2019 Novel Coronavirus (COVID-19)
Long-Term Care Facilities
For up to date information on COVID-19 visit health.mesacounty.us.
Healthcare operations, such as long-term care facilities, are essential functions and not included in stay-at -home orders. This guidance is intended to provide recommendations for this specific industry. This guidance is updated frequently so please check back for the most recent recommendations. For the full stay-at-home order click here.
Latest Update March 26, 2020
- To report a suspected or confirmed outbreak of COVID-19 in a long-term care facility (LTCF), please complete the “Outbreak Reporting Form for Long-Term Care Facilities” and securely email this to CDPHE_HAIOutbreak@state.co.us, or contact Mesa County Public Health. The outbreak reporting form is available here.
- New tool: COVID-19 Long-Term Care Outbreak Investigation Checklist
- Given the level of community transmission, health care workers caring for immunosuppressed or other high risk patients should wear facemasks (surgical masks) during all patient care when feasible.
Instructions for patients diagnosed with COVID-19 and their close contacts
Due to the rising number of confirmed COVID-19 cases in Colorado, CDPHE is asking that clinicians provide the current guidance on isolation to patients at the time of their diagnosis with COVID-19, including those with likely COVID-19 who will not be tested, to ensure that timely recommendations are provided to reduce spread of disease. Isolation recommendations:
- Under the non-test-based release from isolation strategy, patients with COVID-19 (either laboratory-confirmed or suspected based on history) should self-isolate until: at least 7 days after symptom onset AND fever has resolved for 72 hours without antipyretics AND symptoms are improving. Quarantine recommendations for asymptomatic close contacts:
- Close contacts of patients with confirmed or likely COVID-19 should be instructed to self-quarantine for 14 days from the time of their last contact with the patient.
- CDC has recently updated their risk categories for non-healthcare exposure (https://www.cdc.gov/coronavirus/2019-ncov/php/risk-assessment.html); a high risk contact is defined as someone who is living in the same household as, being an intimate partner of, or providing care in a non-healthcare setting (such as a home) for a person with symptomatic laboratory-confirmed COVID-19 infection without using recommended precautions for home care and home isolation.
- Close contacts who are healthcare workers should be instructed to notify occupational health immediately for additional instructions.
Patients who are healthcare workers
- Patients diagnosed with COVID-19 (either laboratory confirmed or suspected) who are healthcare workers should contact their supervisor and occupational health to report their diagnosis.
- CDPHE recommends 10 day isolation for healthcare workers diagnosed with COVID-19 when possible due to limited data about shedding of viable virus beyond 7 days; however, we fully recognize the staffing challenges facing many facilities and understand that this may not be possible in many settings.
- Healthcare workers should work with occupational health to determine an appropriate return to work strategy.
New CDC Guidance
CDC continues to add and update guidance documents. A few new documents to highlight include the following:
March 15, 2020
- Clearly displayed visitor restrictions and strictly enforced employee illness screening are vital to protecting your clients from COVID-19. Begin this now.
- Colorado has issued a governor’s order regarding the current protection of residents in skilled nursing, assisted living, and intermediate care facilities.
- Facilities must follow CMS guidelines related to screening, limiting and restricting visitors.
- Restrict visitation of non-essential individuals.
- For essential individuals entering the building, including personnel, contracted individuals or essential visitors, screen 100% prior to entry into the building, consistent with screening criteria. Essential individuals should be limited.
- If a facility has a suspected, presumptive, or confirmed COVID-19 patient, the facility MUSTfollow guidelines described in the order.
- High-risk populations for COVID-19 include adults 60 years or older and/or anyone who is immunocompromised.
- Community level transmission has been reported in multiple states, including Colorado.
- Mesa County Public Health is available to brief your agency on the current situations and recommendations.
- Mesa County Public Health is not currently offering fit testing for healthcare workers.
- Your facility may be caring for confirmed COVID-19 cases, it is important to plan for this eventuality.
- Facilities should monitor the Mesa County Public Health website for updated information. (https://health.mesacounty.us/covid19/)
Recommendations for facilities now that there are cases in Mesa County and before there are cases in your facility:
Review CDC’s COVID-19 Preparedness Checklist for Nursing Homes and other Long-Term Care Settings:
Educate Residents, Healthcare Personnel, and Visitors
- Reinforce sick leave policies. Remind healthcare personnel (HCP) not to work when ill. Follow guidance regarding return to work from the CDC and MCPH.
- Reinforce infection prevention and control measures, including hand hygiene and selection and use of personal protective equipment (PPE).
- Increase signage for vigilant infection prevention, such as visitor restrictions, hand hygiene and cough etiquette.
- Educate both facility-based and consultant personnel (e.g., wound care, podiatry, barber) and volunteers about symptoms of COVID-19 and disease transmission.
- Educate residents and families regarding:
- Information about COVID-19
- Actions the facility is taking to protect them and their loved ones, including visitor restrictions.
- Actions residents and families can take to protect themselves in the facility.
- Create a plan for cohorting residents with symptoms of respiratory infection, including dedicated HCP to work only on affected units.
Provide Supplies for Recommended Infection Prevention and Control Practices
- Put alcohol-based hand sanitizer with 60-95% alcohol in every resident room (ideally both inside and outside of the room) and other resident care and common areas (e.g., outside dining hall, in therapy gym, in hair salon).
- Respiratory hygiene and cough etiquette:
- Make tissues and facemasks available for coughing people.
- Consider designating staff to steward those supplies and encourage appropriate use by residents, visitors, and staff.
- Increase work supplies to avoid sharing (e.g., pens, pads) and disinfect workplace areas (nurse’s stations, phones, internal radios, etc.).
Environmental cleaning and disinfection
- Make sure that EPA-registered, hospital-grade disinfectants are available to allow for frequent cleaning of high-touch surfaces and shared resident care equipment.
- Properly clean, disinfect and limit sharing of medical equipment between residents and areas of the facility.
Consider New Policies and Procedures for Visitors
- Follow the current governor’s order - postpone all visitation and begin screening visitors.
- Send letters or emails to families advising them to consider postponing or using alternative methods for visitation (e.g., video conferencing, phone calls) during the next several months.
- Post signs at the entrances to the facility instructing visitors to not enter if they have fever or symptoms of a respiratory infection. You must have a visitor sign-in log in case contact tracing becomes necessary.
- Ask all visitors about fever or symptoms of respiratory infection. Restrict anyone with:
- Fever or symptoms of respiratory infection (e.g., cough, sore throat, or shortness of breath.)
- Travel from areas with community transmission.
- Contact with an individual with COVID-19.
- If visitors meet this criteria, facilities may restrict their entry to the facility. Regulations and guidance related to restricting a resident’s right to visitors can be found at 42 CFR §483.10(f)(4), and at F-tag 563 of Appendix PP of the State Operations Manual.
- Visitors should be encouraged to frequently perform hand hygiene and limit their movement and interactions with others in the facility (e.g., confine themselves to the resident’s room).
- If possible (e.g., pending design of building), creating dedicated visiting areas (e.g., “clean rooms”) near the entrance to the facility where residents can meet with visitors in a sanitized environment may be beneficial.
- Facilities should disinfect rooms after each resident-visitor meeting.
- When visitor restrictions are implemented, the facility should facilitate remote communication between the resident and visitors (e.g., video-call applications on cell phones or tablets), and have policies addressing when and how visitors might still be allowed to enter the facility (e.g., end of life situations).
- Residents still have the right to access the Ombudsman program. If in-person access is allowable, use the guidance mentioned above. If in-person access is not available due to infection control concerns, facilities need to facilitate resident communication (by phone or other format) with the Ombudsman program or any other entity listed in 42 CFR § 483.10(f)(4)(i)
Review and Revise Interactions with Outside Personnel
- Take necessary actions to prevent any potential spread inside your facility from outside personnel (e.g., volunteers, vendors, EMS, transportation providers, outside practitioners).
- Consider supply drop-offs outside the building in a dedicated location.
Expanded CMS visitation limitation definitions:
- Restricting means the individual should not be allowed in the facility at all, until they no longer meet the criteria above.
- Limiting means the individual should not be allowed to come into the facility, except for certain situations, such as end-of-life situations or when a visitor is essential for the resident’s emotional well-being and care.
- Discouraging means that the facility allows normal visitation practices (except for those individuals meeting the restricted criteria), however the facility advises individuals to defer visitation until further notice (through signage, calls, etc.).
COVID-19 Case Evaluation and Management Guidance:
Who should be evaluated as a suspect case:
- Travelers from areas with community transmission.
- Someone with close contact* with anyone known to have a lab-confirmed COVID-19 infection.
*Close contact definition:
a) being within approximately 6 feet (2 meters) of a COVID-19 case for a prolonged period of time; close contact can occur while caring for, living with, visiting, or sharing a healthcare waiting area or room with a COVID-19 case
– or –
b) having direct contact with infectious secretions of a COVID-19 case (e.g., being coughed on)
If a suspect case is identified:
- Promptly identify a suspect case,
- Isolate them in a private room with a closed door and limit staff interaction,
- Consult with the case’s healthcare provider.
Evaluate and manage healthcare personnel with symptoms of respiratory illness:
- When transmission in the community is identified, facilities may face staffing shortages. Facilities should develop (or review existing) plans to mitigate staffing shortages.
- Implement sick leave policies that are non-punitive, flexible, and consistent with public health policies that allow ill HCP to stay home.
- As part of routine practice, ask HCP (including consultant personnel) to regularly monitor themselves for fever and symptoms of respiratory infection.
- Remind HCP to stay home when ill.
- If HCP develops fever or symptoms of respiratory infection while at work, they should immediately put on a facemask, inform their supervisor, and leave the workplace.
- Inform the facility’s infection preventionist, and include information on individuals, equipment, and locations the person came in contact with; and
- Contact Mesa County Public Health (970-254-4120) for recommendations, including guidance on performing a risk evaluation of the employee.
- General agency sick leave and infection control procedures should be used for staff who do not meet current COVID-19 risk factors.
Evaluate and Manage Residents with Symptoms of Respiratory Infection:
- Ask residents to report if they feel feverish or have symptoms of respiratory infection.
- Promptly assess residents for fever and symptoms and signs of respiratory infection upon admission and throughout their stay in the facility.
- If a resident has severe respiratory infection, or a cluster of residents (e.g., ≥ 3 residents or HCP with new-onset respiratory symptoms over 72 hours) has symptoms of respiratory infection, or there is an increase in cases reported in the community, begin active monitoring of all residents and HCP in the facility for signs and symptoms.
- Notify Mesa County Public Health (970-254-4120) about residents with severe respiratory infection and clusters of respiratory infection.
- Test for more likely causes of respiratory infection (e.g., influenza, RSV, rhinovirus, etc.).
- In general, when caring for residents with undiagnosed respiratory infection use Standard, Contact, and Droplet Precautions with eye protection unless the suspected diagnosis requires Airborne Precautions (e.g., tuberculosis).
- This includes restricting residents with respiratory infection to their rooms. If they leave the room, residents should wear a facemask (if tolerated) or use tissues to cover their mouth and nose.
- Continue to assess infection control measures as information on the resident’s diagnosis becomes available.
- If a resident requires a higher level of care or the facility cannot fully implement all recommended precautions, the resident should be transferred to another facility that is capable of implementation. Transport personnel and the receiving facility should be notified about the suspected diagnosis prior to transfer.
- While awaiting transfer, symptomatic residents should wear a facemask (if tolerated) and be separated from others (e.g., kept in their room with the door closed). Appropriate PPE should be used by healthcare personnel when coming in contact with the resident.
Management of Confirmed COVID-19 Patient in Your Facility:
- Airborne Infection Isolation Rooms (negative pressure rooms) should be reserved for patients undergoing aerosol-generating procedures.
- Consider designating entire units within the facility, with dedicated HCP, to care for known or suspected COVID-19 patients. HCP would be assigned to care only for COVID-19 patients during their shift.
When should long-term care facilities consider transferring a resident with suspected or confirmed infection with COVID-19 to a hospital?
- Residents infected with COVID-19 may vary in severity from lack of symptoms to mild or severe symptoms.
- Initially, symptoms may be mild and not require transfer to a hospital as long as the facility can follow the infection prevention and control practices recommended by CDC. Facilities without an airborne infection isolation room (AIIR) are not required to transfer the resident assuming:
- the resident does not require a higher level of care and,
- the facility can adhere to the rest of the infection prevention and control practices recommended for caring for a resident with COVID-19.
When should a long-term care facility accept a resident who was diagnosed with COVID-19 from a hospital?
- If a long-term care facility cannot, it must wait until these precautions are discontinued.
- CDC has released Interim Guidance for Discontinuing Transmission-Based Precautions or In-Home Isolation for Persons with Laboratory-confirmed COVID-19.
- Information on the duration of infectivity is limited. CDC states that decisions to discontinue Transmission-based Precautions in hospitals will be made on a case-by-case basis in consultation with clinicians, infection prevention and control specialists, and public health officials.
- Discontinuation will be based on multiple factors (see current CDC guidance for further details: https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-hospitalized-patients.html).
- Long-term care facilities should admit any individuals that they would normally admit to their facility, including individuals from hospitals where a case of COVID-19 was/is present.
- If possible, dedicate a unit/wing exclusively for any residents coming or returning from the hospital. This can serve as a step-down unit where they remain for 14 days with no symptoms (instead of integrating as usual on short-term rehab floor, or returning to long-stay original room).
Obtain Accurate Information
In rapidly changing health events and outbreaks such as COVID-19, there can be large amounts of incorrect or partially correct information that can add to stress and confusion. Providing current, accurate, and frequent updates can help reduce stress and fear.
Get the most up-to-date and accurate information from:
Guidance adapted from Colorado Department of Health and Environment, Centers for Disease Control and Prevention, and Centers for Medicare and Medicaid, Colorado Department of Human Services, and World Health Organization