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EDMUND G. BROWN JR.
Governor

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


AFL 20-33.2
May 15, 2020


TO:
Skilled Nursing Facilities

SUBJECT:
Interim Guidance for Transfer of Residents with Suspected or Confirmed Coronavirus Disease (COVID-19)
(This AFL supersedes AFL 20-33.1)


All Facilities Letter (AFL) Summary

  • This AFL clarifies California Department of Public Health (CDPH) expectations and provides interim guidance for skilled nursing facilities (SNF) for transfer and continuity of care of residents with suspected or confirmed COVID-19 infection, including admission of COVID-19 positive residents following hospitalization who still require transmission-based precautions.
  • This AFL clarifies that the guidance applies when residents are transferred from an alternate care site and that SNFs must accept the return of a resident from a hospital or alternate care site.
  • This AFL also informs SNFs that residents may be transferred between facilities for the purposes of cohorting COVID-19 patients.

California is experiencing increasing numbers of COVID-19 cases and hospitalizations, and there is an urgent need to ensure hospital capacity to be able to meet the demand for patients with COVID-19 requiring acute care. Patients hospitalized, or receiving treatment at an alternate care site, with COVID-19 can be discharged to a SNF when clinically indicated. Meeting criteria for discontinuation of transmission-based precautions is not a prerequisite for discharge from the hospital or alternate care site. SNFs transferring patients to alternate care sites must hold a transferred patient's bed for at least 14 days, and, accept the return of a resident from the alternate care site unless CDPH determines otherwise.

All California SNFs should be implementing the guidance outlined in AFL 20-25.2 Preparing for Coronavirus Disease 2019 (COVID-19) in California Skilled Nursing Facilities, including preparations to be able to safely:

  1. Receive residents with suspected or confirmed COVID-19 infection;
  2. Care for residents with suspected or confirmed COVID-19 infection; and
  3. Prevent spread of COVID-19 within their facility.

Considerations for transfer of patients from hospitals or alternate care sites to SNFs

SNFs should prepare to receive patients that are clinically stable for discharge from hospitals or alternate care sites in the following scenarios:

  • Patients with no clinical concern for COVID-19 may be transferred from hospitals or alternate care sites to SNFs following usual procedures.
    • SNFs may not require a negative test result for COVID-19 as criteria for admission or readmission of residents hospitalized or receiving treatment at an alternate care site with no clinical concern for COVID-19.
    • Hospitals and alternate care sites are NOT required to perform COVID-19 testing on patients solely for discharge considerations unless the patient develops new respiratory infection symptoms, in which case the patient is not likely to be ready for discharge.
    • SNFs are encouraged to develop plans for placement and observation of new admissions and readmissions without COVID-19 testing, such as single rooms or a separate observation unit, wing or building. 
  • Patients investigated for possible COVID-19, with negative test results may be transferred from hospitals or alternate care sites to SNFs following usual procedures.
    • Hospitals and alternate care sites should conduct influenza testing as appropriate, and communicate results and any indication for continued transmission-based precautions upon transfer.
  • Patients with confirmed or suspected COVID-19 should not be sent to a SNF via discharge from a hospital or alternate care site, inter-facility transfer, or readmission after hospitalization or treatment at an alternate care site without first consulting the local health department (LHD).
    • SNFs can be expected to accept a resident diagnosed with COVID-19 and who is still requiring transmission-based precautions for COVID-19 as long as the facility can follow Centers for Disease Control and Prevention (CDC) infection prevention and control recommendations for the care of COVID-19 patients, including adequate supplies of personal protective equipment (PPE).
      • LHD may direct placement of the patient at a facility that has already cared for COVID-19 cases, or that has a specific unit designated to care for COVID-19 residents.
    • Hospital discharge planners and alternative care sites should provide advanced notice to the SNF for any transfer of a patient with COVID-19. If transmission-based precautions have been discontinued* AND patients' symptoms have resolved, patients can be discharged back to the facility they came from, regardless of the facility's PPE supply and ability to adhere to infection prevention and control recommendations for the care of COVID-19 patients.
  • Patients under investigation (PUI) for COVID-19, but test results pending: At this time, PUIs should NOT be transferred to SNFs until test results are available.

Considerations for Care of Residents with Suspected or Confirmed COVID-19 Infection who do not Clinically Require Hospital or Alternate Care Site Transfer
SNFs should only transfer residents with suspected or confirmed COVID-19 infection to higher acuity healthcare settings when clinically indicated. The decision to transfer a patient to an alternate care site will be made by the receiving facility and the SNF, in conjunction with the LHD and CDPH. Prior to transfer, SNFs must notify transport personnel and receiving facility about the suspected diagnosis. If clinically stable, residents with suspected or confirmed COVID-19 should remain at the SNF with appropriate infection prevention and control measures. SNFs may transfer patients between long-term care facilities for purposes of cohorting COVID 19 positive residents in accordance with the guidance provided by the Centers for Medicare and Medicaid Services (CMS) in Quality, Safety and Oversight Memo (QSO) 25-20-NH (PDF). SNFs should review CDPH guidance on facility preparations, and management of suspect or confirmed COVID-19 resident care outlined in AFL 20-25.2

*Transmission-based precautions for COVID-19 should be used for at least 10 days from symptom onset AND 3 days of recovery, defined as being afebrile without fever-reducing medication and improvement in respiratory symptoms (e.g., cough, shortness of breath). Lingering cough after 72 hours would not be an indication for continuation of transmission-based precautions. Consideration should be given to extending transmission-based precautions for individuals with immunocompromising conditions.

 

Sincerely,

Original signed by Heidi W. Steinecker

Heidi W. Steinecker

Deputy Director

 

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