Interim infection prevention and control recommendations for nursing homes

Posted on September 29, 2022 by Kari Everson

Late on Sept. 23, the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) published updated COVID-19 guidance for nursing homes and assisted living. The updated guidance reflects the increased prevalence of vaccine-acquired and disease-acquired immunity. The updated information includes:

• Infection Control Guidance (CDC)
• Potential Exposure at Work (CDC)
• Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic (CDC)
• Strategies to Mitigate Healthcare Personnel Staffing Shortages (CDC)
• Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2 (CDC)
• QSO-20-38-NH REVISED (CMS)
• QSO-20-39-NH REVISED (CMS)

CMS recommends that our settings ensure everyone knows the building's infection prevention and control practices (IPC). Post visual alerts in multiple areas, including the entrance, common areas, elevators, and bathrooms. Additionally, organizations should offer healthcare workers, residents, and visitors resources and counseling  regarding the importance of COVID-19 vaccination.

Eye Protection, Source Control & Screening Update

When our Monday Member Message was sent, there was still a question on whether the updated CDC guidance on eye protection, source control masking and screening would be applicable in Minnesota settings. LeadingAge Minnesota has been in communication with MDH and the updates are as follows:

Eye Protection: Per a message that went out from MDH on Tuesday, eye protection continues to be recommended; however, it is not required. It is up to the individual organization to determine whether routine, universal use of eye protection will continue within the community. Eye protection does still need to be worn during aerosol generating procedures and when caring for a resident who has known or suspected COVID-19.

Source Control: The CDC changed guidance for use of source control masks. Today, Sept. 29, the Minnesota Department of Health sent an email through the compendium indicating they will be following the updated CDC guidance. 

When SARS-CoV-2 Community Transmission levels are not high, healthcare facilities could choose not to require universal source control.  Community transmission levels should be checked weekly. However, even if source control is not universally required, it remains recommended for individuals in healthcare settings who:

• Have suspected or confirmed SARS-CoV-2 infection or other respiratory infection (e.g. those with runny nose, cough, sneeze); or
• Had close contact (patients and visitors) or a higher-risk exposure (HCP) with someone with SARS-CoV-2 infection, for 10 days after their exposure; or
• Reside or work on a unit or area of the facility experiencing a SARS-CoV-2 outbreak.

Healthcare facilities that choose to not require universal source control when SARS-COV-2 Community Transmission levels are not high should have a well-defined process for ensuring: 

• Individuals with suspected or confirmed SARS-CoV-2 infection or other respiratory infection (e.g., runny nose, cough) wear source control
• Patients/residents and visitors who have had a close contact with someone with SARS-CoV-2 infection, wear source control for 10 days after their exposure
• Staff with a higher-risk exposure with someone with SARS-CoV-2 infection, wear source control for 10 days after their exposure
• Individuals who reside or work on a unit or area of the facility experiencing a SARS-CoV-2 outbreak will wear source control until no new cases have been identified for 14 days
• Plan for optimizing COVID-19 vaccination, including all primary series doses and boosters, as well as influenza vaccination of healthcare workers. Ensure that symptomatic healthcare workers are tested for SARS-CoV-2, influenza, and other respiratory illness.

MDH further states, healthcare facilities should consider the Social Vulnerability Index (SVI) score when making decisions about their COVID-19 infection control policy. Areas with higher social vulnerability (lower SVI quartile) have been shown to be at increased risk for COVID-19 outbreaks, in-hospital death, and major cardiovascular events, while experiencing decreased vaccination rates and uptake of antiviral treatments. You can read more about Minnesota’s use of SVI in our COVID-19 pandemic response as well as find a list of MN zip codes with their SVI score and quartile here: COVID-19 Vaccine Equity in Minnesota - Minnesota Dept. of Health (state.mn.us)

Screening: Daily resident COVID screening should continue. However, screening visitors and staff no longer needs to be done to the extent we did in the past. Now, signage should be posted for staff and visitors explaining if they have a fever, COVID symptoms, or other symptoms of respiratory illness they should not enter the building. Information on who to contact should they be asked not to enter should also be posted and available.

Routine Testing Guidance

Testing plays a significant role in protecting older adults living in congregate settings from COVID-19.

Nursing Homes: CMS' Quality, Safety, and Oversight (QSO) memo 20-38-NH Revised changes testing guidance for routine testing of asymptomatic staff and individuals who recovered from COVID-19. Current testing guidance for nursing homes:

• CMS and CDC removed routine surveillance testing guidance
• Vaccination status is no longer a consideration for testing symptomatic or newly identified COVID-19 positive staff and residents
• Test symptomatic staff and residents regardless of vaccination status
• New COVID-19 positive staff and residents with identified close contacts – test all staff and residents that had close contact or high-risk exposure regardless of vaccination status
• New COVID-19 positive staff and residents without identified close contacts – test all staff and residents on an entire unit, floor, or facility-wide

Assisted Living: Routine surveillance testing is NOT required in assisted living organizations. Testing in assisted living is only needed when there is an outbreak or a symptomatic resident or staff member.

Testing Process for Asymptomatic Staff or Residents with Exposure—Nursing Homes & Assisted Living: While routine testing is no longer required, testing asymptomatic staff and residents with a COVID-19 exposure is. The resident exposure standard is close contact. Staff exposure standard is high-risk.

Testing Frequency for Staff with High-risk Exposure & Residents with Close Contact Exposure: Exposure testing requires a series of three tests. The three-test series is as follows:

• Immediately following the close-contact or high-risk exposure but not less than 24 hours after exposure
• If negative, test again 48 hours after the first negative test
• If negative, test again 48 hours after the second negative test.

The date of exposure is day zero; therefore, administer tests on days one, three, and five. Testing is not recommended for those who recovered from COVID-19 in the last 30 days. However, facilities may consider testing if an individual has had COVID in the previous 31-90 days. If settings choose to test an asymptomatic staff person 31-90 days since their last COVID illness, use antigen tests.

Exposure Definitions: Close-contact exposure for a resident or visitor includes contact with someone who is COVID positive that is greater than 15 minutes in 24 hours, and the contact was within six feet of the infected individual.

High-risk exposure for staff includes:

• A healthcare worker working with a COVID-positive individual who is not wearing a respirator – OR – if a healthcare worker is wearing a mask, but the positive individual is not. (Both need to be wearing masks for it not to be a high-risk exposure)
• A healthcare worker is not wearing eye protection if the COVID-positive person is not wearing a mask
• A healthcare worker is present for an aerosol-generating procedure (AGP) and is not wearing a gown, gloves, eye protection, and N95 or higher level respirator.

Asymptomatic Resident Precautions Following Close Contact with COVID Positive Individual

In most cases, asymptomatic residents do not require transmission-based precautions (TBP) following close contact with a COVID-positive person. Residents should still wear source control for ten days following the exposure. Times when an asymptomatic resident should have TBPs implemented include:

• The resident is unable to wear source control for ten days following the exposure
• The resident is moderately to severely immunocompromised
• The resident lives in a unit with others with moderate to severe immunocompromise
• The resident lives in a unit with ongoing COVID transmission not controlled with initial interventions.

If the resident is in TBP for any of the above reasons, follow the guidance for discontinuing TBP for symptomatic residents.

Asymptomatic Staff Precautions Following High-Risk Exposure 

The CDC updated guidance to reflect that staff with high-risk exposures do not require work restrictions regardless of their vaccination status. Staff should monitor for signs and symptoms of COVID or other respiratory infections and report any that develop.

TBP for Symptomatic Residents Under Evaluation for COVID-19 Infection

Residents who have COVID-19 or respiratory symptoms should be cared for using TBPs. To discontinue TBPs, organizations must exclude a diagnosis of COVID-19. Negative test result(s) can exclude infection.

• NAAT test: a single negative test is sufficient in most circumstances.
• If a higher level of clinical suspicion exists, consider maintaining TBP and confirming with a second NAAT test.
• ANTIGEN test: confirm a negative antigen test result by either a negative NAAT test or a second negative antigen test 48 hours after the first negative test.

TBP for Residents with COVID Infection

If a resident tests positive for COVID-19, TBPs may be discontinued based on symptoms, the severity of illness, and immunocompromise status. The date of symptom onset or positive test is considered day zero.

Mild to moderate illness NOT moderately to severely immunocompromised:

• Ten days have passed since symptoms first appeared; and
• 24 hours have passed since the last fever without fever-reducing medications; and
• Symptoms have improved.

Asymptomatic and NOT moderately to severely immunocompromised:

• Ten days have passed since the date of the first positive viral test

Severe or critical illness and are NOT moderately to severely immunocompromised:

• At least ten days and up to 20 days have passed since symptoms first appeared; and
• 24 hours have passed since the last fever without fever-reducing medications; and
• Symptoms improved.

Moderately to severely immunocompromised:

• May use a test-based strategy

TBP for Staff with COVID-19 Infection

Mild to moderate illness NOT moderately to severely immunocompromised:

• Seven days have passed since symptoms first appeared, and a negative viral test within 48 hours of returning to work – OR – 
• Ten days have passed since symptoms first appear; if there is no testing or there is a positive test result when tested on days 5-7
  • 24 hours have passed since the last fever without fever-reducing medications; and
  • Symptoms have improved

It is acceptable to use either a NAAT or antigen test. However, if using an antigen test, staff should have another negative test obtained on day five and a second negative test 48 hours later. This approach is the same as resident testing:

• NAAT test: a single negative test is sufficient in most circumstances.
• If a higher level of clinical suspicion exists, consider maintaining TBP and confirming with a second NAAT test.
• ANTIGEN test: confirm a negative test by either a negative NAAT test or a second negative antigen test 48 hours after the first negative test.

Asymptomatic and NOT moderately to severely immunocompromised:

• Seven days have passed since symptoms first appeared, and there is a negative viral test within 48 hours of returning to work – OR – 
  • If there is no test, 10 days have passed since symptoms first appear, or there is a positive test result when tested on days 5-7

Organizations can use either a NAAT or antigen test. However, if the facility uses an antigen test, staff should have another negative test obtained on day 5 and a second negative test 48 hours later. This process is the same as resident testing:

• NAAT test: a single negative test is sufficient in most circumstances.
• If a higher level of clinical suspicion exists, consider maintaining TBP and confirming with a second NAAT test.
• ANTIGEN test: Confirm a negative result by either a negative NAAT test or a second negative antigen test 48 hours after the first negative test.

Severe or critical illness and are NOT moderately to severely immunocompromised:

• At least 10 days and up to 20 days have passed since symptoms first appeared; and
• 24 hours have passed since the last fever without fever-reducing medications; and
• Symptoms improved.

Moderate to severe immunocompromise:

• May use a test-based strategy

New Admissions and Residents who Leave for More Than 24 Hours

CDC updated guidance for new admissions and residents who leave the building for more than 24 hours. Vaccination status is now not a factor.

Test residents upon admission in counties where community transmission levels are high:

• Test at admission and
• If negative, test again 48 hours after the first negative test
• If negative, test again 48 hours after the second test.

In counties where community transmission is low, moderate, or substantial, communities may decide if they test new, asymptomatic admissions. Testing is recommended for all, but again, at the facility's discretion.

• Advise residents to wear source control for ten days following admission.
• Manage residents who leave the facility for more than 24 hours the same as admissions.

Visitation Guidance Updates

MDH and CDC added guidance requiring settings to guide what organizations expect visitors to do if they have a positive COVID-19 test, symptoms of COVID-19, or other infectious symptoms. Settings should defer in-person visits until the visitor meets the CDC healthcare criteria to end isolation. If a visitor was in close contact with someone who is COVID-19 positive, delay non-urgent visits until ten days after the close contact. Our settings should encourage physical distancing during peak visitation times and large gatherings.

Masks during visits: Everyone should wear masks when the organization is in a high community transmission county. If the county community transmission rate is not high, the safest practice is for residents and visitors to wear face coverings/masks. However, the organization can choose not to require visitors or residents to wear face coverings/masks unless there is an active outbreak in the building.

• When residents and visitors are alone in the resident's room or a designated visitation area, the resident and visitor may choose not to wear masks.
• If a roommate is present during the visit, it is safest for the visitor to wear a face covering/mask.

Visitation During an Outbreak Investigation

Initiate outbreaks when there is a single new case of COVID-19 identified in either a resident or staff member. While there is an active outbreak investigation, organizations should limit visitor movement in the building and physically distance from other residents and staff.

Join Us: Huddle on Friday, Sept. 30

The scope of these CDC and CMS updates mean big changes to your operations. That’s why we are adding a Huddle on Friday, Sept. 30 at 11 a.m. LeadingAge Minnesota staff will provide an overview of these changes and then we'll open the floor to your questions. Register today!

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