AFL 20-22.9 From the California Department of Public Health
August 12, 2021
TO: Skilled Nursing Facilities
SUBJECT: Guidance for Limiting the Transmission of COVID-19 in Skilled Nursing Facilities (SNFs)
(This AFL supersedes AFL 20-22.8)
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 authorizes SNFs to temporarily modify their facility’s visitation policies in accordance with CMS and CDC COVID-19 guidance when necessary to protect the health and safety of residents, staff, and the public.
- This AFL provides CDPH guidance for group activities and communal dining based upon vaccination status of residents.
- This revision 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 who are unvaccinated and incompletely vaccinated to have an indoor visit.
On April 27, 2021, CDC released updated healthcare infection prevention and control recommendations in response to COVID-19 vaccination, and CMS issued a revised QSO 20-39-NH (PDF) with updated guidance for visitation, group activities and communal dining in nursing homes accounting for the impact of COVID-19 vaccination. CDPH recognizes the importance that visitation and social interaction play in improving resident quality of life.
As transmissible variants of the SARS-CoV-2 virus circulate in California, COVID-19 cases are rising rapidly, and the vast majority of 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 visitors who are unvaccinated and incompletely vaccinated seeking indoor visitation. Visitors who are unvaccinated or incompletely vaccinated must show documentation of a negative SARS-CoV-2 test that occurred within 72 hours before each indoor 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.
Visitors that are unvaccinated or incompletely vaccinated and are seeking indoor visitation must show documentation of a negative SARS-CoV-2 test where the specimen collection occurred within 72 hours before each visit and for which the test results are available at the time of entry to the facility. Visitors may choose to use antigen or molecular (e.g., polymerase chain reaction (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 participating in the CDPH Antigen Testing Pilot can offer to conduct onsite testing of visitors but are not required.
General Visitation Guidance
Facilities shall conduct visitation through different means based on the facility’s structure and residents’ needs for circumstances beyond compassionate care situations, such as in resident rooms, dedicated visitation spaces, and outdoors; however, facilities must adhere to the core principles of COVID-19 infection prevention (PDF) at all times. Visitation must 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 scheduled 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, staying at least 6 feet away from others, 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 (medical masks, also called surgical masks, or double masking is recommended) 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.
- All visitors, regardless of their vaccination status, must follow physical distancing guidelines and maintain at least 6 feet distance from other visitors from different households, as well as from facility staff and other residents;
- 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 are unable to adhere to the core principles of COVID-19 infection prevention or who have tested positive for COVID-19 should not be permitted to visit or should be asked to leave. 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. Facilities should limit the number of visits per resident at one time and limit the total number of visitors in the facility at one time (based on the size of the building and physical space). Facilities should consider scheduling visits for a specified length of time to help ensure as many residents as possible are able to receive visitors. Visits should be scheduled for no less than 30 minutes. Longer visits should be supported.
Indoor, In-Room and Large Communal Space Visitation Requirements
Facilities shall allow indoor in-room visitation for:
- All residents, including unvaccinated, partially vaccinated, and fully vaccinated residents (e.g., individual residents who are ≥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), in “green” (unexposed or recovered) or “yellow” (exposed or observation status) areas, regardless of the county.
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 72 hours 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; otherwise, unvaccinated or incompletely vaccinated visitors and residents must wear well-fitting face masks and maintain 6-ft physical distancing during their visit.
- 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) areas.
Facilities shall also accommodate visitation in large communal indoor spaces such as a lobby, cafeteria, activity room, physical therapy rooms, etc. where 6-ft distancing is possible between visitor-resident groups. Facilities may need to rearrange these spaces or add barriers to separate the space to accommodate the need for visitation of multiple residents. During indoor large communal space visits between fully vaccinated residents and fully vaccinated visitors, both the resident and visitor must always wear a well-fitting face mask unless eating or drinking. These visits may be conducted without physical distancing and include physical contact (e.g., hugs, holding hands) while in designated spaces for visitation that maintain 6-ft distancing between the visitor and facility staff and other residents they are not visiting; otherwise, visits between residents or visitors that are unvaccinated or incompletely vaccinated must be conducted with well-fitting face masks during the visit and maintain 6-ft physical distancing.
Continuing Outdoor and Large Indoor Communal Space Visitation Requirements
All facilities must continue to allow outdoor visitation options for all residents, regardless of vaccination status.
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.
Outdoor visits pose a lower risk of transmission due to increased space and airflow; therefore, outdoor visitation is preferred and 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. Facilities should facilitate scheduled 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.
Outdoor visits between fully vaccinated residents and fully vaccinated visitors may be conducted without face masks and physical distancing and include physical contact (e.g., hugs, holding hands) while in designated spaces for visitation that maintain 6-ft distancing between the visitor and facility staff and other residents they are not visiting; otherwise, visits between residents or visitors that are unvaccinated or incompletely vaccinated should be conducted with well-fitting face masks during the visit and maintain 6-ft physical distancing.
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:
- Fully vaccinated residents who are 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 and unvaccinated patients/residents should continue to remain at least 6 feet from others (e.g., limited number of people at each table and with at least six feet between each person).
- Fully vaccinated residents who are 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 fully 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.
- Fully vaccinated residents who 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 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 (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 12 years or older for Pfizer-Biotech, 18 years or older for Moderna and Johnson & Johnson’s Janssen vaccine.
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.
Exception to Visitation Restrictions
Regardless of vaccination status, the following are exempt from a facility’s visitation restrictions and may have access to a resident in any zone:
- Healthcare workers: Facilities should follow CDC guidelines for limiting access to the facility to healthcare workers. Healthcare workers, including those from the local public health offices, should be permitted to come into the facility if they meet the CDC guidelines for healthcare workers. For purposes of this AFL, health care workers include employees, consultants, contractors, volunteers, and caregivers who provide care and services to residents on behalf of the facility, and students in the facility’s nurse aide training programs or from affiliated academic institutions.
- Surveyors: CMS constantly evaluates surveyors and CDPH requires testing of their surveyors weekly regardless of their vaccination status to ensure they do not pose a transmission risk when entering the facility.
- Ombudsman: Facilities must permit ombudsman in the facility. Ombudsman are required to be asymptomatic and CDPH recommends that ombudsman be tested weekly regardless of their vaccination status to ensure they do not pose a transmission risk when entering the facility.
- Students: Students obtaining their clinical experience as part of an approved nurse assistant, vocational nurse, registered nurse, pharmacy, social work or other healthcare training program should be permitted to come into the facility if they meet the CDC guidelines for healthcare workers. Students entering the facility routinely must participate in the facility wide screening testing.
- Compassionate care visitation: For permitted visitors, visits should be conducted using physical distancing; however, if the facility and visitor identify a way to allow for personal contact during compassionate care visitation, visitors must be screened for COVID-19 symptoms, wear a well-fitting face mask while in the building, restrict their visit to the resident’s room or other location designated by the facility, and be reminded by the facility to frequently perform hand hygiene. For a definition of the type of visits that constitute compassionate care visitation please refer to CMS guidance QSO 20-39-NH (PDF).
- Facilities should consider testing compassionate care visitors who have physical contact with COVID-19 positive residents.
- Legal matters: Visitors must be permitted for legal matters that cannot be postponed including, but not limited to, voting, estate planning, advance health care directives, Power of Attorney, and transfer of property title if these tasks cannot be accomplished virtually.
- Protection and Advocacy (P&A) programs: Any representative of a P&A program must be permitted immediate access to a resident, which includes the opportunity to regularly meet and communicate privately with the resident, both formally and informally, by telephone, mail, and in-person.
- Individuals authorized by federal disability rights laws: Facilities must comply with federal disability rights laws such as Section 504 of the Rehabilitation Act and the Americans with Disabilities Act.
- For example, if a resident requires assistance to ensure effective communication (e.g., qualified interpreter or someone to facilitate communication) and the assistance is not available by onsite staff or effective communication cannot be provided without such entry (e.g., video remote interpreting), the facility must allow the individual entry into the facility to interpret or facilitate, with some exceptions.
- This would not preclude facilities from imposing legitimate safety measures necessary for safe operations, such as requiring such individuals to adhere to the core principles of COVID-19 infection prevention.
In circumstances where this guidance does not clearly apply, the facility leadership should work with the local health department to develop an individualized plan of action.
All persons exempt from visitor restrictions are still subject to screening for fever and COVID-19 symptoms, must wear a well-fitting face mask, perform hand hygiene when in the facility and comply with core principles of infection control and prevention.
Use of Civil Money Penalty (CMP) Funds
CDPH encourages facilities apply to use CMP funds to help facilitate visitation, such as purchasing communicative devices (e.g., tablets or webcams), to help residents stay connected with their loved ones. CMS will now approve use of CMP funds to purchase tents for outdoor visitation and/or clear dividers (e.g., Plexiglas or similar products) to create a physical barrier to reduce the risk of transmission during-in person visits. Funding for tents and clear dividers is limited to a maximum of $3000 per facility. This grant opportunity is in addition to the communicative technology CMP grant that was made available previously.
Please see AFL-20-77 for additional information on applying for CMP funds.
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.
Original signed by Cassie Dunham
Acting Deputy Director
 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