Skilled nursing facilities (nursing home) toolkit

1. COVID-19 case count

Create and maintain a positive COVID-19 case list. Include all residents, clients, patients, students, employees, volunteers, and contractors at your facility who test positive for COVID-19. Example of this is found here:  Download a COVID-19 Case List template (MS Excel).  You will need to keep a complete case list for internal use to assist with contact tracing and internal management of your outbreak. However, you will not need to submit this case list to Public Health, instead you will use this list to submit weekly cumulative case counts as well as at the end of the outbreak investigation.

2. Reporting cases and serious outcomes

Report to Public Health – Seattle & King County

• Report positive COVID cases: If there is not an ongoing investigation associated with your facility, report any positive COVID cases (including residents/patients/staff/contractors) using the Public Health COVID-19 Intake Survey. You will receive a confirmatory email with additional information and guidance links.
• Investigation start: After your report has been processed, Public Health may open an investigation for your facility. You will receive an email with follow up instructions and a COVID-19 Investigator may contact you. An investigation is a non-punitive Public Health process for collecting information about how a disease is affecting our community and for providing guidance and resources.
• Submit weekly investigation updates: Every Monday while the investigation is open, you will receive an email prompting you to submit a weekly investigation update. Use the Investigation Update Form link provided to you to report a cumulative case count, most recent symptom onset date, and any hospitalizations or deaths associated with your facility.
• Investigation closure:
  • If your facility meets outbreak criteria, your investigation will close when 15 days have passed since the last positive COVID case was identified. At this time, please submit an Investigation Update Form to indicate that your outbreak is over and report your cumulative case counts.
  • If your facility does not meet outbreak criteria, your investigation will close when 8 days have passed since the last positive COVID case was identified. 
• Report subsequent cases: After the investigation is closed, subsequent cases should be reported using the Public Health COVID-19 Intake Survey.

Report to your licensure

Report to your licensure (DSHS, DDA, HSQA) regarding COVID-19 in your facility.

Notify all staff, residents, and applicable resident families

Notify all staff, residents, and applicable resident families of COVID-19 in your facility while maintaining confidentiality of the positive case(s).

3. Isolation and quarantine guidance and resources

• Review Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2 from the CDC
  
   
• Exclude COVID-19 positive staff (or visitors/contractors) from the facility

Staff should not return to work until they meet CDC return to work guidelines.

For example, HCP with mild to moderate illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met*:

• At least 7 days have passed since symptoms first appeared if a negative viral test** is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7), and
• At least 24 hours have passed since last fever without the use of fever-reducing medications, and
• Symptoms (e.g., cough, shortness of breath) have improved.

*In examples that have a more serious illness or are immunocompromised, please refer directly to CDC guidance as isolation times vary in these instances.

**Either a NAAT (molecular) or antigen test may be used. If using an antigen test, HCP should have negative test obtained on day 5 and again 48 hours later.



• Isolate COVID-19 positive residents

See CDC’s guidance on Duration of Transmission-Based Precautions. Residents should be isolated in their own room and placed on transmission-based precautions for their full infectious period.

For example, patients with mild to moderate illness who are not moderately to severely immunocompromised*:

• At least 10 days have passed since symptoms first appeared and
• At least 24 hours have passed since last fever without the use of fever-reducing medications and
• Symptoms (e.g., cough, shortness of breath) have improved.

*In examples that have a more serious illness or are immunocompromised, please refer directly to CDC guidance as isolation times vary in these instances.



• Identify all facility close contacts and affected unit(s)

Review CDC’s close contact definition and guidance for staff, residents, and affected units.

If a resident was cared for by an infectious caregiver (even if the caregiver was wearing a mask or N95), they are considered an exposed close contact.

Review quarantine guidance (DOH) for residents if they are identified as a close contact.

Typically, exposed residents do not require Transmission-Based Precautions, however there are some instances where this would be recommended:

• Patient is unable to be tested or wear source control as recommended for the 10 days following their [last] exposure.
• Patient is moderately to severely immunocompromised.
• Patient resides on a unit with others who are moderately to severely immunocompromised.
• Patient resides on a unit experiencing ongoing SARS-CoV-2 transmission that is not controlled with initial interventions.
  
  
• Consider pausing group activities and communal dining until two rounds of outbreak testing have been completed.
  
  
• Implement cohorting

Refer to section titled Implement Cohorting (pg. 13), WA Dept. of Health

4. Treatment and testing information and resources

• Stay up to date on COVID-19 treatment guidance. If you need support on acquiring treatment for residents, DOH’s Test to Treat Program" may be able to assist.
• Initiate outbreak testing when any positive case has been identified: Outbreak testing is triggered with one confirmed case, even if the facility does not meet outbreak criteria. Complete contact tracing for that positive case and complete testing frequency according to DOH guidance. Once outbreak testing is triggered the facility can choose one of two approaches: contact tracing or broad-based (facility-wide or unit level) testing.
  • Contact tracing: Test exposed resident on day 1 (day 0 is date of exposure), day 3, and day 5 if tests are negative. If this exact cadence cannot be implemented, test three times while spacing testing dates to every 48 hours.
  • Broad-based testing or if additional cases are identified after contact tracing testing implemented: continue testing all residents and staff on affected unit who previously tested negative every 3-7 days until 14 days pass without any new cases identified.
• Staff Routine Testing: Follow PHSKC, DOH, and CMS guidance. The decision to continue routine staff screening testing is at the discretion of the facility. Be aware that Public Health may update these recommendations to reinstate screening of LTCF staff if there are significant increases in size and severity of outbreaks in LTCF’s. Facilities should be prepared to reimplement these strategies quickly if determined by Public Health.

Ordering testing and testing supplies

• Information on where staff can get testing if they cannot get tested at your facility.
• If you are a CLIA waived facility and wish to order BinaxNow Pro tests please speak with your assigned investigator or email covidtestingstrategy@kingcounty.gov.
• If you are a facility without a CLIA waiver and want information on how to obtain a CLIA waiver to use rapid antigen tests at your facility, email covidtestingstrategy@kingcounty.gov.
• OTC BinaxNow tests are available for non-CLIA waived facilities.

5. Personal protective equipment (PPE) and source control

• PPE and source control may be indicated for wear. Please review and follow DOH Guidance on PPE Use.
  • Ensure staff wear source control after exposure to a confirmed case of COVID-19.
• For help with N95 fit testing, see DOH's Respiratory Protection Program or email HAI-FitTest@doh.wa.gov.
• Ensure your facility has at least a two-week supply of PPE and other infection control supplies on hand at all times.

Ordering PPE Supplies

• Order PPE through your distributor or other resources.

6. Screening and visitation

• Facilities should establish a process to make everyone entering the facility aware of recommended actions to prevent transmission according to DOH and CDC guidance.
• Facilities may choose to conduct active screening such as individual screening on arrival at the facility, but this is at facility discretion.
• There are currently no restriction to visitation in Nursing Homes. Please refer to visitation guidance (CMS) for the most updated guidance on visitation.

7. Admissions

• Communicate information about patients with suspected or confirmed SARS-CoV-2 infection to appropriate personnel before transferring between LTCFs and other healthcare settings.
• During an outbreak, pausing admission is no longer recommended as long as the LTCF can safely care for the incoming resident and the resident (or POA/guardian) is made aware the COVID-19 status of the facility. However, facilities may consider placing a hold on admissions until they can clarify the extent of transmission and implement infection prevention interventions.

8. Vaccination

• Encourage residents and staff to stay up to date with COVID-19 vaccinations.
• For vaccine appointments, visit the DOH Vaccine Locator.
• If you need support with COVID vaccines for your residents, please call 206-848-0243 or email vaccineinfo@kingcounty.gov .
• Encourage staff and residents to get the annual influenza vaccination. Those who are 60 and older are also eligible for the RSV vaccine.

9. Staffing shortages

• For information on staffing shortages, please refer to the following guidance documents:
• SARS-CoV-2 Infection Prevention and Control in Healthcare Settings Toolkit, WA State Dept. of Health
• Staff Shortages, CDC
• To request staffing support from DSHS Rapid Response Team, contact your DSHS Field Manager and use this request form.

10. Facility level mitigation

• Note that local workplace safety and health requirements may differ slightly from federal guidance. Please review WA Dept. of Labor & Industries resources to ensure regulatory compliance.

Ventilation

• Improving indoor air, Public Health – Seattle & King County
• Ventilation in Buildings, CDC

Cleaning and disinfection guidance

• Healthcare Infection Prevention and Control Recommendations, CDC
• About List N: Disinfectants for Coronavirus (COVID-19), EPA