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EDMUND G. BROWN JR.
Governor

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


April 27, 2020


TO:
Project Roomkey Sites

SUBJECT:
Guidance for Sites Housing Suspected or Confirmed COVID-19 Patients Experiencing Homelessness and Those at Higher Risk of Serious Illness


Persons experiencing homelessness may be at high risk for COVID-19 infection (see CDC guidance), especially if they are having frequent close contact with others in the community. Those people who are older or have chronic medical conditions are at higher risk for serious illness if infected. Once identified as having COVID-19 symptoms, a positive test, or close contact with someone known to have COVID-19, these individuals should be prioritized for isolation in individual housing units (e.g., hotel or motel rooms, trailers) or cohorted in group settings with appropriate healthcare personnel and services. Individuals without symptoms or known exposure and who are at higher risk for serious illness due to age 65 years or older, or underlying chronic health condition, may be offered housing to prevent their exposure to others. This document provides guidance for safely operating these Project Roomkey (PDF) sites once suitable sites have been identified in accordance with California’s recommended protocol (PDF) and flowchart (PDF).

Planning for Staff, Equipment and Supplies

Determine in advance how to address all facility needs for opening the facility and providing all ongoing services. Prepare a written plan for all operations, covering all possible contingencies. Consider the following:

  • All necessary types of staffing including:
    • Leadership/management
    • Staff who screen and place clients
    • Healthcare personnel including behavioral health and social services who will monitor health status of clients and provide care
    • Staff who prepare and deliver food
    • Staff who clean rooms, change linens, do laundry
    • Security staff
  • Maintaining security inside and outside the facility 24 hours/7 days
  • Food services
  • Medical supplies and equipment for nonacute and emergency patient care
  • Personal protective equipment (PPE) (e.g., respirators, eye protection, gloves, gowns) and facemasks used to reduce the spread of infection from the wearer to others (e.g., procedure or surgical masks, cloth face coverings)
  • Cleaning and disinfection equipment and supplies
  • Laundry
  • Personal care supplies (e.g., toiletries)
  • Trash removal
  • Transport of clients to/from the facility, emergency transport of patients to hospital
  • Communications (e.g., telephones, walkie-talkies) to allow staff to converse with clients without entering rooms
  • Interpretive services
  • Handling emergency situations
  • Increasing room ventilation to the extent possible:
    • Operate individual room units and central heating/ventilation systems to introduce the maximum amount of outside air.

Procedures for Minimizing Spread of Infection

Implement procedures that follow CDC and CDPH guidance, and applicable Cal/OSHA regulations, for controlling and preventing COVID-19 infection. Some are described further in the sections below or in guidance listed under Resources. Ensure that communications and signage is offered to staff and clients in relevant languages and at appropriate literacy level. Address the following:

  • Person designated to administer/oversee infection control procedures
  • Initial screening of all clients and staff and then daily screening of staff for COVID-19 symptoms
  • Signage and instructions for any client or staff experiencing new symptoms on how to report them to management and steps that will need to be taken
  • Signage and enforcement that requires all clients on isolation to stay in rooms at all times
  • Signage and enforcement that prevents entry of visitors to areas where suspected or confirmed COVID-19 patients are housed
  • Signage and enforcement regarding wearing of face coverings by staff (when not wearing PPE such as a respirator) and clients when in the vicinity of others

Procedures for Screening Clients and Staff

  • Designate a limited number of staff to conduct screening (including temperature measurement with a non-contact thermometer) for fever and COVID-19 symptoms.
  • All staff should be screened daily at the beginning of their shift.
  • All clients should be assessed initially to determine appropriate placement and, if not already known to be COVID-19 positive or symptomatic, screened daily for symptoms.
  • Clients without symptoms on arrival should be instructed to report any new symptoms immediately to management.
  • Staff members conducting screening should wear a fit-tested N95 respirator, goggles/face shield, gown/coveralls, and gloves (see PPE section below for what to do if these are not available); staff should change gloves and perform hand hygiene between clients.
  • A positive screen is identification of fever, defined as temperature of 100.4°F/38°C or higher, or report of cough, shortness of breath, or sore throat.
  • Any staff identified with symptoms should be asked to put on a facemask, sent home, and instructed to seek care.
  • Any client identified with symptoms should be asked to put on a facemask until isolated in an individual room.

Staff Safety Practices and Training

  • Train all staff on the importance of frequent hand-washing with soap and water including:
    • Following CDC guidelines to scrub for at least 20 seconds.
    • When employees arrive at work and before they leave work.
    • Before and after eating, or using the toilet.
    • After close interaction with other persons.
    • After contacting shared surfaces, equipment, or tools.
    • Before and after wearing facemasks, cloth face coverings, and personal protective equipment (PPE) such as respirators and gloves.
    • After blowing nose or sneezing.
  • Ensure consistent use of physical distancing (at least 6 ft) between all clients and staff except for necessary patient care activities. If clients are present in the room during cleaning or changing bed linens, encourage those who are able to wear a facemask or face covering and wait in the part of the room where work is not being performed, for example the restroom or bedroom.
  • Ensure all staff know which PPE is needed for which tasks, where to obtain PPE supplies, and how to use, maintain/store, and dispose of them.
  • Limit entry of staff into rooms that house suspected or confirmed COVID-19 patients to the minimum frequency and duration possible.
  • Encourage communication with clients via telephone, walkie talkie, or other methods that do not require room entry.
  • Provide for staff to have shelter management staff available and monitoring rooms to assist as needed if they are concerned about clients not following safe distancing measures or other unsafe behavior.

Personal Protective Equipment

Staff personal protective equipment (PPE) needs are determined by job task and whether the employee must enter a room occupied by a COVID-19 patient or a Person Under Investigation (PUI) who has symptoms or has been exposed to a person who tested positive for COVID-19. To minimize reliance on the use of PPE, facilities should employ all possible engineering controls, such as physical barriers to create distance between staff and clients, and administrative controls, such as limiting the number of staff assigned to duties that require entry to patient rooms.

Facilities having difficulty procuring necessary PPE should contact their local health department's Medical Health Operational Area Coordinator (MHOAC).

Facemasks and face coverings

During periods when respirators are not required, a procedure mask or surgical mask should be worn by all personnel as source control to limit the possible spread of COVID-19 from infected people who may not have symptoms. This practice is not considered PPE use because the covering provides an unknown level of protection to the wearer. Cloth face coverings in nonpatient/non-PUI areas may be used to conserve supplies of procedure or surgical masks.

Respirators

In non-emergency conditions, employers must provide fit-tested, NIOSH-certified respirators to all employees occupationally exposed to novel pathogens such as SARS-CoV-2. However, for the current COVID-19 crisis, certain respirators from other countries or surgical masks may be used when the respirator supply is insufficient for anticipated surges or when efforts to optimize the efficient use of respirators do not resolve the respirator shortage. When supplies are limited, a single respirator may be worn for an extended period of time, for example while the wearer enters multiple patient rooms to clean or change linens. See guidance from Cal/OSHA (PDF) and CDC on managing respirator supply shortages.

Isolation gowns

Cloth gowns or other garments that cover the arms and body that can be safely laundered may be used as an alternative to disposable gowns. Disposable coveralls, also called bunny suits, can also be used where neither isolation gowns nor cloth gowns are available, as an alternative where specified below.

Eye protection

Eye protection is needed when staff are in patient care areas to prevent infection that may result from respiratory droplets contacting the eye. Either face shields or goggles may be used. If reusable eye protection is used, it must be cleaned and disinfected between uses.

Donning & Doffing PPE

All staff must be trained on the correct procedures for donning (putting on) and doffing (taking off) PPE, per CDC guidance. Fact sheets and posters are available on the CDC website. All required PPE should be donned before entering a client's room.

Personal Protective Equipment (PPE) for Staff Providing Services to Rooms

ClientScenario/TaskMinimum PPE
COVID-19 positive or PUI
Entering room to clean or service rooms while client in room or within 3 hours of client's being in room
  • Minimum of fit-tested N95 respirator or fit-tested elastomeric respirator
  • Disposable isolation gown or coveralls
  • Gloves (preferably non-latex)
  • Eye protection: face shield or non-vented or indirectly vented goggles
COVID-19 positive or PUIEntering empty room to clean or service rooms, at least 3 hours after client left room
  • Procedure mask or surgical mask
  • Disposable isolation gown or coveralls
  • Gloves (preferably non-latex)
COVID-19 positive or PUIWashing laundry (sheets, towels, clothing, etc.)
  • Procedure mask or surgical mask
  • Disposable isolation gown or coveralls
  • Gloves (preferably non-latex)
COVID-19 negative, high risk for complicationsEntering room to clean or service room while client in room
  • Procedure mask or surgical mask
  • Gloves (preferably non-latex)
COVID-19 negative, high risk for complicationsEntering empty room to clean or service room
  • Gloves (preferably non-latex)
COVID-19 negative, high risk for complicationsWashing laundry (sheets, towels, clothing, etc.)
  • Gloves (preferably non-latex)

 

 

Personal Protective Equipment (PPE) for Other Job Tasks

Job TaskMinimum PPE
  • Medical admissions
  • Screening clients or staff
  • Provision of healthcare services
  • Testing clients for COVID-19
  • Task requiring entry of room occupied by COVID-19 positive client or PUI
  • Minimum of fit-tested N95 or elastomeric respirator
  • Disposable isolation gown or coveralls
  • Gloves (preferably non-latex)
  • Eye protection: face shield or non-vented or indirectly vented goggles
Handling soiled laundry from room occupied by COVID-19 positive client or PUI
  • Minimum of fit-tested N95 or elastomeric respirator
  • Disposable isolation gown or coveralls
  • Gloves (preferably non-latex)
Program management
  • Procedure mask or surgical mask
  • Gloves (preferably non-latex)
Operations support
  • Procedure mask or surgical mask
  • Gloves (preferably non-latex)
Front desk
  • Procedure mask or surgical mask
  • Gloves (preferably non-latex)
Food service (e.g., dropping off/picking up food items without entering room occupied by COVID-19 positive client or PUI)
  • Procedure mask or surgical mask
  • Gloves (preferably non-latex)
Security
  • Procedure mask or surgical mask
  • Gloves (preferably non-latex)
  • See additional protection above if room entry is required.
Transport of suspected or confirmed COVID-19 patient if patient is not compliant with source control
  • Fit-tested N95 respirator
  • Disposable isolation gown
  • Gloves (preferably non-latex)
  • Eye protection: face shield or non-vented or indirectly vented goggles

Cleaning and Disinfection

Establish procedures to routinely clean and disinfect commonly touched surfaces and objects (e.g., door knobs, touch screens, food preparation areas, bathrooms), including:

  • Using disinfectants that are EPA-approved for use against the virus that causes COVID-19.

  • Providing EPA-registered disposable wipes for staff to wipe down commonly used surfaces before and after use.

  • Following the manufacturer's instructions for all cleaning and disinfection products (e.g., safety requirements, protective equipment, proper dilution, contact time).

  • Following safe work practices such as never mixing products together and using adequate ventilation.

  • Cleaning visibly dirty surfaces first before disinfection. Disinfectants are less effective if used on soiled surfaces.

  • Ensuring there are adequate supplies to support cleaning and disinfection practices, including cleaning products and tools and chemical resistant gloves. Make sure disinfectants are available to workers throughout the worksite.

Laundry

Staff collecting, sorting or handling soiled laundry and linens should wear PPE as described above. They should collect potentially contaminated laundry into bags or other appropriate containment that are clearly identified as "dirty" by labels or some other method, whether they are transported within the facility or to an off-site laundry service. For clients who can collect their own laundry, three different bags for clothing, towels and sheets may be labeled with the room number and clients instructed to fill them, seal with a knot and place outside the room door at a specified time. Bags need to be made of material with sufficient strength. They may be transported by cart or chute.

Oxygen-based bleach and detergents used in health care settings should be registered by EPA to ensure adequate disinfection of laundry. Hot water provides an effective means of destroying organisms; a temperature of at least 160°F/71°C for a minimum of 25 minutes is commonly recommended for hot-water washing. Dryer temperatures and cycles are dictated by the type of material and fabric. Disinfection of the laundry machines is unnecessary.

Food Safety

  • Food service should be provided to clients in individual rooms to maintain isolation and social distancing.
  • Food delivery to individual rooms should be done without room entry if possible.
  • Do not allow sharing of food, containers, and utensils.
  • Stagger breaks for staff and ensure social distancing in break areas.

Resources

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