAIProgram@cdph.ca.gov.
If you have any questions about state testing prioritization plans, please contact the Testing Taskforce at firstname.lastname@example.org.
Original Signed by Cassie Dunham
Acting Deputy Director
- CDPH Updated Testing Guidance
- CalREDIE Manual Lab Reporting Module (PDF)
- CMS QSO 20-38 (PDF)
- CDC Duration of Isolation and Precautions for Adults with COVID-19
- CDC Criteria for Return to Work for Healthcare Personnel with SARS-CoV-2 Infection (Interim Guidance)
- AFL 20-52 COVID-19 Mitigation Plan Implementation and Submission Requirements for SNFs and Infection Control Guidance for HCP
- Lab Resources for Testing
- Department of Managed Health Care COVID-19 webpage
- CDC Nursing Homes Testing Recommendations
- CDC Long-Term Care Facility Wide Testing
- Nursing Home Preparing for COVID-19
- CDC Guidance on Mitigating Staffing Shortages
- CDPH Guidance on the Use of Antigen Tests for Diagnosis of Acute COVID-19
- Public Health Order – Health Care Worker Protections in High-Risk Settings
- Public Health Order – Health Care Worker Vaccine Requirement
 People are considered fully vaccinated for COVID-19: two weeks or more after they have received the second dose in a 2-dose series (Pfizer-BioNTech or Moderna or vaccine authorized by the World Health Organization), or two weeks or more after they have received a single-dose vaccine (Johnson and Johnson [J&J]/Janssen).
 CDC Defines quarantine as separate and restrict the movement of people who were exposed to a contagious disease to see if they become sick. CDC Quarantine and Isolation
 Healthcare Personnel (HCP) refers to all paid and unpaid persons serving in healthcare settings who have the potential for direct or indirect exposure to patients or infectious materials, including body substances (e.g., blood, tissue, and specific body fluids); contaminated medical supplies, devices, and equipment; contaminated environmental surfaces; or contaminated air. HCP include, but are not limited to, nurses, nursing assistants, physicians, technicians, therapists, phlebotomists, pharmacists, students and trainees, contractual staff not employed by the healthcare facility, and persons not directly involved in patient care, but who could be exposed to infectious agents that can be transmitted in the healthcare setting (e.g., clerical, dietary, environmental services, laundry, security, engineering and facilities management, administrative, billing, and volunteer personnel). For purposes of this guidance, this does not include HCP in other buildings in a site containing a High-Risk Setting, such as a campus or other similar grouping of related buildings, unless such personnel do any of the following: (i) access the acute care or patient areas of the High-Risk Setting; or (ii) work in-person with patients who visit those areas.