Infection Prevention & Control Guidance FAQ for Nursing Homes

Testing

A FDA EUA viral diagnostic test should be performed when testing is indicated. Antibody    testing should not be used in this context.  There are two types of viral diagnostic tests, molecular (e.g., PCR) and antigen. Facilities performing antigen tests should refer to the CDC Considerations for Use of SARS-CoV-2 Antigen Testing in Nursing Homes

An upper respiratory specimen is used to test for SAR-CoV-2. Swabbing can take place in a variety of ways, depending on the specimen collection method that is validated by the laboratory performing tests for your facility. A common method is a nasopharyngeal (NP) swab, where a thin, flexible swab is inserted far back into the nose to obtain material for testing. If the procedure causes more than mild discomfort, then the swabbing technique should be reviewed. It is also important to ensure that swabs intended specifically for NP swabbing are used; these swabs are thinner and more flexible than swabs intended for other specimen types. Other specimen types depend on the test and laboratory, and these may include a nasal swab (inserted about an inch into the nose), a saliva specimen, or an oropharyngeal (OP, throat) swab. Acceptable specimen types should be discussed with your laboratory, as it depends on their typical testing methodology.

When testing is indicated, asymptomatic individuals who have previously tested positive greater than 3 months (90 days) prior should be re-tested. Cases of reinfection with COVID-19 have been reported, but remain rare.  More information is available on the CDC website, however, this guidance may be updated as we learn more information on viral persistence and risk for reinfection. 

CDC recommends that residents and staff who had a positive viral test at any time and become symptomatic after recovering from the initial illness should be re-tested and placed back on the appropriate Transmission-Based Precautions (TBP) or excluded from work, respectively.

Yes. Results of antibody testing should not be used as the sole basis to either diagnose acute infection or make recommendations on limiting social or environmental exposures or changes to work related policies. We do not yet know if the presence of antibodies to SARS-CoV-2 provides any level of protection against reinfection with the virus.  However, this recommendation may be reconsidered at a later time for previously COVID-19 positive individuals as more is learned about immunity following COVID-19.

A growing body of evidence suggests that fully vaccinated people are less likely to have asymptomatic infection and potentially less likely to transmit SARS-CoV-2 to others. However, SARS-CoV2 testing still recommended in the following situations:

1- Anyone with symptoms of COVID-19, regardless of vaccination status, should receive a viral test immediately.

2- Asymptomatic HCP with a higher-risk exposure and patients or residents with prolonged close contact with someone with SARS-CoV-2 infection, regardless of vaccination status, should have a series of two viral tests for SARS-CoV-2 infection. In these situations, testing is recommended immediately and 5–7 days after exposure.

3- In healthcare facilities with an outbreak of SARS-CoV-2, recommendations for viral testing HCP, residents, and patients (regardless of vaccination status) remain unchanged.

For more information, see the CDC guidance.

CMS published a revised LTCFs’ testing requirements on April, 27, 2021, and according to that the following conditions should trigger testing in LTCFs:

1- When a symptomatic individual is identified: test any staff and residents vaccinated and unvaccinated, with signs and symptoms.

2-  Outbreak: test all staff and residents, vaccinated and unvaccinated, that previously tested negative until no new cases are identified.

For healthcare facilities that are performing expanded screening testing for asymptomatic HCP who do not have a known exposure, vaccinated HCP can be excluded from such a testing program. However, per CDC and CMS recommendations, vaccinated HCP should have a viral test if the HCP is symptomatic, has a higher-risk exposure or is working in a facility experiencing an outbreak.

Routine testing of unvaccinated staff should continue and be based on the extent of the virus in the community. Facilities should use their county positivity rate in the prior week as the trigger for staff testing frequency.

Community COVID-19 Activity County Positivity Rate in the past week  Minimum Testing Frequency of Unvaccinated Staff
Low <5%  Once a month
Medium 5% - 10%  Once a week
High  >10% Twice a week

No, staff do not need to be tested at each facility. If documentation of the test result is provided to each facility, the results from one setting are adequate to meet the testing recommendations at any facility. Each facility should maintain appropriate documentation of test results. Staff should be encouraged to tell facilities if they have had exposures at other facilities with recognized COVID-19 cases. Similarly, staff who become symptomatic should alert each facility and be tested as soon as possible.

The definition of staff that should be tested is defined in the  CMS interim final rule. When staff testing is recommended, those staff members should be offered a test. See below response for addressing staff refusals.

Yes. Diagnostic tests of nursing home staff that are performed outside of the facility meet the testing recommendation, as long as the employee has the appropriate documentation to provide to the nursing home administrator and the test was conducted in a reasonable time frame (e.g., 3-7 days) from when the test was recommended.

If staff with symptoms consistent with COVID-19 decline testing, they should be presumed to have COVID-19 and excluded from work. Return to work decisions should be based on COVID-19 return to work guidance at the discretion of the facility’s occupational health program. More information can be found in the CMS interim final rule.

If asymptomatic staff decline testing, work restriction, if any, should be determined by the facility’s occupational health. All staff should be trained in proper use of personal protective equipment, including universal facemask policies, hand hygiene, and other measures needed to stop transmission.

Residents, or their medical powers of attorney, have the right to decline testing. Clinical discussions about testing may include alternative specimen collection sources that may be more acceptable to residents than nasopharyngeal swabs (e.g., anterior nares). Providing information about the method of testing and reason for pursuing testing may facilitate discussions with residents and their medical powers of attorney. More information can be found in the CMS interim final rule.

If a resident has symptoms consistent with COVID-19, but declines testing, they should remain on Transmission-Based Precautions until they meet the symptom-based criteria for discontinuation.

If a resident is asymptomatic and declines testing at the time of facility-wide testing, decisions on placing the resident on Transmission-Based Precautions for COVID-19 or providing usual care should be based on whether the facility has evidence suggesting transmission (i.e., confirmed infection in staff or nursing-home onset infection in a resident).If outbreak testing has been triggered and an asymptomatic resident refuses testing, the facility should be extremely vigilant, such as through additional monitoring, to ensure the resident maintains appropriate distance from other residents, wears a face covering, and practices effective hand hygiene until the procedures for outbreak testing have been completed.

VDH recommends "When testing is indicated, asymptomatic individuals who have previously tested positive greater than 3 months ago should be re-tested. It is unknown at this time whether an individual can be re-infected. Residents and staff who had a positive viral test at any time and become symptomatic after recovering from the initial illness should be re-tested and placed back on the appropriate Transmission-Based Precautions (TBP) or excluded from work, respectively. However, if a staff member refuses to be tested, the facility should: 

  1. Educate the refusing individual on the importance of testing in providing protection to other facility residents and facility staff. 
  2. Answer any questions posed by the refusing individual. 
  3. Address any concerns about testing raised by the refusing individual. 
  4. Have a plan in place for how to handle staff who refuse to be tested. This may require consultation with employment law experts and/or Human Resources personnel. 

More information on staff testing guidance and recommendations is available here: https://www.cdc.gov/coronavirus/2019-ncov/hcp/testing-healthcare-personnel.html

Based on the information available (which is subject to change when more data becomes available) and per CDC guidance, persons who have recovered from SARS-CoV-2 infection and a positive PCR during the 90 days after illness onset, more likely represents persistent shedding of viral RNA than reinfection.

  • If such a person remains asymptomatic during this 90-day period, then any re-testing is unlikely to yield useful information, even if the person had close contact with an infected person.
  • If such a person becomes symptomatic during this 90-day period and an evaluation fails to identify a diagnosis other than SARS-CoV-2 infection (e.g., influenza), then the person may warrant evaluation for SARS-CoV-2 reinfection in consultation with an infectious disease or infection control expert. Isolation may be warranted during this evaluation, particularly if symptoms developed after close contact with an infected person.

There is limited data about reinfection with SARS-CoV-2 after recovery from COVID-19. While viral RNA shedding declines with resolution of symptoms, it may continue for days to weeks. However, the detection of RNA during convalescence does not necessarily indicate the presence of a viable infectious virus. More information is available on the CDC webpage.

Yes. The community prevalence rate guides the frequency of a facility’s routine staff testing. But during an OB, all staff and residents should be tested, and all staff and residents that tested negative should be retested every 3 -7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result.

Symptomatic and asymptomatic staff and residents in LTCFs, if RT-PCR testing is not available or the TAT is long (more than 48hrs.), might use antigen testing as part of an outbreak response in a nursing home. Serial testing (antigen or PCR) should be performed every 3-7 days for all residents and healthcare personnel until no new cases are identified in a 14-day period. More information is available here: https://www.vdh.virginia.gov/coronavirus/antigen-testing-recommendations/

Personal Protective Equipment (PPE)

Visitors are required to wear a facemask or cloth mask for the duration of their visit. In case of PPE shortage, visitors should bring their own masks. If the resident being visited is on Transmission-Based Precautions (TBP), other PPE like gowns or gloves might be required for entering their room. In such a scenario, before giving permission to visit a resident on TBP, the facility should ensure that enough PPE is available.

The facility under conventional conditions might supply all required PPE to VDH staff visiting the facility. However, during PPE shortage, VDH staff shall bring their own PPE.  VDH staff should avoid entering a resident room without wearing the appropriate PPE.

MRC volunteers working on units have suspected or confirmed COVID-19 cases, should wear full PPE  including N95 respirator (or face mask if not available), eye protection, gown, and gloves.

KN95 masks cannot be used as a replacement for N95 respirators because they lack a tight enough seal.  If a facility has KN95 masks, they can be used as face masks for droplet precautions.  FDA maintains a list of PPE EUAsThese authorized respirators should be used in accordance with CDC recommendations.   As of May 2021, The supply and availability of NIOSH-approved respirators have increased significantly over the last several months. Healthcare facilities should not be using crisis capacity strategies at this time and should promptly resume conventional practices. Check the NIOSH Certified Equipment List to identify all NIOSH-approved respirators.

HCPs caring for suspected or confirmed COVID-19 cases in nursing homes should wear full PPE including fit tested N95 respirator, eye protection, gown and gloves.

Infection Prevention and Control

An updated symptom list and details regarding screening can be found on the CDC website.

Each nursing home should assign an individual with training in infection prevention and control (IPC) to provide onsite management of all COVID-19 prevention and response activities. A detailed training module has been developed by CDC and CMS and is available free of charge; it provides 23 training courses on core activities of effective IPC programs. In addition, CMS recently published an IPC training course for LTCFs which is available here: https://qsep.cms.gov/COVID-Training-Instructions.aspx

Facilities should develop policies for safely conducting food service activities. Only essential staff are permitted in units/care areas for suspected or confirmed COVID-19 cases, and food delivery can be done by nurses or CNAs. When delivering food to a resident with suspected or confirmed COVID-19, staff should perform hand hygiene, don PPE (gloves, gown, mask, eye protection), drop off food, take off and dispose of PPE and perform hand hygiene. Repeat this process between each room of a resident with suspected or confirmed COVID-19. Discarding gloves between patients is necessary to prevent transmission of infectious material.

When delivering food to a resident without suspected or confirmed COVID-19 infection, staff should perform hand hygiene and don gloves, then remove gloves and repeat hand hygiene if staff has contact with the resident or any surfaces that have significant potential for being contaminated with infectious material in their room.

While we want to ensure social distancing and protect residents from exposure to the virus, there is also a need to find ways to maintain overall physical and psychosocial health. Facilities should consider the current COVID-19 situation in their facility and community when making decisions about relaxing certain restrictions. While taking a person-centered approach and adhering to the core principles of COVID-19 infection prevention, outdoor visitation is preferred even when the resident and visitor are fully vaccinated against COVID-19.The following should be considered when incorporating visitations off-site or spending time outdoors into the plan of care: 

  • Only asymptomatic residents and residents who meet criteria for discontinuation of TBP are allowed to have visitations.. 
  • Residents should always maintain social distancing. 
  • Residents should wear a face mask if able to do so. Visitors should wear a face mask.  
  • If the resident requires physical assistance or supervision, an appropriate staff member should be present to assist. The staff member should wear a face mask. 
  • Increase the frequency of cleaning and disinfecting benches and other frequently touched outdoor surfaces. 
  • Encourage residents to perform hand hygiene before and after spending time outside of the facility. 

Visitations should occur in controlled areas, not in the general public. More information can be found in the Revised CMS guidance for Nursing Home Visitations- COVID-19.

It is important to weigh the risk and benefit of home visits and try to limit contact with elders to keep them safe. When a facility gives permission for a resident to leave the building for a home visit, multiple factors should be taken into consideration including resident's medical status/provider input, COVID-19 prevalence in the local community, possible resident exposure to someone sick or exposed in the household or direct contact with the public, etc. Facilities shall provide education to residents and their families about potential risks of public settings, particularly if they have not been fully vaccinated, and reminded to avoid crowds and poorly ventilated spaces. In addition, residents should inform the facility if they have close contact with a person with SARS-CoV-2 infection while outside the facility.

Before granting permission for a home visit, facilities should consult with the medical provider.  HCPs should evaluate the resident's clinical condition and potential risks for exposure to inform decisions. Residents should be encouraged and assisted with adherence to all recommended infection prevention and control measures, including source control, physical distancing, and hand hygiene.If fully vaccinated residents 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 the Interim Public Health Recommendations for Fully Vaccinated People.

In most circumstances, quarantine is not recommended for fully vaccinated residents who leave the facility for less than 24 hours and do not have close contact with someone with SARS-CoV-2 infection. However, facilities might consider quarantining residents who leave the facility if there is uncertainty about their adherence or the adherence of those around them to recommended IPC measures based on risk assessment. Residents who leave the facility for 24 hours or longer should generally be managed as described in the CDC New Admission and Readmission guidance.

Visits for residents who share a room should ideally not be conducted in the resident’s room. If in‐room visitation must occur (resident is unable to leave the room), an unvaccinated roommate should not be present during the visit. If neither patient/ resident is able to leave the room, facilities should attempt to enable in-room visitation while maintaining recommended infection prevention and control practice, including physical distancing and source control.

Residents and visitors should physically distance themselves from other residents and HCP in the facility. Outdoor visitation is preferred even when the resident and visitor are fully vaccinated. Outdoor visits generally pose a lower risk of transmission due to increased space and air flow. 

When conducting facility-wide testing, a large number of residents might be identified with COVID-19 infection and cohorting them can be complicated and might increase the chances of cross-contamination. “Shelter in place” is a practical solution in these circumstances if the following conditions are implemented: 

  • In shared rooms, the distance between resident’s beds should be at least 6 feet and curtains can be used as a physical barrier. However, staff should don and doff the appropriate PPE between residents in the same room.
  • Increase the frequency of environmental cleaning and disinfection.  
  • Do not cohort residents based on symptoms only.

CDC defines HCPs as "HCP refers to all paid and unpaid persons serving in healthcare settings who have the potential for direct or indirect exposure to patients or infectious materials, including body substances (e.g., blood, tissue, and specific body fluids); contaminated medical supplies, devices, and equipment; contaminated environmental surfaces; or contaminated air. HCP include, but are not limited to, emergency medical service personnel, nurses, nursing assistants, physicians, technicians, therapists, phlebotomists, pharmacists, students and trainees, contractual staff not employed by the healthcare facility, and persons not directly involved in patient care, but who could be exposed to infectious agents that can be transmitted in the healthcare setting (e.g., clerical, dietary, environmental services, laundry, security, engineering and facilities management, administrative, billing, and volunteer personnel).

For persons who remain asymptomatic following recovery from COVID-19, retesting (e.g., as part of a contact tracing investigation) is not necessary during the first 3 months after the date of symptom onset. When a positive test occurs less than 3 months after the person’s symptom onset of their most recent illness, the positive test may represent a new infection or a persistently positive test associated with the previous infection. If a positive test occurs more than 3 months after a person’s symptom onset, clinicians and public health authorities should consider the possibility of reinfection. Until we have more information, the determination of whether a patient with a positive test in these situations is contagious to others should be made on a case-by-case basis. Consider consultation with infectious diseases specialists and public health authorities to review all available information (e.g., medical history, time from initial positive test, RT-PCR Ct values, and presence of COVID-19 signs or symptoms).  Persons who are determined to be potentially infectious should undergo evaluation and remain isolated until they again meet criteria for discontinuation of isolation or discontinuation of transmission-based precautions, depending on their circumstances.

More information regarding patients with persistent or recurrent positive tests can be found in the CDC FAQ

Aerosol Generating Procedures (AGP) include, but not limited to: sputum induction, manual ventilation, open suctioning of airways, endo tracheal intubation and bronchoscopy. More information is available here: https://www.vdh.virginia.gov/content/uploads/sites/182/2020/05/AGPs-and-COVID-19_FINAL_v3.pdf

In most cases, electrostatic spraying and fogging is not recommended as a primary means of surface disinfection and has several safety risks to consider. These methods are not currently able to replace existing cleaning and disinfection processes. According to the CDC, these devices are typically used as a supplementary or adjunct technology to terminal room cleaning. This means that the patient has been transferred or discharged and is no longer occupying the space, so that EVS may begin cleaning and disinfecting the room in preparation for a new patient (e.g., terminal cleaning).

  •   Foggers can be hand-held or no-touch devices (NTDs).
  •   When using an electrostatic sprayer or a fogger to apply disinfectants, always follow manufacturer directions for operation and maintenance of the sprayer or fogger and the disinfectant label’s use directions (e.g., application rate, distance to surface while applying, and contact time).
  • Follow the disinfectant’s label recommendations for appropriate personal protective equipment (PPE) for the operator, and adhere to any recommended re-entry times for bystanders, other staff members, or patients

For information about the application of EPA List N disinfectants with electrostatic sprayers and foggers, refer to the EPA’s Frequent Questions about Disinfectants and Coronavirus (COVID-19external icon). If a product does not have an electrostatic spraying or fogging use on a label, the EPA has not evaluated the safety and efficacy of using that product with an electrostatic sprayer or a fogger.

Note: The CDC does not recommend disinfectant fogging (with chemicals such as formaldehyde, phenol-based agents, or quaternary ammonium compounds) for routine purposes to decontaminate environmental surfaces in patient-care areas or to disinfect the air in patient rooms. These recommendations do not apply to newer technologies involving fogging for room decontamination (e.g., ozone mists, vaporized hydrogen peroxide) that have become available since the 2003 and 2008 recommendations were made. CDC has made no recommendation (unresolved issue) for the use of newer technologies such as ozone mists, vaporized hydrogen peroxide) that have become available. CDC states that more research is required to clarify the effectiveness and reliability of fogging, UV irradiation, and ozone mists to reduce environmental contamination.

More information can be found in these references:

https://www.cdc.gov/infectioncontrol/guidelines/disinfection/recommendations.html#r6

https://www.cdc.gov/infectioncontrol/guidelines/disinfection/updates.html

https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Finfection-control-faq.html#Cleaning-and-Disinfection-of-Environmental-Surfaces

https://www.cdc.gov/coronavirus/2019-ncov/community/disinfecting-building-facility.html

https://www.epa.gov/coronavirus/can-i-use-fogging-fumigation-or-electrostatic-spraying-or-drones-help-control-covid-19

Resident Placement/Cohorting

Quarantining residents who regularly leave the facility for medical appointments (e.g., dialysis, chemotherapy) would result in indefinite isolation of the resident that likely outweighs any potential benefits of quarantine.

CDC states that  in most circumstances, quarantine is not recommended for residents who leave the facility for less than 24 hours (e.g., for medical appointments, dialysis sessions) and do not have close contact with someone with SARS-CoV-2 infection.

Facilities might consider quarantining residents who leave the facility if, based on an assessment of risk, uncertainty exists about their adherence or the adherence of those around them to recommended IPC measures.

In addition to the following  recommendations:

  • Residents should wear a cloth face covering or facemask when they leave their room and or facility (including dialysis)
  • Regular communication between the dialysis facilities and the LTCF (in both directions) is essential to help identify patients with fever or symptoms consistent with COVID-19 before they enter the facilities and facilitate resident's care
  • Physical distancing measures should be implemented, such as minimizing movement of these residents within the facility as much as possible
  • LTCFs should comply with all other IPC recommendations (link to playbook, other VDH guidance, etc.)

Closure of facilities to new admissions may be recommended as a standard part of VDH disease control measures. However, any decision to close and/or accept new admissions or readmissions has to be made based on a risk assessment and tailored to the situation. The decision to close a facility to new admissions should follow the CMS requirements and be made in consultation with the LHD. The following criteria should be met when making a decision on accepting new admissions or readmissions:

  • The number of COVID-19 cases identified in the facility (staff and residents) is decreasing.
  • No evidence of widespread transmission of COVID-19 in the facility.
  • Facility is compliant with IPC best practices.
  • Enough space for cohorting positive versus negative residents, and an observational unit for new admissions is available.
  • Adequate staffing, PPE, and other supplies.
  • The facility has a plan to manage new admissions and readmissions

If a HCP tests positive for COVID and is symptomatic, they should be excluded from work until all Return to Work Criteria are met. Persons who are asymptomatic and tested positive for COVID cannot return to work until their isolation period is completed and they meet all Return to Work Criteria.  Healthcare facilities must be prepared for potential staffing shortages and have plans and processes in place to mitigate them, including considerations for permitting HCP to return to work without meeting all return to work criteria above. Refer to the Strategies to Mitigate Healthcare Personnel Staffing Shortages document for information.

 In regards to fully vaccinated HCPs, CDC currently recommends that fully vaccinated HCP with higher-risk exposures who are asymptomatic do not need to be restricted from work for 14 days following their exposure. However, fully vaccinated HCP who have traveled should continue to follow CDC travel recommendations and requirements, including restriction from work, when recommended for any traveler.

Extended-use of N95s is recommended as a contingency strategy and not during conventional capacity. As of May 2021: The supply and availability of NIOSH-approved respirators have increased significantly over the last several months. Healthcare facilities should not be using crisis capacity strategies at this time and should promptly resume conventional practices. Check the NIOSH Certified Equipment List to identify all NIOSH-approved respirators.

If the facility is operating under conventional capacity, all PPE should be removed upon exiting the patient's room and hand hygiene performed.  New PPE should be donned before entering a patient's room (unless optimization strategies are necessary).

More information is available on the CDC website.