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COVID-19

MA DPH Revised LTCF Guidance 12.7.2020

Update to Caring for Long-Term Care Residents during the COVID-19 Emergency

Memorandum

TO: Long-Term Care Facilities

FROM: Elizabeth Daake Kelley, MPH, MBA, Director

Bureau of Health Care Safety and Quality

SUBJECT: Update to Caring for Long-Term Care Residents during the COVID-19 Emergency

DATE: December 7, 2020

The Massachusetts Department of Public Health (DPH) recognizes that providing care for individuals seeking treatment for Coronavirus Disease 2019 (COVID-19) may prove to be especially challenging for health care practitioners and facilities. As part of ongoing statewide preparations and to address the increase in COVID-19 cases, DPH is issuing this memorandum to long-term care facilities for admitting residents and caring for residents with presumed or confirmed COVID-19 to help mitigate the spread of COVID-19. This update replaces the November 18 version and now includes clear updated action steps long-term care facilities must take to prevent and mitigate transmission of COVID-19 in facilities.

All rest homes and nursing homes must be prepared to care for COVID-19 positive residents. Residents infected with COVID-19 may vary in severity from lack of symptoms to mild or severe symptoms. Symptoms may be mild and not require admission to a hospital. All facilities are expected to follow the infection prevention and control practices recommended by DPH and the Centers for Disease Control and Prevention (CDC).

The following guidance is consistent with Centers for Medicare and Medicaid Services (CMS) guidance.

Screening of All Individuals

Long-term care facilities should be screening all individuals entering the facility, including healthcare personnel and visitors, for symptoms on a daily basis. In accordance with previously issued guidance, every individual regardless of reason for entering a long-term care facility should be asked about COVID-19 symptoms and must also have their temperature checked by a trained screener.

Long-term care facility personnel must be screened for symptoms at the beginning of every shift. If long-term care facility personnel were screened at the beginning of their shift and must then leave the facility and return during that shift, the long-term care facility personnel do not need to be rescreened upon re-entry to the facility.

Residents should be asked about COVID-19 symptoms and must have their temperatures checked a minimum of two times per day.

Use of Personal Protective Equipment (PPE)

Long-term care facilities should ensure all staff are using appropriate PPE when they are interacting with residents and in alignment with DPH and CDC guidance on conservation of PPE. All long-term care facility personnel should wear a facemask while they are in the facility and eye protection while in patient care areas.

Full PPE, including N95 respirator or, if not available, facemask, eye protection, gloves and gown, should be worn per DPH and CDC guidelines for the care of any resident with known or suspected COVID-19 per CDC guidance on conservation of PPE. If any residents admitted for longer than fourteen days or staff are confirmed to be COVID-19 positive within the past fourteen days, healthcare personnel should wear additional PPE for the care of all residents, except COVID-19 recovered (less than six months from infection) residents. Appendix A provides PPE guidance, based upon the resident’s COVID-19 status.

When possible, all long-term care facility residents, whether they have COVID-19 symptoms or not, should cover their noses and mouths any time they leave their room and when they are in their room and staff are present. Such face coverings can include cloth and non-medical masks.

Staffing

DPH requires long-term care facilities to implement the following staffing recommendations to mitigate the risk of transmission within facilities.

Ensure all staff can recognize the signs and symptoms of COVID-19 and that a procedure is in place for alerting the nurse responsible for the resident’s care.
Create separate staffing teams that are dedicated for residents that are COVID-19-positive.
Exercise consistent assignments of staff to residents regardless of symptoms or COVID-19 status. This practice can help with detection of emerging condition changes.
As much as possible, staff should not work across units or floors.
Minimize the number of staff caring for each resident.
Limit staff’s onsite work to only one facility, whenever possible.

Separation of COVID-19 Positive Residents

Long-term care facilities must separate residents who are COVID-19 positive from residents who do not have COVID-19 or who have an unknown COVID-19 status. Whenever possible, long-term care facilities must establish a separate, dedicated wing or unit (hereafter “dedicated space”) within the facility to care for COVID-19 positive residents. Facilities with dedicated COVID-19 space must be capable of maintaining strict infection control practices and testing protocols. Facilities must make every effort to have separate staffing teams for COVID-19-positive and COVID-19-negative residents

When possible, a long-term care facility should establish designated space – such as a room at the end of a unit or hallway, or a dedicated unit or wing within the facility – to care for recovered residents who previously tested positive for COVID-19 and are no longer exhibiting any symptoms. These residents may transition to the dedicated recovery space after fourteen days. Please note that although staff are no longer required to use full PPE, facemasks are still required when caring for such recovered residents.

Updated Admissions Policies

When a long-term care facility resident is transferred from a long-term care facility to a hospital for evaluation of any condition, including but not limited to, COVID-19 care, each long-term care facility must accept the resident’s return to the facility when the resident no longer requires hospital level of care.

Long-term care facilities shall not condition admission or return to the facility on COVID-19 testing or COVID-19 test results. If a test is not performed before hospital discharge, the long-term care facility should test the resident upon admission, if a test is available. Awaiting the test results should not delay an individual’s discharge from the hospital to the long-term care facility.

Newly admitted or readmitted residents to a long-term care facility or residents returning from any setting outside of the facility who are not recovered from COVID-19 within the previous six months should be quarantined in a private room or, if unavailable, placed in a room with another resident who is recovered (less than six months from infection), in a dedicated quarantine space and monitored for symptoms of COVID-19 for fourteen days after admission to the facility. Newly admitted or readmitted residents should be cared for using all recommended COVID-19 PPE. If a resident receives a positive COVID-19 test result during the fourteen days of quarantine, the resident should be moved to a dedicated COVID-19 space.

Residents who are readmitted or return after less than 24 hours in a health care setting such as a hospital or dialysis center do not need to be quarantined upon return.

Planned Resident Leave of Absences

Because of ongoing community transmission of COVID-19 within the Commonwealth of Massachusetts and concerns for the health and safety of residents, the Department recommends that residents do not participate in planned leaves of absence at this time. If, however, a long-term care facility resident wants to schedule a planned leave of absence from the facility, the facility clinical leadership should work with the resident and their loved ones to create a plan for a safer leave. This plan must include education for the resident and loved ones about:

wearing cloth face coverings;
practicing physical distancing;
limiting interaction to the fewest number of people possible while the resident is on their planned leave.
Loved ones also limiting their interaction to the fewest number of people possible for two weeks before the resident’s planned leave/visit.
assessment about the possible exposure risks while the resident is on their planned leave and instructions about how to mitigate them.
The need for the resident to quarantine for fourteen days upon return from leave

If the facility does not have a room available for quarantine for a resident who is returning from a planned leave of absence, then loved ones may be required to keep and care for the resident until a room is available. The facility must communicate this to the resident and their loved ones prior to the resident leaving the facility.

Long-term care facilities should test any resident returning from a planned leave of absence, however, a negative test result does not remove the requirement to quarantine for the 14 day period.

Nursing Homes with Dedicated COVID-19 Space

Whenever possible, hospitalized patients who are confirmed to be infected with COVID-19 and require skilled nursing level of care should be admitted to a facility with a dedicated COVID-19 space.

Testing

In addition to the circumstance-specific testing requirements described above in this memo, long-term care facilities are required to perform weekly surveillance testing of all staff and outbreak testing on all residents and staff within 48 hours of a newly identified case pursuant to DPH Guidance: Updates to Long-Term Care Surveillance Testing.

As outlined in the checklist in Appendix B, once a new case is identified in a facility, following the requisite outbreak testing, long-term care facilities should test all residents and staff every three days until the facility goes seven days without a new case or their assigned epidemiologist directs otherwise. In addition, facilities should immediately test any symptomatic resident or staff member or newly exposed resident or staff member. The facility may use the BinaxNOW tests to perform testing described in this paragraph, consistent with DPH Guidance: BinaxNOW Rapid Point of Care COVID-19 Testing for Long-Term Care Facilities.

Long-Term Care Facility Outbreak Prevention and Management Checklist

The Department has developed an outbreak prevention and management checklist (see Appendix B) as a tool for long-term care facilities to use to mitigate the spread of COVID-19 and ensure the health and safety of long-term care residents and staff. All facilities should use this checklist as a reference tool while still referring to DPH guidance documents for the full recommendations and requirements for responding to COVID-19. If the Department determines that a facility is unable to implement or adhere to any of the components of the checklist, the Department may require the facility to engage external resources to assist with implementation and adherence

DPH continues to work with state, federal and local partners on the outbreak of novel Coronavirus 2019 (COVID-19), caused by the virus SARS-CoV-2, and we continue to appreciate the essential role you have in responding to this evolving situation.

DPH strongly encourages all nursing homes in Massachusetts to monitor the Centers for Medicare & Medicaid Services (CMS) website and the Centers for Disease Control and Prevention (CDC) website for up-to-date information and resources:

Additionally, please visit DPH’s website that provides up-to-date information on COVID-19 in Massachusetts: https://www.mass.gov/2019coronavirus.

Appendix A

Personal Protective Equipment Used When Providing Care to Residents in Long Term Care***

Resident Type	Recommended PPE	Recommended Sign for Resident Room
*COVID Negative Residents and COVID-Recovered Residents (>6 months from infection) When there are resident or staff case(s) identified within the last 14 days in the facility.	Full PPE to include Facemask, Face Shield/Goggles, Gown and Gloves. Gown use can be prioritized for high-contact resident care activities1. Gown and gloves must be changed between residents.	COVID-Negative (with recent cases) Sign
*COVID Negative Residents and COVID-Recovered Residents (>6 months from infection) When no resident or staff cases are identified within the last 14 days in the facility.	Facemask and Face Shield/Goggles	COVID-Negative (without recent cases) Sign
COVID-Recovered Residents (< 6 months from infection) (meet 10 d/24h threshold clearance)	Facemask and Face Shield/Goggles	N/A
COVID-Positive Residents	Full PPE to include N95 respirator or alternative (Facemask is acceptable if N95 respirator not available), Face Shield/Goggles, Gown and Gloves. May consider extended use during shortages if no known co-infected residents.	Isolation Sign
COVID-Suspected Residents (i.e. Symptomatic, with test results pending)	Full PPE upon room entry to include N95 respirator or alternative (Facemask is acceptable if N95 respirator not available), Face Shield/Goggles, Gown and Gloves. Gown and gloves must be changed between residents.	Isolation Sign
Quarantined (i.e. New admission or exposed to a confirmed COVID case,)	Full PPE to include N95 respirator or alternative (Facemask is acceptable if N95 respirator not available, or if resident not known to have exposure to a confirmed COVID case), Face Shield/Goggles, Gown and Gloves. Gown and gloves must be changed between residents.	Quarantine Sign

*“Negative” refers to a resident who has never tested positive.

**”Resident case” means a case that was acquired in the facility (i.e. not within 14 days of admission)

***Individuals infected or co-infected with a communicable disease (such as Clostridioides difficile) should be cared for using appropriate PPE, changed between residents.

1 https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html

Prioritizing gowns for activities where splashes and sprays are anticipated (including aerosol-generating procedures) and high-contact resident care activities that provide opportunities for transfer of pathogens to hands and clothing of HCP, is recommended.

CDC provides these examples of high-contact resident care activities:

Dressing
Bathing/showering
Transferring
Providing hygiene
Changing linens
Changing briefs or assisting with toileting
Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator
Wound care: any skin opening requiring a dressing

https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html

Appendix B

Long-Term Care Facility Outbreak Prevention and Management Checklist

Purpose: DPH has developed this outbreak prevention and management checklist as a tool for long-term care facilities to use to prevent COVID-19 cases and, if any cases are confirmed, to mitigate the spread of COVID-19 within the facility and ensure the health and safety of long-term care residents and staff.

COVID-19 Prevention Checklist: Facilities that do not have a COVID-19 positive staff member or a resident with a facility-acquired COVID-19 infection within the past 14 days are urged to maintain vigilance and to review and implement the checklist below:

Facility Assessment:

Conduct an Infection Prevention and Control Assessment using the CDC tool at least once per week. The tool may be found at the following link: https://www.cdc.gov/coronavirus/2019-ncov/hcp/assessment-tool-for-nursing-homes.html
- Review findings with the facility’s leadership team and make an actionable plan to address any improvement areas that includes a leader responsible for each area identified

Identify additional alternate spaces for staff break rooms and limit break room areas to one staff person at a time
- Post signage in break rooms and consider implementing scheduled breaks
- Ensure environmental services is cleaning the room frequently throughout the day

Testing:

Weekly surveillance testing of 100% of all staff. See DPH Surveillance Testing Guidance.

In addition to the surveillance testing outlined above, the facility should immediately test any symptomatic resident or staff member. The facility may use the BinaxNOW test kits to perform such testing. See DPH BinaxNow Guidance.

Personal Protective Equipment (PPE) and Hand Hygiene:

Perform PPE and hand hygiene audits using a tool, document the findings, review with the facility’s leadership team and provide feedback to frontline staff
- Perform hand hygiene audit once per shift on all units with a minimum of 10 observations
- Perform PPE audit once per shift on all units with a minimum of 10 observations

Ensure that alcohol-based hand-rub (ABHR) stations are available throughout the facility
- ABHR stations should be available outside of every resident room and accessible to staff unless otherwise contraindicated

All facility personnel are wearing a facemask while in the facility and eye protection when in resident care areas.

Residents, as they are able to tolerate, should wear a facemask anytime a staff member enters their room and whenever they leave their room or are around others, including whenever they leave the facility for essential medical appointments

COVID-19 Outbreak Checklist: If the facility identifies one new resident or staff case then the facility should take the following steps to mitigate any further transmission:

Facility Assessment:

Conduct an Infection Prevention and Control Assessment using the CDC tool within 24 hours of a new case to identify potential vulnerabilities or deficiencies; conduct an assessment no less than once per week thereafter.
- Review findings with the facility’s leadership team and make an actionable plan to address any improvement areas that includes a leader responsible for each area identified

Consider having an assessment conducted by a peer or external organization with quality assurance and performance improvement experience, or as otherwise required by DPH.

Testing:

Once a new case is identified, the facility should initiate outbreak testing. Outbreak testing should include:
- Testing all staff and all residents as soon as possible and no later than 48 hours after identification of the positive using laboratory PCR testing.
- Once the facility has completed the requisite outbreak testing described above, the facility should test all staff and residents every three daysuntil the facility goes seven days without a new case or their assigned epidemiologist directs otherwise. The facility may use BinaxNOW test kits to perform this testing.

Contact the DPH epidemiologist assigned to their home and Local Board of Health once a positive case is identified.

Asymptomatic recovered staff and residents can be excluded from outbreak testing unless there is an exposure or they become symptomatic. Facilities should follow the Recovered Resident guidance.

Continue to conduct surveillance testing of 100% of all staff weekly. See DPH Surveillance Testing Guidance.

In addition to outbreak testing outlined above, the facility should immediately test any symptomatic resident or staff member or newly exposed resident or staff member. The facility may use the BinaxNOW test kits to perform such testing. See DPH BinaxNow Guidance.

Staffing:

Limit direct care nursing staff to working on one unit for the duration of the outbreak. If staff need to be assigned to work on a different unit then test the staff member using the BinaxNOW test kit prior to the beginning of the shift on the alternate unit.

Environmental services, therapy and dietary staff should be limited to working on one unit to the extent possible.

Personal Protective Equipment (PPE) and Hand Hygiene:

Use gowns and gloves in addition to facemasks and eye protection for high contact care activities for COVID-19 negative residents until 14 days with no new COVID-19 positive residents and/or staff.

Ensure PPE and Hand Hygiene Compliance.

Designate a PPE coach or coaches for each shift who are responsible for performing PPE and hand hygiene audits as well as performing just-in-time education to staff on PPE use.

Perform PPE and hand hygiene audits using a tool, document the findings, share with facility’s leadership team at least daily and provide feedback to frontline staff
- Perform hand hygiene audits three times per shift on all units with a minimum of 10 observations
- Perform PPE audits three times per shift on all units with a minimum of 10 observations
- Establish adherence goals for hand hygiene and PPE audits; if the facility’s performance falls below the goal then identify plan to address any causal factors for non-adherence

Ensure that alcohol-based hand-rub (ABHR) stations are available throughout the facility
- ABHR stations should be available outside of every resident room and accessible to staff unless otherwise contraindicated

Residents, as they are able to tolerate, should wear a face mask when a staff member enters their room and whenever they leave their room or are around others, including whenever they leave the facility for essential medical appointments.

Post precaution signs immediately outside of resident rooms indicating appropriate infection control and prevention precautions. See DPH Precautions Signs.