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Guidelines for Residential Living Facilities and COVID-19 Infected or Exposed Health Care Workers

 

These guidelines are effective June 16, 2020 in St. Louis County. In accordance with DPH’s Amended Order for Residential Living dated and effective June 15, 2020. These guidelines may be replaced or modified by DPH based on new scientific information and local information including the trajectory of influenza-like illnesses, cases of COVID-19, and any other information deemed relevant to protect public health in St. Louis County.

These guidelines place restrictions on residential living facilities and the management of health care professionals exposed to or testing positive for COVID-19. Please refer to the DPH Residential Living Facilities for definitions.

 

The current coronavirus pandemic has impacted the most vulnerable populations in St. Louis County, with certain residential living facilities, especially long-term care facilities (“LTCFs”) being particularly affected. This has resulted in ‘lockdown’ situations where the facility has to severely limit outside visitors and families. In addition, the preparation and maintenance of facilities, with respect to staffing as well as the inability to acquire sufficient Personal Protective Equipment (PPE), have created major challenges. Health care systems have more resources to respond to these challenges, and, for the most part, have been able to adequately handle their staffing and nursing needs, as well as addressing PPE needs and obstacles. Unfortunately, the same is not true of LTCFs and other facilities that provide assisted living or nursing care, which are suffering from critical staffing shortages and the unavailability of adequate PPE. The St. Louis County Department of Public Health (“DPH”) developed this document to provide guidelines for the Residential Living facilities that serve this vulnerable population. Guidelines for the management of patients and health care workers (HCP) are highlighted in this document.

In line with guidance set forth by the Centers for Disease Control and Prevention (CDC), the Saint Louis County Department of Public Health (DPH) supports the recommendations as guidelines and tools for facility management use and for reference purposes.

Since it is critical to minimize any exposure to these vulnerable populations, it is imperative that the health care professionals that assist and treat this population are adequately screened before entering these facilities and that they follow specific requirements if exposed to COVID-19 or if testing positive for COVID-19. Facilities employing these professionals as well as the professionals, themselves, must comply with these guidelines.

For purposes of these guidelines and the DPH order, personnel providing hospice services, whether employed by the facility or from another outside provider, are considered to be health care professionals and essential personnel.

Management of Heath Care Professional (“HCP”) with Exposures to COVID-19

HCP with known healthcare, non-healthcare or other continuous exposures to COVID-19 (e.g. household exposures) may continue working in that capacity provided that the facility or provider assures that:

  • The HCP wears a facemask (not cloth covering) while in the healthcare facility for the entire time they are at work for 14 days after the last date of exposure to the positive individual.
  • The HCP is actively monitored to assure a temperature <100 degrees F and absence of symptoms consistent with COVID-19 prior to starting each workday for at least 14 days after the last date of exposure to the positive individual.
  • The last date of exposure to the positive individual is defined by the date that the HCP had an exposure, or in the case of continuous household or work exposures, the date that the positive individual is released from isolation by DPH. (https://www.cdc.gov/coronavirus/2019-ncov/hcp/ disposition-in-home-patients.html)

If the HCP develops any symptoms that could be consistent with COVID-19, they must:

  • Cease patient care activities immediately and notify their supervisor or occupational health office prior to leaving work.
  • Be prohibited from working while they are symptomatic.
  • Be tested for COVID-19 in accordance with current public health guidelines.
  • Remain out of work in isolation while awaiting COVID-19 test results.

HCP with negative test results for COVID-19 and an explanatory alternate diagnosis may return to work under the following conditions:

  • Resolution of fever for 24 hours without use of fever reducing medications.
  • Symptoms have resolved.
  • The HCP wears a facemask while in the healthcare facility for the entire time they are at work for 14 days after the last date of exposure to the positive individual.

Using clinical judgment, healthcare facilities are strongly encouraged to avoid HCP with known continuous exposures to COVID-19 caring for patients with high-risk of significant morbidity and mortality from

COVID-19 whenever feasible.

Management of HCP Testing Positive for COVID-19

HCP who have tested positive for COVID-19 may be released from isolation according to the CDC test-based strategy (https://www.cdc.gov/coronavirus/2019-ncov/hcp/return-to-work.html).

HCP who have tested positive for COVID-19 may be released from isolation according to the following symptom-based strategy:

  • At least 3 days (72 hours) have passed since recovery defined as resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms (e.g., cough, shortness of breath); and,
  • At least 10 days have passed since symptoms first appeared.

In accordance with current CDC guidelines, HCP who return to work shall:

  • Wear a facemask (not a cloth face covering) for source control at all times while in the healthcare facility until all symptoms are completely resolved or at baseline. After this time period, these HCP should revert to their facility policy regarding universal source control during the pandemic.
    • A facemask for source control does not replace the need to wear an N95 or higher-level respirator (or other recommended PPE) when indicated, including when caring for patients with suspected or confirmed COVID-19.
    • Of note, N95 or other respirators with an exhaust valve might not provide source control.
  • Be restricted from contact with severely immunocompromised patients until symptoms have resolved.
  • Adhere to standard hand hygiene, respiratory hygiene, and cough etiquette.
  • Self-monitor for symptoms, and seek re-evaluation from occupational health if respiratory symptoms recur or worsen.

Management of HCP who display symptoms of COVID-19 and do not have a positive test result

HCP who have symptoms consistent with COVID-19 and an epidemiological link to a confirmed positive case of COVID-19, as determined by DPH or an office of occupational health, but have not been tested, have inconclusive test results, or have negative test results for COVID-19 without an explanatory alternate diagnosis (i.e., they meet the CSTE/CDC probable case definition) shall be presumed COVID-19 positive and follow clearance guidelines as outlined above.

All healthcare facilities and providers are encouraged to continue to reference up-to-date guidance from the CDC and the Centers for Medicare & Medicaid Services (CMS).

Management of HCP who test positive for COVID-19 on screening but are asymptomatic

In accordance to CDC, LTCFs have several options for this situation. If the HCP is asymptomatic:

  • The staff member can be furloughed on medical isolation for 10 days from the date of specimen collection before return to work, as long as no symptoms have developed during isolation.
  • The staff member can work remotely during the isolation period, with return to work as above.
  • If crisis staffing shortage is critical, facilities should collaborate with human resources and occupational health services to discuss the need to implement crisis capacity strategies to continue to provide patient care. This may include allowing a positive HCP who remains asymptomatic to be allowed to provide direct care to patients that have confirmed COVID-19, preferably in a cohort setting (COVID unit).

Visitor restriction and CMS guidelines

Residential living facilities have had to limit visitors in order to protect this vulnerable population from symptomatic or asymptomatic COVID-19 contacts. This has led to severe limitations of family and close friends’ interaction with the residents. If a facility develops positive cases, CMS has developed a

recommended process of containment and mitigation to protect uninfected residents as well as staff. This is outlined in a Centers for Medicare and Medicaid Services (CMS) document on May 18, 2020: (https://www. cms.gov/files/document/qso-20-30-nh.pdf). A summary of the key points follows:

Given the critical importance in limiting COVID-19 exposure in residential living facilities, decisions on relaxing restrictions will be made by DPH. Because the pandemic is affecting different communities and populations within St. Louis County in different ways, DPH regularly monitors the factors for reopening and will adjust the guidelines accordingly.

Factors that will inform DPH decisions about relaxing restrictions in nursing homes include:

  • Case status in community: State-based criteria to determine the level of community transmission and guides progression from one phase to another. For example, a decline in the number of new cases, hospitalizations, or deaths (with exceptions for temporary outliers).
  • Case status in the nursing home(s): Absence of any new nursing home onset1 of COVID-19 cases (resident or staff ), such as a resident acquiring COVID-19 in the nursing home.
  • Adequate staffing: No staffing shortages and the facility is not under a contingency staffing plan.
  • Access to adequate testing: The facility should have a testing plan in place based on contingencies informed by the Centers for Disease Control and Prevention (CDC).

At minimum, DPH guidelines will consider the following components:

  • The capacity for all nursing home residents to receive a single baseline COVID19 test. Similarly, the capacity for all residents to be tested upon identification of an individual with symptoms consistent with COVID-19, or if a staff member tests positive for COVID-19.
  • Capacity for continuance of weekly re-testing of all nursing home residents until all residents test negative.
  • The capacity for all nursing home staff (including volunteers and vendors who are in the facility on a weekly basis) to receive a single baseline COVID-19 test, with re-testing of all staff continuing every week.
  • Written screening protocols for all staff (each shift), each resident (daily), and all persons entering the facility, such as vendors, volunteers, and visitors.
  • An arrangement with laboratories to process tests. The test used should be able to detect SARS-CoV-2 virus (e.g., polymerase chain reaction (PCR) with greater than 95% sensitivity, greater than 90% specificity, with results obtained rapidly.

A “new nursing home onset” case refers to COVID-19 cases that originated in the nursing home, and not cases where the nursing home admitted individuals from a hospital with a known COVID-19 positive status, or unknown COVID-19 status but became COVID-19 positive within 14 days after admission. In other words, if the number of COVID-19 cases increases because a facility is admitting residents from the hospital AND they are practicing effective Transmission-Based Precautions to prevent the transmission of COVID-19

to other residents, that facility may still advance through the phases of reopening. However, if a resident contracts COVID-19 within the nursing home without a prior hospitalization within the last 14 days, this facility should go back to the highest level of mitigation, and start the phases over.

Visitation is generally prohibited in the interior premises of LTCFs, except for compassionate care situations and by hospice personnel. Even in those situations, visitors must be screened, social distancing and hand hygiene precautions must be taken, and all visitors must wear a face covering.

Visits outside the interior premises of the LTCF, such as in courtyards and other areas, however, are allowed with the facility deciding their own protocols with respect to the visits.

Facility-wide testing should be done, if possible, with all staff tested weekly and residents at baseline and when any new staff member or resident becomes positive. Weekly testing should continue until all residents test negative.

LTCFs must also not allow “non-essential resident movement,” which includes travel off the premises other than for specific healthcare treatment. Non-medically necessary trips outside the building for residents should be avoided. LTCFs must also not allow group activities (on or off the premises), communal dining, and any other type of resident movement that requires groups to congregate or for residents to leave the facility in a group.

Optional process to facilitate visiting LTCF residents safely:

It is advisable for facilities to develop structured mechanisms to allow outdoor, by appointment only, visiting of residents with screened family or close friends in a manner that allows no entry to the facility (e.g. a courtyard accessible from outside parking) and provides adequate social distancing and protective apparel. Alternatively, outdoor visits could be accommodated through an open window for residents who are bedbound or who otherwise cannot leave their room. Other options for the facility to consider are communication devices that can be made available to families and residents, with supervision, to allow contact with loved ones.

Visitation of residents in residential living facilities that are not LTCFs

Residential living facilities that are not LTCFs may allow visitors as long as they comply with screening requirements, social distancing and disinfection processes and require visitors to wear face coverings.

These facilities may also allow residents access to dining halls and other communal facilities as long as the residential living facility maintains disinfection processes and involved residents maintain social distancing requirements and wear a face covering.

Residential living facilities that are not LTCFs may also allow residents to travel off of the facility premises for specific healthcare treatment and other reasons. Unlike LTCFs, there is no restriction for “non-essential resident movement” for these residents.