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

AFL 22-31
December 12, 2022

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
(This AFL supersedes AFL 20-87.1)


​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.
  • This AFL revision includes updated guidance based on SARS-CoV-2 testing and management of new SNF admissions and readmissions.

NOTE: This AFL is no longer in effect and is for historical purposes only.

Please refer to the most recent CDC guidance. ​​


In an ongoing effort to ensure resident safety and to minimize the spread of SARS-CoV-2 and other respiratory viruses among vulnerable individuals, the California Department of Public Health (CDPH) is revising this AFL to include updated guidance from the Centers for Disease Control and Prevention (CDC) on SARS-CoV-2 testing and management of new SNF admissions and readmissions. CDPH is providing this guidance to SNFs and general acute care hospitals to support safe, appropriate, and timely access to SNF care following acute hospitalization.

Seasonal Surges During the COVID-19 Pandemic

The influenza season has begun in California with the ongoing circulation of transmissible SARS-CoV-2 variants and other respiratory illnesses, 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 personal protective equipment (PPE), appropriate isolation areas 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 LHDs 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 influenza season. Additionally, facilities that experience critical staffing shortages may refer to AFL 21-08.9 Guidance on Quarantine for Health Care Personnel (HCP) Exposed to SARS-CoV-2 and Return to Work for HCP with COVID-19. Facilities experiencing urgent staffing needs may also request resources through their local Medical Health Operational Area Coordinator using the process described in AFL 20-46.3.

Testing and Management of Newly Admitted and Readmitted Residents

The CDC has updated guidance on testing and management of newly admitted and readmitted residents.

Newly admitted residents and residents who have left the facility for >24 hours, regardless of vaccination status, should have a series of three viral tests for SARS-COV-2 infection; immediately upon transfer or admission and, if negative, again at 3 days and 5 days after their admission.

Quarantine is not required for newly admitted and readmitted residents, regardless of vaccination status.

Results for asymptomatic patients tested in the hospital do not have to be available prior to SNF transfer. SNFs may not require a negative test result prior to accepting a new admission. Two negative tests are not required prior to transfer. 

Testing is not required for hospitalized residents who tested positive for COVID-19 and met criteria for discontinuation of isolation and precautions prior to SNF admission or readmission and are within 30 days of their infection; testing of recovered residents within 31-90 days of prior infection should be done using an antigen test, preferably.

Procedures for the Duration of Isolation of Residents

CDC generally recommends against the use of a test-based strategy (two tests 24 hours apart) to discontinue isolation and transmission-based precautions for SARS-CoV-2 positive patients or residents, 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. Residents who test positive and are symptomatic should be isolated (regardless of their vaccination status) until the following conditions are met:

  • At least 10 days have passed since symptom onset; AND
  • At least 24 hours have passed since resolution of fever without the use of fever-reducing medications; AND
  • Any other symptoms have improved
  • NOTE: The timeframe from symptoms onset could be extended up to 20 days for individuals who had critical illness (e.g., required intensive care) and beyond 20 days for individuals who are severely immunocompromised (e.g., currently receiving chemotherapy, or recent organ transplant); use of a test-based strategy and (if available) consultation with an infectious disease specialist is recommended to determine when transmission-based precautions could be discontinued for these individuals.

Residents who test positive and are asymptomatic throughout their infection should be isolated for at least 10 days following the date of their positive test.

Limitations on New Admissions during an Outbreak

Many LHDs require SNFs to close to new admissions during an outbreak until transmission is contained; for COVID-19 outbreaks, containment is generally evidenced by no new cases among residents for 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 post-exposure or response testing, cohorting, 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 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.

Request for Admission/Transfer Review or Guidance

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 LHD, or 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

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



Original signed by Cassie Dunham

Cassie Dunham
Deputy Director



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