The reopening guidance can be applied to both nursing homes and assisted living facilities. The DSS Reopening Guidance for Assisted Living Facilities (ALFs) can be found here. DSS has advised ALFs to follow the VDH Nursing Home Reopening Guidance.
Which type of test, viral or antibody, should be performed when testing is indicated by the recommendations?
An 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. Molecular tests are preferred over antigen tests. Positive results from antigen tests are highly accurate, but negative results do not rule out infection (false negative). Thus, negative results are considered presumptive and must be followed up with a confirmatory molecular test.
Are there other types of specimens that can be collected that don’t involve swabbing the nasopharynx?
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.
Do staff or residents with a previous positive viral test who have recovered still need to be tested when indicated by the recommendations?
When testing is indicated, asymptomatic individuals who have previously tested positive greater than 8 weeks ago should be re-tested. It is unknown at this time whether an individual can be re-infected. This guidance may be updated as we learn more information on viral persistence and risk for reinfection.
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.
See CDC guidance for more information.
Do staff or residents with a previous positive antibody test still need to be tested when indicated by the recommendations?
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.
If staff work at multiple facilities, do they need to receive a viral test at each facility?
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.
Can facilities use a point prevalence survey (PPS) that was conducted prior to the guidance being released as their first round of testing for the Phase I recommendations?
Facilities that completed a COVID-19 PPS for residents and staff can use the PPS as their first round of testing as long as all the following are met:
- PPS occurred on or after May 15, 2020
- All staff and all residents were given the opportunity to be tested at that time
When a facility is conducting facility-wide testing, if the first week of testing all staff and all residents reveals NO positives, does testing need to be repeated for a second week (i.e., second round)?
Yes. A facility should test all staff and all residents that have not previously tested positive for at least two consecutive weeks, or two consecutive rounds in some instances where the baseline test was conducted more than a week prior. Testing should continue weekly until there are no new cases among staff or nursing home-onset cases in residents for the previous 14 days.
Which staff members should be tested when indicated by the recommendations?
The definition of staff that should be tested is defined in the VDH Nursing Home Guidance for Phased Reopening. When staff testing is recommended, those staff members should be offered a test. See below response for addressing staff refusals.
If a staff member receives a test from an outside entity (e.g., community testing location, drive-thru pharmacy, private practitioner), does that meet the testing recommendation?
Yes. Diagnostic tests of nursing home staff that are performed outside of the facility meet the testing recommendation, so 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.
How should facilities approach staff who decline testing?
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.
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.
How should facilities approach residents who decline testing?
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.
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).
Should a facility proceed with repeat testing if the results from the previous week aren’t back yet?
VDH is aware of increased turnaround times causing delays in receiving and responding to testing results and planning additional testing. It is reasonable to wait for results, however, there are situations where waiting would not be recommended to conduct more testing. If a facility is testing in response to identification of one case and subsequent testing resulted in additional cases, the next round of weekly testing should not be delayed while waiting for results. For example, if a facility found positives on their first round of facility-wide testing, they will have to do at least two more rounds of testing (14 days of no new positives), so waiting for results from the second round of testing shouldn’t delay the third round.
Does the facility have to supply PPE to visitors?
Visitors are required to wear a facemask or cloth mask for the duration of their visit. Because of PPE shortages, 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.
Does the facility have to supply PPE to VDH staff (e.g., OLC surveyors, local health department communicable disease nurses or epidemiologists)?
The facility under conventional conditions might supply all required PPE to VDH staff visiting the facility. However, while PPE supply is limited, VDH staff shall bring their own PPE. VDH staff should avoid entering a resident room without wearing the appropriate PPE.
Can KN95 respirators be worn in place of N95 respirators?
No. KN95s are not a NIOSH-approved respirator and cannot be substituted for N95s. FDA has issued Emergency Use Authorizations (EUAs) for some respirators but the EUA for KN95s was revoked. KN95 masks always fail fit-testing and cannot be used as N95 respirators because they lack a tight enough seal. If a facility has KN95 masks, they can be used as facemasks for droplet precautions. FDA maintains a list of PPE EUAs. These authorized respirators should be used in accordance with CDC recommendations.
Is fit-testing required for a facility to enter Phase I if there are no positive cases in the facility?
Fit-testing is meant to determine the appropriate size of N95 respirator to obtain the best 'fit' or seal for each individual staff member. If a facility only has surgical masks or one-size-fits-all respirators, then the facility is responsible for a lower level of protection afforded their staff members caring for COVID-19 positive patients. A facility can move to Phase I, but should continue to check with their normal vendors and fit-test staff to the appropriate N95 respirator as soon as possible in preparation for having a COVID-19 positive resident. VDH encourages facilities to take advantage of train-the-trainer sessions being offered free of charge; more information is available here.
Prior to entering Phase III, VDH recommends facilities establish a written plan for implementing a respiratory protection program that is compliant with the OSHA respiratory protection standard for employees as per CDC guidance. The program should include medical evaluations, training, and fit-testing.
Where can I find more details regarding staff and resident screening for COVID-19 symptoms?
The VDH Nursing Home Reopening Guidance is a supplement to other guidance documents that have been previously disseminated. An updated symptom list and details regarding screening can be found in the VDH Guidance for LTCFs.
What qualifications does the infection preventionist (IP) in the nursing home need to have?
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. More training might be available, as more federal dollars are being designated for that purpose.
What infection prevention and control practices should be implemented when serving a meal or delivering a food tray to a resident with a suspected or confirmed COVID-19 infection?
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/CNAs. Extended use of gloves between residents is not recommended. 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.
When delivering food to a resident without suspected COVID-19 signs and symptoms, 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 in their room.
What are VDH recommendations for distant or outdoor visitations?
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. 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 outside the facility.
- 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 CMS FAQ on Nursing Home Visitation.
What should a facility do if a large number of symptomatic residents or positive COVID-19 cases have been identified?
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.
CMS has now mandated all certified nursing homes must receive an onsite focused infection control survey by July 31, 2020. Do earlier assessments from the local health department (LHD) or other assessment teams satisfy this requirement?
No. This is an independent regulatory requirement from the Centers for Medicare & Medicaid Services (CMS).
A person who previously tested positive and clinically recovered from COVID-19 is later tested again. If that person again tests positive by PCR, should they be managed as potentially infectious to others, and should be isolated again for COVID-19.
The person should be managed as potentially infectious and isolated. 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 or excluded from work, respectively.
When a positive test occurs less than about 6 weeks after the person met criteria for discontinuation of isolation, it can be difficult to determine if the positive test represents a new infection or a persistently positive test associated with the previous infection. If the positive test occurs more than 6-8 weeks after the person has completed their most recent isolation, clinicians and public health authorities should consider the possibility of reinfection. Ultimately, the determination of whether a patient with a subsequently positive test is contagious to others should be made on a case-by-case basis, in consultation with infectious diseases specialists and public health authorities, after review of 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 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.
Where should a facility place residents receiving hemodialysis or leaving the facility on a regular basis for necessary medical care?
Residents leaving the facility frequently for necessary medical care are at an increased exposure risk to SARS-CoV-2. They should be screened very closely for signs and symptoms of COVID-19 and they should be prioritized for testing whenever testing capacity is limited. Facilities should not put these residents on new admission units.
VDH acknowledges the science regarding SARS-CoV-2 is evolving and plans to update information regarding Phase Regression as more information is known.
Can a facility use a date prior to June 19, 2020 as the start of Phase I?
VDH recognizes the effort and measures that have been implemented prior to the release of the Nursing Home Reopening Guidance on June 19, 2020. A facility can use the date when all recommended criteria for Phase I were met, including if it was before June 19. Please enter the date the facility started Phase I when you submit the attestation form. The facility is still encouraged to seek consultation from their LHD.
Does the local health department (LHD) need to approve phase progression?
No. However, facilities should submit a Phase Change Attestation to their LHD when they meet all the criteria to move from one phase to another. Facilities are encouraged to seek consultation from their LHD when moving from phase to phase. The LHD will acknowledge receipt of the attestation.
Why does a positive staff case not trigger phase regression?
Healthcare workers have multiple exposure risks including their job, the community, and potentially their household. One positive case in a staff member does not suggest the infection was transmitted at the facility and therefore should not hold bearing on whether a facility should regress. A positive staff case would trigger testing of staff and residents as is indicated in the Nursing Home Reopening Guidance; if through those testing efforts a nursing home-onset case is identified, the facility should regress to Phase I. In the event two or more staff are epidemiologically linked and tested positive, the LHD might recommend regression to Phase I until the outbreak is contained.
The guidance states a facility should have access to adequate PPE as indicated in NHSN to progress in a phase. Does VDH recommend phase progression if the facility is still relying on the Healthcare Coalition or Local Health Department to maintain adequate PPE?
VDH recommends that a facility can progress to the next phase if adequate PPE is available for the next seven days, whether the supplies are received through their normal procurement channels or from the Healthcare Coalition or the LHD.
NHSN provided updated instructions on July 16 to clarify data entry in NHSN. Adequate PPE is defined as having enough supplies and PPE (i.e., N95 masks, surgical masks, eye protection, gowns, gloves, and alcohol-based hand sanitizer) for the next seven days using conventional capacity.
When responding to PPE questions, any item in which the facility does not have any or enough for conventional use should be marked as “No” in the COVID-19 Module - Supplies and Personal Protective Equipment pathway. While the CDC’s contingency and crises optimization strategies for PPE can be implemented when PPE supplies are low or unavailable, the goal is for LTCFs to resume standard practices when possible. CDC’s optimization strategies for PPE, such as contingency and/or crisis level strategies are NOT considered as having “Enough” supply, and therefore, “No” must be selected for each supply item in which contingency or crisis strategies are expected to be used for one week on the date responses are reported. For example, a facility that only has KN95 masks and not N95 masks for one week would answer “No.” Another example, extended use or reuse of a PPE item such as gowns or utilizing a decontamination method for N95 masks would answer “No.”
For phase progression in Virginia, if a facility responds “No” per NHSN PPE instructions, the facility should not progress.
The guidance states a facility should have adequate staffing as indicated in NHSN to progress in a phase. Does VDH recommend phase progression if the facility is still relying on MRC resources to supplement staffing?
Each facility should identify staffing shortages based on their facility needs and internal policies for staffing ratios. The use of temporary staff does not count as a staffing shortage if staffing ratios are met according to the facility’s needs and internal policies for staffing ratios.