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

AFL 24-15
June 13, 2024

Skilled Nursing Facilities (SNF)
General Acute Care Hospitals (GACH) with a SNF Distinct Part (D/P)

Enhanced Barrier Precautions (EBP)
(This AFL Supersedes AFL 22-21)


​All ​Facilities Letter (AFL) Summary

​​On March 20, 2024, CMS distributed CMS QSO-24-08-NH (PDF)​, which updated its infection prevention and control guidance for long-term care facilities to include the CDC guidance for EBP. California SNFs should refer to the CDC website on Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) and CDC's EBP Frequently Asked Questions (FAQs) for guidance and tools for implementing EBP. ​

To facilitate California SNF compliance with the CMS requirement, CDPH is retiring its ESP guidance document and adopting CDC's EBP guidance and terminology. CDPH will continue to provide additional California-specific EBP implementation considerations, available in the Enhanced Barrier Precautions​: Additional Considerations for California Skilled Nursing Facilities​ (PDF). SNFs that previously implemented CDPH's ESP should be aware that ESP was based on the same core principles as EBP. Specifically, both ESP and EBP involve glove and gown use during high-contact care activities based on a resident's risk factors for MDRO transmission. SNFs that have used either ESP or EBP guidance to educate and train their healthcare personnel and have made gloves and gowns readily available to staff should be well-positioned to comply with the CMS requirements for EBP implementation.

All SNFs in compliance with the CMS's EBP requirement are able to admit and provide care for residents with MDROs. Thus, there is no basis for a SNF to refuse admission of a resident based on their need for EBP or MDRO status. Residents on EBP do not require placement in a single-person room, even when known to be infected or colonized with an MDRO. CDPH provides additional guidance for cohorting multiple residents in the same room or designated area of the facility, based on MDRO status, in the Cohorting Guidance for Patients or Residents Infected or Colonized with Multidrug-resistant Organisms (PDF).

For EBP implementation questions not addressed in CDC's guidance or FAQs, contact the CDPH Healthcare-Associated Infections (HAI) Program at



Original signed by Cassie Dunham

Cassie Dunham

Deputy Director

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