Long Term Care Facilities Guidance

COVID-19 Control Measures for Long Term Care
Interim Guidance (subject to change)

Long term care facility residents are at high risk of being affected by COVID-19.  Risk factors associated with living in a congregate setting and characteristics of the populations served (often older adults with chronic medical conditions) can result in more severe disease from COVID-19 in these individuals.

The following guidance is to help prevent transmission of COVID-19 in long term care facilities.

Residents:

  • All residents should be screened for symptoms AND temperature, heart rate, respirations (Vital signs) AND pulse oximetry every 8 hours (Q8 hours). Blood pressure may be taken once a day.
  • NOTE: Contact Clinical Supervisor for any of the following: new-onset fever, SOB, cough, sore throat or for any decrease in pulse oximetry from resident baseline level or any pulse oximetry reading < 92%. The clinical supervisor should alert the provider to strongly consider transfer to a higher level of care. Monitoring every 4 hours is appropriate for patients with evidence of clinical deterioration.
  • If patients have been screened and their testing is POSITIVE for COVID-19 OR if patients
  • have signs/symptoms of a respiratory viral infection:
    1. Obtain Vitals (temperature, heart rate, respirations) AND pulse oximetry every 4 hours (Q4hours) {twice a shift}. Blood pressure can be taken every 8 hours.
    2. Private Room or Cohort with another symptomatic/positive patient
    3. Maintain Standard, Contact and Droplet Precautions (including eye protection)
    4. Consider that staff caring for positive or symptomatic patients do NOT care for negative or asymptomatic patients.
    5. Positive or symptomatic patients should be given a surgical mask and encouraged to wear at all times. These patients should be wearing a surgical mask when close contact with others is anticipated.
  • Any resident identified with symptoms of fever and lower respiratory illness (cough, shortness of breath, sore throat) should be immediately placed in both Contact and Droplet transmission-based precautions.
  • The isolation should be implemented by the healthcare member who discovers the symptoms pending a physician order.
  • Residents with confirmed COVID-19 or displaying respiratory symptoms should receive all services in room with door closed (meals, physical and occupational therapy, activities, and personal hygiene, etc.)
  • Symptomatic residents should only leave their room as required for medical procedures not available on site (i.e., dialysis, medical specialist appointment, and critical testing not available at the facility).
    • If the resident is to leave room for these purposes the shortest route should be utilized and the immediate are/route to the exit/treatment areas should be cleared of all residents and unnecessary staff.
  • Ensure all residents wear a cloth face covering for source control whenever they leave their room or are around others, including whenever they leave the facility for essential medical appointments. Whenever a resident is outside their room, they should wear a cloth face covering or facemask, perform hand hygiene, limit their movement in the facility, and perform social distancing (stay at least 6 feet away from others).
  • Residents should wear a face covering or facemask (if tolerated) during direct care activities
  • Testing to rule out routine pathogens may be completed via rapid influenza testing and respiratory pathogen panels (Rhinovirus, RSV, etc.).
  • Determination to send the resident to the hospital should be based on the same criteria used for other illnesses.
  • EMS and the receiving hospital should be notified when a resident with confirmed or suspected COVID-19 or other respiratory symptoms of unknown etiology require transport and hospitalization.

Facilities:

  • Communicate with physicians, local health department, regulatory agency, families, staff and residents.
  • Follow IDPH guidelines for reporting COVID-19 cases and outbreaks.
  • Processes and activities which increase residents’ risk should be modified or suspended.
  • Immediately inform the local health department and IDPH of symptomatic residents to determine if COVID-19 testing is indicated. Testing strategies for staff and residents will be determined based on available epidemiological and situational data.
  • Stop large group congregate activities and provide alternatives (arrange in room dining or dining that maintains social distancing and activities, stop bingo, beauty shop, outside volunteer presentations, church, etc.)
  • Screen residents: If not already being performed, begin screening all residents, including temperature checks and use of checklists to identify symptomatic individuals.
  • Inform staff to stay home when sick; ensure  non-punitive practices during this period.
  • Screen staff:  Screen all staff for respiratory symptoms and check temperatures at the beginning of the shift and again at mid-shift.  If a COVID-19 respiratory symptom or fever is present, the staff member should be sent home.  Refer to the guidance below for when healthcare personnel can return to work.
  • Focus on decreased staff rotation and cohort staff who work with symptomatic residents whenever possible.
  • Ensure staff are educated on and correctly performing hand hygiene, donning and doffing of PPE, and using appropriate products for environmental cleansing/disinfection.
  • Ensure adequate supplies of PPE are easily accessible to staff.
  • Post signage for hand hygiene and cough etiquette; ensure necessary supplies to accomplish these tasks are present at all entries and patient care areas.
  • Notify all residents, staff, visitor and families of current COVID-19 situation.
  • Visitation should be restricted to essential individuals.  All visitors should be informed of risk and instructed on proper PPE use prior to entering unit. Other avenues of communication with family should be explored (i.e., face time, skype, etc.).
  • Identify additional isolation rooms limiting to single unit if possible, cohort like-cases if necessary (e.g., influenza with influenza, COVID-19 with COVID-19, etc.).
  • Ensure adequate testing supplies and masks are available for staff collecting specimens (for first resident being tested).
  • Avoid aerosol generating procedures. If necessary, use face and eye protection, N95 or respirator, close door and pull curtain. Wipe horizontal surfaces with EPA registered and approved product (List N products) after procedure. If supplies become scarce, follow CDC recommendations for crisis capacity use. Follow IDPH guidance on Nebulizers.
  • Facilities should be able to accept COVID-19 residents from the hospital if clinically stable. Follow IDPH Interim Guidance for Accepting Transfers from Acute Care Settings.
  • New admissions (residents and families) should be notified if the facility has COVID-19 in the building.
  • Residents with a DNR status must be reevaluated due to COVID19. The facility should have a conversation with the resident and family to determine if a higher level of care is desired should the resident develop COVID19 illness. Some residents may not want to be transferred to a hospital and may only want comfort level measures taken.

Environmental Services/Controls:

  • Disinfect frequently touch surfaces every two hours or as frequently as possible with EPA registered and approved product (List N products).
  • Educate and observe practice on appropriate disinfection (clean to dirty, appropriate dwell time, when to switch clothes and wipes, etc.).
  • Ensure cleaning and disinfection policies and procedures are being followed consistently and correctly.
  • Ensure appropriate PPE is worn during cleaning and disinfection work.
  • Limit access to facility and post signage with rationale. Only essential visitors, employees and contract staff should be allowed to enter.
  • Ensure adequate facilities for completion of hand hygiene-hand washing sink or alcohol-based hand rub.
  • Alcohol-based hand rub should ideally be both inside and outside of patient rooms, at all entrances, and throughout the clinical areas.
    • Ensure all dispensers contain product within expiration date.

Environmental Services/Controls:

  • Disinfect frequently touch surfaces every two hours or as frequently as possible with EPA registered and approved product (List N products).
  • Educate and observe practice on appropriate disinfection (clean to dirty, appropriate dwell time, when to switch clothes and wipes, etc.).
  • Ensure cleaning and disinfection policies and procedures are being followed consistently and correctly.
  • Ensure appropriate PPE is worn during cleaning and disinfection work.
  • Limit access to facility and post signage with rationale. Only essential visitors, employees and contract staff should be allowed to enter.
  • Ensure adequate facilities for completion of hand hygiene-hand washing sink or alcohol-based hand rub.
  • Alcohol-based hand rub should ideally be both inside and outside of patient rooms, at all entrances, and throughout the clinical areas.
    • Ensure all dispensers contain product within expiration date.

Employees:

  • All employees should promptly notify supervisor of any symptoms of illness in themselves or any individual in their care.
  • Employees who are ill will exclude themselves from work environments and will seek the advice of their health care provider.
  • All employees should be pre-screened for fever and symptoms prior to shift and at mid-shift.
  • Symptomatic staff should be considered possible cases and excluded from work and told to self-isolate at home for a minimum of 10 days after onset.  See Return to Work guidance at https://www.cdc.gov/coronavirus/2019-ncov/hcp/return-to-work.html  for information on when an employee with suspected or confirmed COVID-19 can return to work. 
  • Testing strategies for staff and residents will be determined based on available epidemiological and situational data.
  • Employees may utilize extended use or re-use techniques with masks and eye protection when PPE supply is low. Masks must be changed when visibly soiled.
  • All employees must wear a mask (universal masking) during their shift to protect residents.
  • All staff must wear masks when entering the building.
  • Agencies of contract employees should be notified of risk and should screen their staff to prevent transmission from facility to facility. Use limited and or consistent agency staff during the COVID-19 pandemic if possible.
  • Perform hand hygiene on arrival at the facility, during the 5 moments of patient care activities, and prior to going home.
  • PPE should not be worn off affected units or areas unless approved as enhanced control measure.
  • If an employee has been tested and has a negative COVID19 test and does NOT have symptoms, they may continue to work. Symptom screening is done pre-shift and every 4 hours during shift.

Return to Work Criteria for HCP with Confirmed or Suspected COVID-19

See https://www.cdc.gov/coronavirus/2019-ncov/hcp/return-to-work.html

Return to Work Practices and Work Restrictions

After returning to work, HCP should:

  • Per CDC guidance, the HCP is to wear a facemask at all times while in the healthcare facility until all symptoms are entirely resolved or until 14 days after illness onset, whichever is longer. With universal masking, this measure should already be enforced.
  • Be restricted from contact with severely immunocompromised patients (e.g., transplant, hematology-oncology) until 14 days after illness onset
  • Adhere to hand hygiene, respiratory hygiene, and cough etiquette in CDC’s interim infection control guidance (e.g., cover nose and mouth when coughing or sneezing, dispose of tissues in waste receptacles)
  • Self-monitor for symptoms, and seek re-evaluation from occupational health if respiratory symptoms recur or worsen

Guidance for Communal Dining

Residents identified as being positive for COVID-19 or who are displaying symptoms of COVID-19-like illness (fever, cough, sore throat, shortness of breath) should have meals in their rooms (dine-in meals).

If residents are not displaying ANY symptoms of COVID-19, the facility should consider the following measures to balance the directive to eliminate communal dining and the need to provide nutritional meals to residents in a safe manner.

  • Stagger dining periods, so fewer residents dine at a time.
  • Utilize all available dining halls in the facility (providing additional space to separate residents)
  • Those residents who can feed themselves without any issues or concerns should dine in their room (this decreases the number of residents in the dining hall).
  • Those residents needing assistance to eat should be separated by at least six feet. Depending on the size of the dining table, only 1 to 2 residents per table. Tables need to be at least six feet apart as well.
  • The facility should consider utilizing resident attendants and speech therapists to assist nursing assistants in feeding residents.
  • Staff should wear a facemask when feeding residents.
  • Hand hygiene is to be performed between resident care (feeding).
  • Only ONE resident should be transported (pushed) at a time to the dining room.  Do not attempt to push more than one wheelchair at a time. The same process is used for return trips to resident rooms---only ONE resident at a time.
  • Ensure cleaning and disinfection of environmental surfaces between dining periods. Only use EPA registered disinfectants. Ideally, use a product from List N.  Refer to CDC/EPA website for List N products. If your current disinfectant is not listed on the List N products, check the label and ensure the product is at least effective against human coronavirus.

Reporting COVID-19 Cases and Outbreaks

Healthcare providers and laboratories are required by the Control of Communicable Disease code to report COVID-19 cases and outbreaks to the local health department. 

Clusters of 2 or more suspect cases of COVID-19 among residents of congregate settings that serve vulnerable populations should be reported to the local health department as soon as possible but within 24 hours.

When COVID-19 is suspected to be or known (laboratory-confirmed case) to be the cause of death in an individual, this should be reported to the local health department.