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COVID-19

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​June 27, 2020

To: Behavioral Health Facilities

Subject: Infection Mitigation in Behavioral Health Facilities – COVID-19 FAQs


This document is a compilation of resources from the California Department of Public Health and other public health sources that may be relevant to mitigating COVID-19 infection in behavioral health facilities, such as inpatient and outpatient mental health and substance use disorder treatment facilities (BHF). DHCS recommends that all facilities follow the directives of their local public health departments and continue to review updates to CDPH's COVID-19 website and Cal/OSHA (PDF) regulations because information about COVID-19 is evolving with time.

Every behavioral health facility is different with different physical settings, staffing, and capabilities. Therefore, although this document may suggest policies, it should only be used as a resource because it is important for each facility to develop policies and protocols for the specifics of its situation and licensing standards.

General Infection Mitigation Recommendations:

Facilities should post signage to remind staff, patients, and visitors of the importance of wearing face coverings, staying six feet apart, frequent use of alcohol-based hand sanitizers and hand-washing when hands are visibly soiled, and any other infection mitigation policies specific to the facility.

If a case of COVID-19 is identified in a mental health or SUD treatment facility, the facility should immediately contact the local health department (PDF) for specific advice.

As knowledge grows about COVID-19, please see the most recent guidance from CDC about symptoms of COVID-19, as not all patients present with respiratory illness. Altered level of consciousness and neurologic changes have been recognized recently as signs of COVID 19.

General resources:

  • Overview of Considerations for Residential Treatment
  • Triaging Patients Based on Need for Residential or Inpatient Care
  • Screening for COVID-19 Symptoms and Risk
  • Managing Patients who Screen Positive
  • Protecting and Monitoring Staff
  • Facility Policies and Procedures
  • Resources
    • General Guidance for Residential Programs
    • Guidance on Accepting New Clients
    • Guidance on How to Respond if Client Develops Symptoms
    • Guidance for Handling Clients Returning from the Hospital
    • Guidance for Health Care Personnel Return to Work (including return to work practice and work restrictions and crisis strategies to mitigate staffing shortages)
    • Frequently Asked Questions, with resources from CDC and CMS
  • California Occupational Safety and Health Information (Cal/OSHA) General Guidelines on Protecting Health Care Workers from COVID-19
    • Regulations and guidance addressing employee health and safety
    • Includes guidance on infection prevention, personal protective equipment (PPE) and staff training

COVID-19 testing and management of positive results

The below questions and answers reflect CDPH guidance at the time of publication of this document. Facilities should contact their local health departments (PDF) and continue to review updates to CDPH's COVID-19 website for more specific and current guidance.

1. Who should be screened for signs and symptoms of COVID 19 when entering BHFs?

From CDC guidance:

  • Screen everyone (patients, HCP, visitors) entering the healthcare facility for symptoms consistent with COVID-19 or exposure to others with COVID 19 and ensure they are practicing source control.

  • Actively take their temperature and document absence of symptoms consistent with COVID-19. Fever is a measured temperature ≥100.0°F or a report that the person has been feeling feverish even if the temperature was not measured or if the measured temperature is below the threshold.

  • Ask them if they have been advised to self-quarantine because of exposure to someone with SARS-CoV-2 infection.

2. Who should be tested for COVID-19? Should testing be used prior to admission to a behavioral health facility?

See California's COVID-19 Testing Taskforce website for up-to-date recommendations, as the recommendations are updated frequently due to changes in prevalence of the disease and the availability of testing. CDPH's All Facilities Letter (AFL) 20-44 provides information on testing prioritization.

 A negative test in an asymptomatic individual should not be required for admission to a treatment facility. Current CDPH guidance does not require testing prior to admission to treatment facilities. However, as testing becomes more widely available, pre-admission testing could be used to identify infected persons who need to be isolated at the time of admission to a mental health or SUD treatment facility. See the attachment (PDF) to AFL 25.2 and the third   FAQ on the CDC site for additional information.

If, however, an individual is symptomatic at the time admission to a treatment center is considered, that person should be evaluated by a medical provider and tested if indicated. Such individual should not be admitted until test results are available. See #3 for additional information for individuals who are test positive.

To reduce the risk of causing trauma to children and youth, especially those in the foster care system who may experience multiple transitions between placements, it is recommended that routine preadmission COVID-19 testing not be used unless testing is specifically indicated as determined by the child or youth's medical team. 

Negative test results should not be used to "clear" exposed persons who are still in their incubation period at the time of admission. All exposed persons need to be quarantined for 14 days, as a negative test does not rule out the possibility of infection in an incubation period after exposure.

Quarantine is used to separate exposed people from others.

Quarantine helps prevent the spread of disease that can occur before an infected person develops symptoms or is infected but does not develop symptoms. The quarantine period for COVID-19 is 14 days after the last exposure.

Isolation is used to separate infected people from others.

The isolation period for COVID-19 is a minimum of 10 days from symptom onset or from test date in asymptomatic people.

See CDC guidance for the difference between quarantine and isolation and CDC guidance on when isolation can end. Contact the local health department (PDF) for specific advice. 

 3. What should Psychiatric Health Facilities (PHFs) do about admissions for patients known to have COVID-19?

Title 22, California Code of Regulations, Section 77135 requires PHFs to divert admission of patients who have communicable diseases, including COVID-19 and promptly transfer the patient to a facility capable of accommodating such patients.  However, PHFs may seek approval from DHCS for a program flexibility in accordance with Title 22, California Code of Regulations, Section 77049, to treat individuals with COVID-19. DHCS approval may be granted on a case by case basis.  For a PHF to accept positive COVID 19 patients, the PHF must have a plan, space, trained staff, and PPE to care for such patients who require isolation. 

4. What should other behavioral health facilities do if staff or patients test positive for COVID-19?

If a case is identified, facilities should contact the local health department (PDF) for specific advice, including guidance about the need for notifying potentially exposed patients (including those already discharged), testing contacts and managing the illness. The facility shall also adhere to all statutory and regulatory requirements specific to the facility type. Facilities should also be aware of the Cal/OSHA recording and reporting requirements for COVID-19.

5. A patient who is detained for evaluation and treatment under the Lanterman-Petris Short Act tests positive for COVID-19. When the hold expires, the patient leaves against medical advice (AMA). Who should be notified?

The facility should immediately notify the local health department (PDF) about any positive COVID-19 test results for patients or staff, including patients who have tested positive or had a known exposure and leave AMA. In addition, PHFs must report to DHCS and the county mental health director, within 24 hours, any events identified in Title 22, California Code of Regulations, Section 77036, which would include cases of an actual or threatened walkout and communicable diseases, such as COVID-19. 

6. Should facilities notify families and conservators when a patient has been exposed to COVID-19 at a facility?

Contact the local health department (PDF) for specific guidance, based on the situation.  Please keep in mind that facilities need to comply with privacy and confidentiality rules.

7.What happens if an exposed or symptomatic patient is discharged before a test result is available?

Some patients may be discharged home prior to receiving their COVID-19 test results. The patient should be advised to be quarantined at home until it is established that quarantine is no longer indicated. The provider ordering the test must contact the patient with test results as soon as they are available, and contact the local health department (PDF) for guidance if positive. For positive test results, the provider should also coordinate care with the patient's outpatient behavioral health provider and primary care provider (PCP), if known, and ensure the patient receives appropriate instructions from the local public health department about follow-up surveillance and medical care for COVID-19. This CDC guidance provides information on the management of COVID-19 positive patients in home settings. 

8. If a patient with COVID-19 is ill, when should they be transferred to a higher level of care?

It is preferable not to house exposed patients together as not all exposed patients will become infected, and this practice could cause infection spread. The local health department (PDF) can advise facilities on how to handle specific situations, including an exposure at the facility. 

9. If a patient with COVID-19 is ill, when should they be transferred to a higher level of care?

When a patient with COVID 19 is identified, vital signs including pulse oximetry should be performed every 8 hours to detect worsening clinical condition. To determine whether a patient's illness requires a higher level of care than can be provided at the facility, a medical professional acting within their scope of medical practice should evaluate the patient to make that assessment. In SUD treatment facilities without incidental medical services available, the client should contact his or her primary care provider and/or health plan to obtain a telehealth or in-person consultation. Uninsured patients (or Medi-Cal patients without a primary care provider) may contact Medi-Nurse, the COVID-19 triage line (877) 409-9052.

Emergency medical attention (911) should be sought for patients showing any of these signs of emergency:

  • Trouble breathing
  • Persistent pain or pressure in the chest
  • New confusion
  • Inability to wake or stay awake
  • Bluish lips or face

 10. What needs to be considered during transportation from the ED to a BH facility when a patient is known or suspected to be infected with COVID-19?

Facilities should refer to the CDC's Interim Guidance for Emergency Medical Services for guidance on transportation for patients with COVID-19. The transportation provider and receiving facility should be notified in advance that the patient may have COVID-19 infection. Facial covering of the patient for source control should be observed whenever possible.

Management of patients with behavioral issues

11.How should patients with known or suspected COVID-19 be managed when agitated?

Facilities must provide close monitoring and assessment of levels of potential harm to self or others to ensure safety for patients and staff. Addressing the patient's immediate needs (offering food, drink, reading or writing materials) can be helpful. Staff should provide emotional support, and can offer disposable activities (e.g., origami, coloring materials, puzzles, word games, etc.) if available. All reusable equipment must be sanitized after use. See above CDC guidance links for additional information for special populations.

12.How should a MH or SUD treatment facility manage a COVID-19 positive patient who is not directable and is not able to follow isolation protocols? 

If a patient refuses to comply with isolation protocols, the facility shall inform the patient's attending physician and legally authorized representative, if applicable, to develop an appropriate treatment plan to address the patient identified treatment needs.  Each situation may need to be handled differently, depending on the treatment needs of the patient, and the need to balance safety of staff and other patients. Contact the local health department (PDF) for guidance. Spatial distancing should be prioritized. The facility shall have appropriate policies, procedures and resources to ensure the health and safety of all patients and staff; it is useful to have protocols for management of common situations in advance.

13.  Could an infected patient constitute a danger to others? 

Each situation may need to be handled differently, depending on the treatment needs of the patient, and the need to balance safety of staff and other patients. Contact the local health department (PDF)  and the county patients' rights advocate office for guidance. The facility shall have appropriate policies, procedures and resources to ensure the health and safety of all patients and staff; it is useful to have protocols for management of common situations in advance.

Infection mitigation, disinfection, and PPE

14.   Many behavioral health treatment activities are done in groups; how should these be adapted?

Specific public health guidance will shift with the shifting dynamics of the pandemic. However, these basic principles are expected to persist over time: the recommended isolation period should be completed before a patient with a positive COVID-19 test joins a group; use telephone and live video wherever possible; limit group size, ensure physical distancing of at least six feet, practice frequent hand hygiene,  ensure cloth face coverings are worn by all present (staff and clients) and disinfection of surfaces after individuals leave the area.

15.  What types of masks or face coverings are appropriate for staff and patients?

On June 18, 2020, CDPH issued guidance broadly requiring that face coverings be worn when in public statewide. Details and exceptions are described in this CDPH guidance (PDF). See Department of Industrial Relations (DIR) for a helpful diagram (PDF) about the difference between face coverings, masks, and respirators. CDC guidance also provides useful information including feasibility and adaptations.

Cloth face coverings provide source control (to reduce the amount of aerosolized virus being released from a person while speaking or coughing). Cloth face coverings should be used by asymptomatic staff at all times when in the facility and by asymptomatic patients whenever they are around others (the recommended isolation period should be completed before a patient with a positive COVID-19 test joins a group). A person known or suspected to have COVID should be given a surgical mask to provide more effective source control. It is important to regularly wash cloth masks to keep them clean and effective.

If a patient has COVID-19, the use of a respirator (one that at minimum is as protective as a fit-tested disposable N95 respirator) and eye protection(face shield or goggles is required for staff working with that patient (Cal/OSHA under the Aerosol Transmissible Disease (ATD) standard (PDF). Surgical masks may be used if N95 respirators are not available due to supply shortages – see DIR guidance for respiratory shortages (PDF).

If PPE is limited in supply, the recommendation is to reserve PPE for employees caring for patients known or suspected to have COVID-19. See Strategies to optimize PPE supply. 

16.  What disinfection strategies should be used?

CDPH published guidance on cleaning and waste management considerations for residences and CDC guidance for facility disinfection.

Hospitals should refer to the CDPH All-Facilities Letter 20-14 (PDF) which cites the CDC's Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings.

See the EPA list of approved disinfectants. See CDC guidance for assisted living facilities for relevant tips.

17. Are precautions necessary during food service?

CDPH is not aware of any reports that COVID-19 can be transmitted by food or food packaging. Appropriate handwashing and physical distancing will help avoid transmission during food preparation and/or distribution. See CDPH website for more details. All those preparing and delivering food must wear cloth face coverings.

Although food and food packaging are not thought to be vehicles of transmission, the way that food is distributed and consumed can contribute to transmission. Facilities should develop procedures for meals to be individually served in patients' rooms.  If communal meals are necessary, six feet of physical distancing should be maintained at all times and the members groups eating at the same time should be maintained to avoid exposure to many different individuals. Buffet-style and family-style service should be strictly avoided. See CDPH website for more details.

18.   How should physical distancing recommendations be implemented in residential care facilities licensed by California Department of Social Services?

The California Department of Social Services' has guidance available on infection control in residential care facilities (PDF).

19. How should facilities manage visitors?

The time when visitor restrictions are lifted will vary by county. Wherever possible, live video can be used as a method of maintaining social connection while avoiding risk of spreading infection in a facility through visitors.  CDSS provides Guidance for Adult and Senior Care Program Licensees (PDF) that can be helpful. Also, this CDC guidance.

CDPH recommends that visiting only be allowed only when physical distancing can be safely practiced. All visitors should be screened for potential infection, such as asking about contact with confirmed cases of COVID-19, and asking about current fever or other symptoms of COVID-19. Visitors should use cloth face coverings at all times when in the facility. See AFL 20-22.3 for more information about management of visitors.

Staffing

Information for employers about infection mitigation can be found at the Department of Industrial RelationsCal/OSHA regulations and Cal/OSHA COVID-specific guidance for hospitals and skilled nursing facilities.

20. Should staff work if they have been exposed to COVID-19?

If staff members with a COVID-19 exposure are believed to be essential and must work, they may work if asymptomatic. They should be actively screened at the beginning of the work shift for fever and symptoms of COVID-19 for the duration of the 14-day incubation period.

21. Should staff work if they are sick (such as respiratory or gastrointestinal symptoms)?

No. See Department of Labor guidance on leave policies, to help ensure employees stay home if ill and to seek medical advice to determine if COVID-19 testing is indicated.

22. Should staff be tested if they have symptoms consistent with COVID-19?

Yes, CDPH recommends that staff contact their health care provider or the facility's occupational health service for testing and notify their employer if they test positive for COVID-19. Health care providers may also access free testing across the state: more information here.

23.  What are the rules around return-to-work for staff after illness?

The CDC published guidance on when health care providers can return to work after suspected or confirmed COVID-19, based on either symptoms or timing after testing if asymptomatic. Check the CDC website for the most current updates.

24. How should facilities manage staff shortages?

The CDC published guidelines on managing staff shortages: mitigating staff shortagesidentifying health care workers with suspected COVID-19 and return-to-work.

Facilities experiencing substantial staff or supply shortages that could jeopardize care should contact DHCS liaison (MHLC@dhcs.ca.gov for mental health facilities and LCD (LCDQuestions@dhcs.ca.gov for SUD treatment or other facilities).

25. Does California have rules around employee leave, to encourage employees not to work while sick?

See Department of Labor for information about paid employee leave rights during the pandemic emergency and for information about employee benefits.  See also the Department of Industrial relations for a side-by-side comparison of state and federal leave policies.

26. What resource can we share to help staff cope with anxiety?

California has a COVID-19 website with emotional support resources, including a stress-busting playbook (PDF) from California's Surgeon General. CDC also has information on coping with stress and building resilience.

Special populations

27.   What considerations should be in place for people experiencing homelessness?

See CDC and CDPH (PDF) guidance for homeless service providers, and this CDPH flow sheet (PDF) regarding recommended placement for people experiencing homelessness, based on risk.

28.  Where can I find resources focused on children and youth regarding COVID-19, especially in foster care?

See the CDPH resource list. Also, the DSS All-County Letter 20-33 (PDF) states that children with symptoms of or exposure to COVID-19 should be cared for in a way that is consistent with the current, available public health and medical guidance provided to all families. Children should be cared for at home, unless illness severity requires inpatient care. A close exposure (fifteen minutes or more within 6 feet) poses the greatest risk and it is prudent to exclude that child from group care until the 14-day incubation period is complete. Caring for Children on the CDC website also provides useful information.

29. What options do residential and inpatient MH and SUD providers have for overflow capacity?

CDPH released All-Facilities Letter 20-26 (PDF), which provides authority for hospitals to make physical space and bed changes necessary without CDPH approval.
For questions, entities should contact the relevant DHCS and/or CDPH liaison for case-by-case guidance on what type of overflow capacity is available within existing emergency flexibilities.

DHCS Mental Health Licensing Section             
(916) 323-1864

DHCS MHLC Inbox                                           


 CDPH Centralized Application Branch
 (916) 552-8632

CDPH CAB Inbox


DHCS AOD Licensing and Certification
(916) 322-2911

DHCS AOD Licensing and Certification Inbox

30. How can a facility order Personal Protective Equipment (PPE)?

If a facility is unable to obtain PPE through usual channels, the Medical Health Operational Area Coordination Program (MHOAC) is responsible for managing disaster medical resources, including personnel, equipment, and supplies. The MHOAC assesses local resources and may request or provide mutual aid as conditions warrant. If the MHOAC cannot fulfill a request using local sources, counties may request public health and medical resources from outside of the operational area via the Region Disaster Medical Health Coordination/Specialist Program (RDMHC/S).

If regional resources are inadequate or delayed, the RDMHC Program will forward the request to the State. If in-State resources are unable to fill the request in a timely manner, the State will request Federal assistance through the California Office of Emergency Services (Cal OES). Acting through Cal OES, the Governor will request Strategic National Stockpile (SNS) via the Department of Homeland Security. Please be aware that while every effort will be made to obtain resources as quickly as possible, requesting entities should anticipate that time from acceptance of a request to actual receipt of the resource may be 48-96 hours or longer, depending on the type and scope of the incident.

Please visit Medical Health Operational Coordinators for each county. And please see the Medical Health Operational Area Coordination (MHOAC) Manual (PDF) for more information.

In addition, the National Behavioral Health Council orders PPE on behalf of behavioral health organizations, including nonmembers – see the National Council for Behavioral Health website  for updates.

References:

  1. California Coronavirus Disease 2019 (COVID-19) Health Care System Mitigation Playbook (PDF) 
  2. AFL 20-30
  3. AFL 20-34
  4. AFL 20-38
  5. ACL 20-29 (PDF)
  6. ACL 20-33 (PDF)
  7. DSS PIN 20-07-ASC for Adult And Senior Care Program Licensees (PDF)
  8. Los Angeles County DPH COVID-19 Resources for SUD providers (note: this list is provided as a courtesy, and does not indicate endorsement by DHCS):

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