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State of California—Health and Human Services Agency
California Department of Public Health

AFL 20-25.1
March 20, 2020

Skilled Nursing Facilities

Preparing for Coronavirus Disease 2019 (COVID-19) in California Skilled Nursing Facilities
(This AFL supersedes guidance provided in AFL 20-25)

AUTHORITY:     Executive Order N-27-20

All Facilities Letter (AFL) Summary

  • This AFL provides information for Skilled Nursing Facilities (SNFs) on preparing for COVID-19.
  • This AFL revises guidance on asymptomatic healthcare personnel in accordance with Executive Order N-27-20.

California Department of Public Health (CDPH) strongly recommends SNFs prepare for COVID-19. Elderly persons and those with chronic medical conditions may be at higher risk for severe illness and death from COVID-19.

All California SNFs should take steps to:

  1. Prevent introduction of COVID-19 into their facility;
  2. Detect COVID-19 in their facility;
  3. Prepare to receive residents with suspected or confirmed COVID-19 infection;
  4. Prepare to care for residents with suspected or confirmed COVID-19 infection; and
  5. Prevent spread of COVID-19 within their facility.

1)    Prevent Introduction of COVID-19 into your Facility

Visitors and healthcare personnel (HCP) displaying symptoms of illness are the most likely sources of introduction of COVID-19 into a SNF.

Visitors Entering Facility:

  • Restrict all nonessential visitors.
    • Screen essential visitors for travel within the prior 14 days to areas with COVID-19 transmission, (see the CDC COVID-19 travel website for updated travel information), and for signs or symptoms of a respiratory infection (e.g., fever, cough, or shortness of breath), or contact with someone with suspected or confirmed COVID-19 infection.
    • If a visitor meets any of these criteria, facilities should restrict their entry to the facility until he or she is no longer potentially infectious (for example, 72 hours after resolution of fever without antipyretic medication).
  • Post signs at the entry, reception area, and throughout the facility to help visitors self-identify relevant symptoms and travel history.
  • Restrict visitor movement within the facility and avoid common areas.
  • Before visitors enter a resident's room, provide instructions for hand hygiene, limiting surfaces touched, and appropriate use of personal protective equipment (PPE).
  • Educate visitors on basic infection control measures for respiratory infections, including hand hygiene, respiratory hygiene and cough etiquette (sneeze/cough into tissue or elbow, place used tissues in a waste receptacle and wash hands immediately after using tissues).
  • Facilitate remote communication between the resident and visitors (for example, video-call applications on cell phones or tablets), and develop policies addressing when and how visitors might still be allowed to enter the facility (such as, end of life situations).
  • See AFL 20-22.1 Guidance for Limiting the Transmission of COVID-19 in Long-Term Care Facilities for additional details.

Healthcare personnel:

  • Instruct healthcare personnel (HCP) to not report to work if they are symptomatic with fever or respiratory symptoms. HCP must report symptoms to their supervisor.
  • Implement sick leave policies that are non-punitive, flexible, and consistent with public health policies that allow ill HCP to stay home.
  • Instruct HCP who develop signs and symptoms of a respiratory infection while at work to immediately stop work, put on a facemask, alert their supervisor, leave the facility, and self-isolate at home.
  • Educate HCP on basic infection control measures for respiratory infections, including hand hygiene, respiratory hygiene and cough etiquette.
  • Restrict nonessential HCP (for example, volunteers).
  • Screen HCP prior to shift starting.
  • In accordance with Executive Order N-27-20, healthcare workers who are asymptomatic may continue working during the period of this COVID-19 emergency, provided those healthcare workers are taking precautions to prevent transmission.

2)    Detect COVID-19 in your Facility

Perform surveillance to detect respiratory infections, including COVID-19.

  • Implement a protocol for daily (or more frequent) monitoring for acute respiratory illness (fever, cough, shortness of breath) among residents and HCP.
  • Track suspected and confirmed respiratory infections using a line list, see the CDC's Long Term Care (LTC) Respiratory Surveillance Line List (PDF) for further details.
  • Report identification of a resident with severe respiratory infection, or more than two residents with acute respiratory illness over 72 hours, to your local public health department.
  • Assess incoming residents with acute respiratory illness upon admission for travel to areas with COVID-19 transmission in the 14 days prior to illness onset or contact with persons with confirmed COVID-19 infection.
  • Alert your local health department if you identify a resident who might have COVID-19. Notify other facilities prior to transferring a resident with acute respiratory illness, including suspected or confirmed COVID-19 infection.

3)    Prepare to Receive Residents with Suspected or Confirmed COVID-19 Infection

Although COVID-19 infection can be severe and require inpatient care, some infections may be mild and not require medical care in an acute care facility. Hospitalized patients with COVID-19 infection may be medically stable for discharge prior to discontinuation of transmission-based precautions; therefore, SNF should prepare to accept such residents and institute the appropriate precautions to prevent spread of infection to HCP and other patients.

  • Ensure all HCP are familiar with standard and transmission-based precautions.
  • Verify all HCP are familiar with proper PPE donning and doffing procedures by demonstrating competency.
  • Identify dedicated HCP to care for residents with COVID-19 and ensure they are N95 respirator fit-tested.
  • Ensure the facility has an adequate supply of facemasks, N95 respirators, face shields or goggles for eye protection, gowns and gloves; place supplies in all areas where patient care is provided.
  • Ensure the facility has adequate supply of alcohol-based hand rub and that it is easily accessible in every resident room (ideally both inside and outside the room and in other resident care areas).

4)    Prepare to Care for Residents with Suspected or Confirmed COVID-19 Infection

Most SNFs do not have airborne infection isolation rooms (AIIR) for placement of residents with COVID-19 infection.

  • Place residents with suspected or confirmed COVID-19 infection in single occupancy rooms (or cohorted in multi-occupancy rooms with other residents with confirmed COVID-19 infection), with the door closed.
  • Symptomatic residents and exposed roommates must limit movement outside their room; if they need to leave the room, they should wear a facemask.
  • HCP dedicated to care for residents with suspected or confirmed COVID-19 infection should use an N95 respirator wherever available (if unavailable, a facemask), eye protection (face shield or goggles), gloves, and gown.
  • Clean and disinfect high touch surfaces and shared resident care equipment with Environmental Protection Agency (EPA)-registered, healthcare-grade disinfectants. See the EPA Pesticide Registration List N: Disinfectants for Use Against SARS-CoV-2 for list of products with label claims against COVID-19.

5)    Prevent Spread of COVID-19 within your Facility

  • Cohort residents with suspected or confirmed COVID-19 infection on the same unit, wing, or building.
  • Use single-use equipment for residents with COVID-19 infection whenever possible; otherwise, dedicate re-useable medical equipment to residents with COVID-19 infection (for example, thermometers, stethoscopes, etc.) and clean and disinfect between use.
  • Minimize the number of HCP assigned to patient care activities for residents with COVID-19.
  • Suspend large group activities and close communal dining areas.



Original signed by Heidi W. Steinecker

Heidi W. Steinecker
Deputy Director



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