Interim Guidance for Long Term Care Facilities with Confirmed COVID-19 Cases

As COVID-19 rapidly spreads across the country, more long term care communities may have COVID-19 enter the facility. These guidelines describe implementation steps to help limit the spread of infection when a staff member or resident develops COVID-19 in your facility.

Click to download a PDF version of the COVID-19 LTCF Guidance

Administrative Actions

  • Consider temporarily halting admissions to the facility, at least until the extent of transmission can be clarified and interventions can be implemented.
  • Quarantine: If an resident who has no symptoms consistent with COVID-19  or who has tested negative for COVID-19 is required to enter the facility ensure the resident is assigned to a single room and restricted from communal activities with the rest of the resident population for 14 days. Continuously monitor for the development of symptoms. See section for Resident Management.
    • If the resident remains asymptomatic and testing is available, consider COVID-19 testing for the resident at the end of the quarantine period before returning them to the general population.
    • If the resident develops any symptoms arrange for COVID-19 testing as soon as possible.
  • Facilities may also consider readmitting residents with a recent COVID-19 diagnosis based on their ability to care for such patients and with proper infection prevention control in place.  Readmission to long term care for eligible patients from hospitals will help ensure availability of hospital beds for COVID-19 patients with acute care needs.  A key component in determining care for these residents is based on the need for Transmission-Based Precautions to continue.  According to the CDC guidance on Discontinuation of Transmission-Based Precautions of Patients with COVID-19 in Healthcare Settings there are two strategies to determine if Transmission-Based Precautions may be discontinued - a test-based strategy and a non-test based strategy.
    • Isolation: If Transmission-Based Precautions are still required, the facility must have the ability to adhere to infection prevention and control recommendations for the care of COVID-19 patients.  Preferably, the patient would be placed in a location designated to care for COVID-19 residents.  CDC’s infection prevention and control recommendations can be found at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html and https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care-strategies.html.
    • Per CDC recommendations, if Transmission-Based Precautions have been discontinued, but the patient has persistent symptoms for COVID-19 (e.g., persistent cough), they should be placed in a single room, be restricted to their room, and wear a facemask (if tolerated) during care activities until all symptoms are completely resolved or at baseline.  
    • If Transmission-Based Precautions have been discontinued and the patient’s symptoms have resolved, they do not require further restrictions, based upon their history of COVID-19.
  • Review potential discharges with family or receiving facilities that residents are transferred to or must visit for care.  State and/or Federal discharge notification requirements must be followed if the resident is being discharged from the facility. 
  • Ensure advance notification of appropriate health care entities, such as hospitals, medical transport, etc. of suspected or confirmed COVID-19 diagnoses within the facility.

Reporting and Notification Requirements

  • Congregate Living Facilities are required to notify the Department of Health and Senior Services within 24 hours of the positive staff/resident.
  • Notify the Local Public Health entity to coordinate patient and contact investigations.
  • Notify the Department of Health and Senior Services of positive case(s) and deaths utilizing the Communicable Disease case report (CD-1) form to the Bureau of Reportable Disease Informatics (BRDI).
    • Options for submitting CD-1 forms:
      • Fax submissions: 573-751-6417. Please note that this fax line experiences high volume during normal business hours.
      • Secure File Transfer Protocol (SFTP): providers that would like to submit reports via SFTP, please call 573-526-5271. The SFTP option functions as a secure online folder where files may be submitted with no wait. In order to use this option, at least one contact e-mail address for the submitting organization must be provided. Further instructions will be sent to the indicated e-mail address(es) once an account is set up for the organization.
      • Phone: For single COVID-19 reports, providers have the option to call the Missouri COVID-19 Hotline at 877-435-8411 and convey information verbally to an operator who will complete the CD-1 for the provider. When utilizing this method of reporting, please choose option 2 at the prompt.
  • Orders requiring reporting can be found here:

Personal Protective Equipment (PPE)

  • Assess the amount of PPE available and necessary for staff use.  Use the CDC PPE burn rate calculator to anticipate PPE needs.
  • Visit the MO DHSS COVID-19 site for information on PPE.
    • To attempt to obtain necessary PPE from vendors, including partial shipments, visit the Missouri PPE Marketplace under the heading “Expanding Access to PPE”
  • Ensure staff using N95 respirators are medically cleared and fit tested to confirm the N95 fits properly and the staff is able to safely wear it.
  • Utilize strategies to manage PPE use and ensure adequate supplies

Testing

(point prevalence study) is recommended once a COVID-19 positive resident or staff is confirmed.  Consider consultation with local and State public health agencies regarding all decisions on widespread testing and retesting in the facility.

  • Utilize confirmatory molecular tests, such as those that utilize reverse transcription polymerase chain reaction (RT-PCR).  At the present time, serological tests are not considered confirmatory.
  • Testing should be used to lead to specific infection prevention activities such as decisions for resident cohorting, identifying asymptomatic COVID-19 positive staff for work exclusion, enabling staff return to work, etc. 
  • Initial facility-wide testing can help identify positive but asymptomatic or pre-symptomatic staff and residents.
  • Repeat testing may be warranted.
    • Any resident or staff who develops symptoms consistent with COVID-19.
    • Any residents or staffs who previously tested negative at some frequency shortly (e.g., 3 days) after the initial point prevalence survey, and then weekly to detect those with newly developed infections. Consider continuing retesting until point prevalence studies no longer identify new cases.
    • Any previously positive resident or staff in order to remove them from isolation or allow them to return to work in the facility.
    • Consider retesting HCP at some frequency based on community prevalence of infections (e.g., once a week).
  • Options for testing:
    • Conduct testing through a private lab. Be sure to clearly identify costs and billing beforehand. 
    • Match with a Federally Qualified Health Center. DHSS staff will assist with the matching process upon the report of a positive case. 

Physical Environment

  • Cohort patients based on symptoms and/or test results (symptomatic residents away from asymptomatic residents, COVID-19 positive patients away from negative residents, etc.)
    • Ensure at least 6 feet of space between beds
    • Provide physical barrier between beds (such as a privacy curtain) and ensure resident privacy during care.
  • Dedicate a physically separate COVID-19 positive area within the facility when possible:
    • Separate wing within the building with fire doors or other structure barrier to create a natural physical barrier,
    • Work with DHSS-SLCR to identify other building locations that can be used (independent living, cottages, unoccupied floors or wings, closed facilities, etc.) and obtain approval for housing residents.
    • When at or over capacity, identify spaces not normally used for resident bedrooms that could be used for cohorting, such as a therapy gym or enclosed dining room.  Work with DHSS-SLCR on approval for use while cohorting.
  • Provide sufficient designated space for clean and dirty storage on the COVID unit.
  • Ensure that air exchange is sufficient in rooms, and take necessary steps to increase air flow as needed.

Visitor Management

  • Suspend visitor access to the facility except for end of life circumstances.  Ensure proper infection control procedures are followed in these limited visiting situations.
    • provide instruction on hand hygiene
    • limit surfaces touched
    • Visitors must wear a cloth face covering or facemask for the duration of the visit; provide PPE according to current facility policy while in the resident’s room
    • Individuals with fevers, other symptoms of COVID-19, or unable to demonstrate proper use of infection control techniques should be restricted from entry.
  •  Post “No visitors” signs on the doors, and consider limiting access through only one access point, ensuring that emergency egress can still be accomplished.
  • Ensure notification letters are distributed to family of residents so they are aware of restrictions at the facility.  If possible, consider ensuring availability of electronic communication between residents and families.
  • Review and revise how interactions with vendors and receiving supplies, agency staff, EMS personnel and equipment, transportation providers (e.g., when taking residents to offsite appointments, etc.), and other non-health care providers (e.g., food delivery, etc.), and take necessary actions to prevent any potential transmission. For example, do not have supply vendors transport supplies inside the facility. Have them dropped off at a dedicated location (e.g., loading dock). Allow entry of these visitors if needed, as long as they are following the appropriate CDC guidelines for Transmission-Based Precautions.

Resident Management

  • Suspend group dining and activities.  Residents should stay in their rooms as much as possible.  If a resident must leave their room for medically necessary reasons, they must wear a facemask and perform hand hygiene and social distancing measures, staying at least 6 feet from others.
  • Assess vital signs and check for symptoms at least daily, including temperature, cough or shortness of breath for all residents.  Any other symptoms outside of the residents’ normal baseline should be reason for further evaluation including but may not be limited to: 
    • unexplained/increased fatigue/malaise
    • lethargy
    • chest pain
    • sore throat
    • diarrhea
    • delirium (acutely altered mental status and inattention)
    • falls
    • acute functional decline
    • exacerbation of chronic conditions
    • chills
    • headaches
    • croup
    • unexplained tachycardia
    • decrease in blood pressure
    • unexplained hypoxia (even if mild i.e. O2 sat <90%)  
  • Execute a cohort plan to ensure that ill residents are separated from those that are not ill.
    • When possible, care should be provided in a single-person room with the door closed.
    • Residents should have dedicated bathrooms, as applicable, and should be restricted to their room to the extent possible.
    • If a resident must leave their room for medically necessary reasons, they must wear a facemask and perform hand hygiene and social distancing measures, staying at least 6 feet from others.
  • Where possible, assign dedicated staff to care for ill residents only while cohort procedure is in place.
  • Continually reevaluate physical location of cohorting areas to maximize staffing in those areas.
  • Initiate droplet precautions and standard precautions for all residents.  Recent evidence suggests that transmission prior to symptom onset is possible, so each resident in a facility with a confirmed COVID-19 case should be under the same precautions in order to reduce spread of the disease within the facility
    • Implement universal facemask use by healthcare personnel at all times.
    • Healthcare Personnel entering the room of a patient with known or suspected COVID-19 should adhere to Standard Precautions and use a respirator (or facemask if a respirator is not available), gown, gloves, and eye protection. When available, respirators (instead of facemasks) are preferred; they should be prioritized for situations where respiratory protection is most important, such as performance of aerosol generating procedures. Prioritize full recommended PPE for confirmed COVID-19 residents, especially those still under Transmission-Based Precautions, and symptomatic residents, whether there is a confirmed COVID-19 test or not. 
    • Ensure isolation carts and isolation supplies with isolation signs are outside resident rooms.  Include signs to instruct staff on donning and doffing PPE.
  • Prior to entering and exiting the unit and resident room, healthcare personnel must perform hand hygiene by washing hands with soap and water or applying alcohol-based hand sanitizer.
  • Minimize visits into rooms by bundling patient care activities.
  • Assess the use and necessity of aerosolizing procedures (nebulizer treatments, suction, etc.).  In consultation with the residents’ health care providers, minimize aerosol generating procedures to only those that are essential.
  • When performing aerosolizing procedures, or if a resident’s cough is heavy or productive:
    • Staff should utilize full PPE including an N95 respirator
    • The number of staff should be minimized

Considerations for Special Populations

  • Assist residents with frequent hand hygiene, social distancing, and use cloth face coverings.
  • Dedicate personnel to work only on memory care units when possible and try to keep staffing consistent. Limit personnel on the unit to only those essential for care.
  • Frequently clean often-touched surfaces in the memory care unit, especially in hallways and common areas where residents and staff spend a lot of time.
  • Resources for Memory Care Units
  • Resources for Behavioral Health Units  

Staff Management

  • Ensure access to supplies for hand hygiene in resident rooms, as well as easy availability for staff and encourage frequent use.
  • Assess training needs of staff (hand hygiene, donning and doffing of PPE, infection control measures, etc.) and provide as needed.  Include audits and spot checks for hand hygiene. See CDC references and videos and DHSS references and videos on PPE training and guidance.
  • Trash disposal bins should be positioned near the exit inside of the resident room to make it easy for staff to discard PPE after removal, prior to exiting the room, or before providing care for another resident in the same room.
  • Actively monitor and record signs and symptoms of fever or respiratory illness of all staff at the beginning of each shift.
    • Log temperature and any symptoms.
    • Provide clear instructions, including posting them in writing, for ill staff regarding when to stay home and how to seek health care and/or COVID-19 testing.
      • Staff without close contact to confirmed case should be excluded with fever (measured or reported subjective fever), cough, or shortness of breath
      • Staff with close contact to confirmed case should be excluded when any new symptoms that could be consistent with COVID-19 are reported, including:
        • Measured or reported subjective fever
        • Cough
        • Shortness of breath
        • Sore throat
        • Loss of taste/smell
        • Diarrhea
        • Nausea
        • Vomiting
        • Headache
        • Myalgia
        • Fatigue
        • Malaise
    • Ensure they know to contact the healthcare facility ahead of arrival and identify themselves as a possible COVID-19 contact.
    • If possible, check in daily with ill staff members that are at home.
  • Ensure staff are educated to notify other facilities they are work with that they are working at a facility with COVID-19 case(s).
  • Ensure contingencies are in place for high staff absenteeism. Options to consider:
    • Enter into a contract with a staffing agency to provide additional staffing support.
    • Explore corporate assistance with staffing and possibilities of designating COVID facilities.
    • Initiate additional recruitment strategies such as tapping into local job recruitment efforts and consider offering additional incentives for working with positive residents.
    • Determine how waivers of state and federal regulations will assist in increasing the staffing pool, for example, the ability to hire nurse aides without the requirement to complete CNA training program within four months.
    • Utilize the Disaster Medical Assistance Team (DMAT). This is a resource of last resort after all other options are exhausted and a critical need still exists. Requests to DMAT must be coordinated Shelly Williamson at shelly.williamson@health.mo.gov
  • Consult the CDC guidance on staff who may have been exposed to a COVID-19 positive case.
    • In general, staff who have been exposed to a COVID-19 positive case and fall within the medium or high risk categories should exclude themselves for work while monitoring for symptoms.
    • During times of high staff absenteeism, exposed but asymptomatic staff may work with the following in place for 14 days after the last exposure:
      • Staff must remain asymptomatic while performing resident care
      • Staff must wear facemasks during their entire shift.
      • Monitoring must continue for fever and respiratory symptoms through the facility employee health program before each shift
  • If HCP develop even mild symptoms consistent with COVID-19, they must cease patient care activities and notify their supervisor or occupational health services prior to leaving work. These individuals should be prioritized for testing.
  • Except in extreme crisis staffing situations, staff who test positive for COVID-19, should exclude from work for the appropriate amount of time based on either the time-based or test-based strategy.
  • Consider providing childcare services for staff.

Environmental Management

  • Ensure training and access to appropriate supplies and PPE for environmental staff.
  • Ensure that appropriate EPA disinfectants are being used according to instructions for dilution and contact times.
  • Implement at least daily cleaning and disinfection of resident rooms.
  • Implement cleaning and disinfection several times a day for high touch surfaces in the facility, such as doorknobs and countertops.
  • Consider dedicated environmental services staff for specific zones in the facility, at a minimum assigning according to cohort (well, ill) status.
  • Use dedicated medical equipment where possible for each resident and sanitize rental and shared equipment prior to use.
  • Ensure personnel providing laundry services are using appropriate PPE and performing hand hygiene after gathering clothing and linens.