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

AFL 20-87
November 24, 2020

Skilled Nursing Facilities
General Acute Care Hospitals

Movement of Patients/Residents in the Healthcare Continuum During Seasonal Surges and the Coronavirus Disease 2019 (COVID-19) Pandemic

All Facilities Letter (AFL) Summary

  • This AFL provides guidance for admission and readmission of skilled nursing facility (SNF) residents during seasonal hospital surges and the COVID-19 pandemic.
  • This AFL provides guidance on working with local public health departments (LHD) and hospital discharge planners to ensure appropriate placement of resident following hospital discharge. 

As we move into the influenza season with the co-occurrence of COVID-19, anticipated surges in hospital admissions and emergency department (ED) visits can affect hospital capacity when SNFs do not accept new admissions or readmissions of residents from hospitals. This barrier to hospital discharges will lead to SNF residents remaining in the acute care hospital for longer than medically necessary. At the same time, SNFs must be operationally prepared to safely and appropriately accept admissions or readmissions in relation to acceptable staffing levels, adequate supply of PPE, appropriate separate zones within the facility, and following applicable testing strategies. Hospitals should proactively communicate with SNFs early to facilitate transfers. SNFs should work collaboratively with hospital discharge planners and LHD to facilitate the safe and appropriate placement of SNF residents. SNFs should be prepared to provide care safely without putting existing residents at risk during the COVID-19 pandemic and upcoming influenza season.

The purpose of this AFL is to clarify considerations for SARS-CoV-2 testing and quarantine of new SNF admissions in the yellow-observation area, management of readmissions and for limitations on new admissions during an outbreak. This guidance is provided to SNFs and general acute care hospitals to support safe, appropriate, and timely access to SNF care following acute hospitalization.  

SARS-CoV-2 testing and quarantine of new SNF admissions
The purpose of SARS-CoV-2 testing and quarantine in the yellow-observation area for new admissions to SNFs is to monitor the resident for 14 days since the date of their last likely potential exposure outside the SNF, which could be in the community or in the transferring healthcare facility if that facility is having an outbreak. SNFs should refer to AFL 20-74 and AFL 20-80 for guidance on resident placement and cohorting based on COVID-19 and influenza status. In general, an acute care hospital stay is not considered an exposure unless that hospital is having a suspected or confirmed outbreak. AFL 20-53.3 includes criteria for assessing whether or not a transferring acute care hospital should be considered a site of potential exposure, for the purpose of determining whether to count the acute care hospital days as part of the 14-day quarantine observation period from the date of last potential exposure for new admissions.

CDC recommends against use of the test-based strategy (two tests 24 hours apart) to discontinue isolation and transmission-based precautions for SARS-CoV-2 positive individuals, except under special circumstances. Facilities should use the symptoms or time-based strategy for discontinuing isolation and transmission-based precautions for SARS-CoV-2 positive individuals. COVID-19 recovered individuals who have met criteria for discontinuation of isolation and transmission-based precautions and:

  • Are within 90 days of a positive test can be admitted to the green "recovered" area of a SNF
  • More than 90 days have passed since their prior positive test should be admitted to the "yellow" observation area of the SNF for 14 days since the date of their last potential new exposure.   

 The two tests 24 hours apart test-based strategy is not a strategy for screening asymptomatic new admissions whose COVID status is unknown. SNFs may not require two negative tests 24 hours apart for screening of new admissions. One screening test collected during the hospitalization within 48 hours of discharge date is sufficient.  Particularly during hospital surges, the results of the test obtained in the hospital on asymptomatic individuals for the purposes of SNF discharge do not necessarily have to be available at the time of SNF transfer, since these newly admitted residents will be placed in the yellow-observation area for 14 days since the date of their last potential exposure even if their test result upon transfer was negative. 

Residents re-admitted to the same SNF after a hospital stay or ED visit
When there is no suspected SARS-CoV-2 transmission at an outside facility, re-admitted residents do not necessarily require SARS-CoV-2 testing and quarantine upon readmission to the same SNF; rather than quarantine, SNFs can consider periodic SARS-CoV-2 testing of individuals who frequently leave the facility (for example, for dialysis).  In addition, SNF residents hospitalized and requiring transmission-based precautions for COVID-19 or influenza should be discharged from the acute care setting when clinically appropriate, not based on the period of potential virus shedding or recommended duration of transmission-based precautions.  SNFs must prepare for and have the necessary staffing and PPE supplies available to implement transmission-based precautions as needed for residents re-admitted after hospitalization.

Limitations on new admissions during an outbreak
Many LHD require SNFs to close to new admissions during an outbreak until transmission is contained; for COVID-19 outbreaks, containment is generally evidenced by two sequentially negative rounds of response testing among residents over 14 days, and for influenza, containment is generally evidenced by no new cases for one week.  However, demonstration of containment should not be the sole basis for determining closures to new admissions. Particularly during hospital surges, LHD should consider the following factors to allow flexibility for SNFs to continue admitting new residents before outbreak containment is demonstrated:

  • SNF has implemented outbreak control measures, as appropriate, such as response testing, cohorting, dedicated staff for the COVID-19 positive zone with no crossover, transmission-based precautions, and chemoprophylaxis (for influenza, assuming adequate availability)
  • SNF has no staffing shortage or operational problems (e.g., administrator or director of nursing out sick). SNF must have a trained infection preventionist. Long term staffing plans should be documented.
  • SNF has adequate personal protective equipment (PPE), staff from all shifts have access to N95 respirator fit testing and all staff have been fit-tested to the respirator model(s) currently available for use in the facility, and access to adequate hand hygiene and environmental cleaning supplies
  • SNF has a well-demarcated "yellow" COVID-19 observation area (unit or wing) for new admissions

Request for admission/transfer review or guidance
The California Department of Public Health (CDPH) requests that hospitals or SNFs that encounter difficulty in transitioning new or returning residents from an acute care hospital to a SNF based on their COVID-19 status or COVID-19-related admission hold contact the LDH, the healthcare associated infections program of CDPH for review of the admission decision and suggestions for next steps. 

LHDs and their acute hospital and SNF partners are encouraged to proactively communicate on issues relating to SNF access, and the implications for regional capacity and surge planning, and to collaborate on development and dissemination of policies most appropriate for their specific county. 

SNFs may submit any questions about infection prevention and control of COVID-19 to the CDPH Healthcare-Associated Infections Program via email at or

If you have any questions about this AFL, please contact your local district office.



Original signed by Heidi W. Steinecker

Heidi W. Steinecker
Deputy Director


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