Guidance for Limiting the Transmission of COVID-19 in Skilled Nursing Facilities (SNFs)

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AFL 22-07 From the California Department of Public Health

February 7, 2022

TO: Skilled Nursing Facilities

SUBJECT: Guidance for Limiting the Transmission of COVID-19 in Skilled Nursing Facilities (SNFs)
(This AFL supersedes AFL 20-22.9)

All Facilities Letter (AFL) Summary

  • This AFL notifies SNFs of updated CDPH, 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 COVID-19, including guidance for visitation.
  • This AFL provides CDPH guidance for group activities and communal dining based upon vaccination status of residents.
  • This AFL requires SNFs to develop and implement processes for verifying the vaccination status of all visitors, and for obtaining and tracking documentation of SARS-CoV-2 diagnostic test of all visitors.
  • This AFL updates restrictions on visitation and also removes outdated exemptions to visitation restrictions.

Background

On November 12, 2021, CMS revised QSO 20-39-NH (PDF) with updated guidance for visitation. During the COVID-19 pandemic, CDPH enforced visitation restrictions for SNFs to mitigate the transmission of COVID-19; however, a large percentage of residents and staff are now fully vaccinated and are obtaining boosters. In light of increased vaccination rates and the value SNF residents derive from the physical, emotional, and spiritual support they receive through visitation from family and friends, CDPH is revising this AFL to align with updated CMS guidance to further expand visitation.    

While further expanding visitation opportunities for SNF residents, CMS and CDPH continue to require that visits are conducted in a manner that adheres to the core principles of COVID-19 infection prevention and does not increase risk to other residents.

As transmissible variants of the SARS-CoV-2 virus continue to circulate in California, the vast majority of COVID-19 cases are occurring in unvaccinated individuals. Despite the availability of safe and highly effective COVID-19 vaccination, many individuals remain unvaccinated and are at high risk of acquiring COVID-19 and exposing SNF residents and health care personnel. 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 visitors seeking indoor visitation, and for obtaining and tracking documentation of SARS-CoV-2 diagnostic test of all unvaccinated visitors. In compliance with the Public Health Order issued February 7, 2022, beginning February 8, 2022, SNFs must verify visitors are fully vaccinated or have provided evidence of a negative SARS-CoV-2 test within one day of visitation for antigen tests, and within two days of visitation for PCR tests for indoor visitation. Visitors that are unvaccinated or incompletely vaccinated or are unable to show a negative SARS-CoV-2 test may only have an outdoor visit.   

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 Card1) 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.

Visitors may access their digital vaccination record by using the Digital COVID-19 Vaccine Record website.

In the absence of knowledge to the contrary, SNFs may accept the documentation presented as valid. Facilities must have a plan in place for tracking verified visitor 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 for one year following the end of the public health emergency.

Visitor Testing Requirements:

Unvaccinated visitors seeking indoor visitation must show documentation of a negative SARS-CoV-2 test where the specimen collection occurred within two days if using PCR or one day if using antigen testing before each visit and for which the test results are available at the time of entry to the facility. For visitors who visit for multiple consecutive days proof of negative test is only required every third day (meaning testing is only required on day one, day 4 and day 7, and so on).

Unvaccinated or incompletely vaccinated visitors with history of COVID-19 within the prior 90 days may provide documentation of recovery from COVID-19 in lieu of testing.

Visitors may choose to use antigen or molecular (e.g., PCR testing) to satisfy this requirement. Any 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. SNFs can offer onsite point-of-care testing of visitors (either performed by facility staff, or observed self-testing) but are not required.

Visitors who are visiting a resident in critical condition, when death may be imminent, are exempt from the vaccination and testing requirements, however, must comply with all infection control and prevention requirements applicable for indoor visits. 

General Visitation Guidance

Facilities shall conduct visitation through different means; however, facilities must adhere to the core principles of COVID-19 infection prevention (PDF) at all times. Visitation should be person-centered, consider the residents’ physical, mental, and psychosocial well-being, and support their quality of life. SNFs must also enable visits to be conducted with an adequate degree of privacy and should be allowed at times convenient to visitors (e.g., outside of regular work hours).

At this time, vaccinated SNF residents and HCP should continue to follow current guidance to protect themselves and others, including wearing a mask, avoiding crowds and poorly ventilated spaces, covering coughs and sneezes, washing hands often, and following guidance for personal protective equipment use and SARS-CoV-2 testing.

Any visitor entering the facility, regardless of their vaccination status, must adhere to the following:

  • All visitors, regardless of their vaccination status, must be screened for fever and COVID-19 symptoms and/or exposure within the prior 14 days to another person with COVID-19; if a visitor has COVID-19 symptoms or has been in close contact with a confirmed positive case, they must reschedule their visit, regardless of their vaccination status.
  • All visitors, regardless of their vaccination status, must wear a well-fitting face mask with good filtration (N95, KF94, KN95, or surgical masks are preferred over cloth face coverings) and perform hand hygiene upon entry and in all common areas in the facility; 
  • If personal protective equipment (PPE) is required for contact with the resident due to quarantine or COVID-19 positive isolation status (including fully vaccinated visitors), it must be donned and doffed according to instruction by HCP.
  • Facilities should limit visitor movement in the facility, regardless of the visitor’s vaccination status; for example, visitors should not walk around the hallways of the facility and should go directly to and from the resident’s room or designated visitation area.

Visitors who have tested positive for COVID-19 should not be permitted to visit or should be asked to leave if they are still within their isolation period (within 10 days of their positive test). Under such circumstances, facilities must offer alternatives for remote (Skype, etc.) or telephone visitation. Staff should provide monitoring for those who may have difficulty adhering to core principles, such as children.

If a SNF resident is not able to leave their room or otherwise meet with visitors outdoors, the visitation may take place indoors even for visitors who cannot provide vaccine verification or a negative test; however, these visits cannot take place in common areas, or in the resident’s room if the roommate is present, and the visitor must wear a well-fitted mask with good filtration (N95, KF94, KN95, or surgical masks are preferred over cloth face coverings) and the resident must wear a well-fitting face mask at all times and physically distance.

Indoor, In-Room and Large Communal Space Visitation Requirements

Facilities shall allow indoor in-room visitation for:

  • All residents, regardless of vaccination status, in “green” (unexposed or recovered), “yellow” (exposed or observation status) and “red” (isolation) areas.

Indoor in-room visitation shall meet the following conditions:

  • Facilities must verify vaccination status or document evidence of a negative test of the visitor within 48 hours if using PCR or 24 hours if using antigen testing of the indoor visit.
  • Indoor visits must be conducted with both the resident and visitor wearing a well-fitting face mask. If both the resident and visitor are fully vaccinated, they do not need to physically distance and can include physical contact (e.g., hugs, holding hands) but must wear a well-fitting face mask while in the resident’s room unless eating or drinking.
  • Visits for residents who share a room should be conducted in a separate indoor space or with the roommate not present in the room (if possible), regardless of the roommate’s vaccination status.
  • Visitors should be provided personal protective equipment (gloves, gown, eye protection and N95 respirator) and instructed in a N95 respirator seal check for visitation of residents in yellow (exposed or observation status) and red (isolation) areas.

Facilities shall also accommodate visitation in large communal indoor spaces for residents who are not in isolation or quarantine:

Indoor spaces used for visitation such as a lobby, cafeteria, activity room, physical therapy rooms, etc. should be arranged to accommodate 6-ft distancing between visitor-resident groups. Facilities should assess the maximum number of resident-visitor groups that can be accommodated while maintaining physical distancing between groups in communal indoor spaces designated for visitation; when the maximum is reached, visits will need to be conducted in the resident’s room (if appropriate) or outdoors (preferably).

During indoor large communal space visits between residents and visitors who are all fully vaccinated, both the resident and visitor must always wear a well-fitting face mask unless eating or drinking while in designated spaces for visitation. These visits may be conducted without physical distancing and include physical contact (e.g., hugs, holding hands).

Continuing Outdoor Visitation Requirements

All facilities must continue to allow outdoor visitation options for all residents, regardless of vaccination status. Outdoor visits pose a lower risk of transmission due to increased space and airflow; therefore, outdoor visitation should be offered unless the resident cannot leave the facility, or outdoor visitation is not possible due to precipitation, outdoor temperatures, or poor air quality. When providing outdoor visitation facilities should facilitate visits on the facility premises (e.g., visits on lawns, patios, and other outdoor areas, drive-by visits, or visit through a window) with 6-ft or more physical distancing between visitor-resident groups, and staff monitoring of infection control guidelines. Visitors that are unvaccinated or incompletely vaccinated may only have an outdoor visit.

Outdoor visits between residents and all visitors who are fully vaccinated, must be conducted with face masks and may include physical contact (e.g., hugs, holding hands). Visits between residents or visitors that are unvaccinated or incompletely vaccinated should be conducted with well-fitting face masks during the visit.

Other Visitation Options in Addition to Outdoor and Communal Spaces

In addition, to maximize visitation opportunities and keep residents and families connected, facilities are encouraged to:

  • Offer alternative means of communication for people who would otherwise visit, including virtual communications (phone, video-communication, etc.).
  • Assign staff as primary contact to families for inbound calls and conduct regular outbound calls to keep families up to date.
  • Offer 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.
  • Create/increase listserv communication to update families, such as the status and impact of COVID-19 in the facility.

Communal Dining and Group Activities:

Communal activities and dining may occur in the following manner:

  • Residents who are fully vaccinated and not in isolation or quarantine may eat in the same room without physical distancing; if any unvaccinated residents are dining in a communal area (e.g., dining room) all residents should use source control when not eating.
  • Residents who are fully vaccinated and not in isolation or quarantine may participate in group/social activities together without face masks or physical distancing; if any unvaccinated residents are present, then all participants in the group activity should wear a well-fitting face mask for source control and unvaccinated residents should physically distance from others.

When it is not possible to ensure all persons participating in an activity are vaccinated (e.g., in break rooms and other common areas where staff or residents may come and go), then all participants should follow all recommended infection prevention and control practices including physical distancing and wearing a well-fitting face mask for source control. As such, activities where participants do not use source control and physical distancing should be carefully planned in advance and monitored so that vaccination status of all participants can be verified and ensured throughout the activity. Facilities should consider, in consultation with their local health department, reimplementing limitations on communal activities and dining based on the status of COVID-19 infections in the facility, e.g., when one or more cases has been identified in facility staff or residents.

Residents Who Leave and Return to the Facility

Residents taking social excursions outside the facility should be educated about potential risks of public settings, particularly if they have not been fully vaccinated, and reminded to avoid crowds and poorly ventilated spaces. They should be encouraged and assisted with adherence to all recommended infection prevention and control measures, including source control, physical distancing, and hand hygiene. If they are visiting friends or family in their homes, they should follow the source control and physical distancing recommendations for visiting with others in private settings as described in CDPH and CDC’s Interim Public Health Recommendations for Fully Vaccinated People.

  • 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, regardless of their vaccination status.
  • Residents who are fully vaccinated and leave for any duration (including hospital admissions) and return to the facility do not routinely need to quarantine and be tested upon return to the facility.
  • Unvaccinated and incompletely vaccinated residents who leave the facility for < 24 hours and return to the facility should be tested at 2 days after their return and again 5-7 days after their return; unvaccinated and incompletely vaccinated residents who leave the facility for > 24 hours should be quarantined in the yellow-observation area for 14 days and tested prior to return to their usual room in green-unexposed/recovered area.

Non-essential Personnel/Contractors

Non-essential personnel/contractors (e.g., barbers, manicurists/pedicurists), who comply with the same diagnostic screening testing and universal face mask requirements of the facility, may enter the facility and provide services to residents in appropriate spaces (outdoors, if feasible, or indoors in a well-ventilated area where at least 6-ft distancing can be maintained between residents); non-essential personnel/contractors who enter the facility should be encouraged to seek COVID-19 vaccination through the resources available in their community including the local health department.

Additional Considerations for Pediatric Residents

  • Visitors are essential for the mental health and developmental needs of pediatric residents. Visitation must be permitted for pediatric residents.
  • Involve Child Life workers, parents, legal guardians, or authorized representatives in planning the facility visitation program and the most developmentally appropriate visitation program for each resident, including residents who may not have family who can visit. The visitation program shall provide routine and ongoing visitation to meet each resident’s developmental and medical needs. 
  • Visitors may include parents, legal guardians, or authorized representatives of the pediatric resident and family, regardless of age. Child visitors must be able to observe the required infection control practices, (e.g., source control, hand hygiene, physical distancing) and should be accompanied by an adult visitor.
  • Visitors may also include educational instructors, special education aides, and physical, speech or other therapists and service providers who are referenced in a resident’s Individualized Education Plan, Section 504 Plan, Individualized Program Plan, or Community Placement Plan.
  • Extended periods of physical contact may be allowed between the pediatric resident and fully vaccinated visitors.
  • Encourage COVID-19 vaccination of staff, visitors, and residents who are 5 years or older.

Required Visitation

All facilities must comply with state and federal resident’s rights requirements pertaining to visitation. Facilities should follow CDPH and local public health department guidance when implementing visitation policies. Failure to facilitate visitation, without adequate reason related to clinical necessity or resident safety, would constitute a violation of resident’s rights and the facility would be subject to citation and enforcement actions.

As a reminder, ombudsmen and CDPH surveyors are not visitors and are subject to vaccination verification and testing requirements established by the state. Facilities do not need to verify the vaccination or testing status of surveyors and ombudsmen when they are on site conducting state business.

CDPH will continuously review the scientific literature and CDC guidance for updates on vaccine effectiveness in the SNF resident population, how much the vaccines reduce transmission, how long protection lasts, and efficacy of the vaccines against new SARS-CoV-2 variants. As data emerge to support vaccination coverage levels among SNF residents and HCP that could allow further lifting of restrictions, CDPH will update this AFL.

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

Sincerely,

Original signed by Cassie Dunham

Cassie Dunham

Acting Deputy Director

Resources:

CDPH Guidance on the Use of Antigen Tests for Diagnosis of Acute COVID-19

[1] Fully Vaccinated Definition:  See CDC Information on COVID-19 Vaccines for information on acceptable vaccines, definition for “Fully Vaccinated,” and updates on additional vaccines and recommendations as they are approved.

[2] 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