COVID-19 DOCUMENTATION GUIDEBOOK Introduction COVID-19 Documentation...The facility’s COVID-19 Team assigns specific team member(s) to be responsible for: o Obtaining and reviewing

COVID-19 DOCUMENTATION GUIDEBOOK

Arnall Golden Gregory LLP Page 1 of 2 Copyright 2020

Introduction

When the World Health Organization declared the novel coronavirus a pandemic on

March 11, 2020, the long-term care field had already begun preparations for responding

to the situation; however, the rapid spread of the disease, together with an almost daily

supply of guidance and directives from various federal, state and local agencies, quickly

overwhelmed providers. While the situation is unprecedented and the source of

infections is impossible to identify, good documentation by long-term care providers may

prove helpful in demonstrating that facilities undertook reasonable efforts to respond to

the pandemic.

What follows is a documentation guidebook consisting of seven (7) modules, each of

which incorporates a robust checklist of items around a general topic that is designed to

guide consideration and documentation by facilities of specific COVID-19 regulatory

directives, guidance and recommendations from the Centers for Medicare and Medicaid

Services, the Centers for Disease Control and Prevention, the Occupational Safety and

Health Administration, the Georgia Department of Public Health, the Georgia Department

of Community Health, and the Healthcare Facilities Regulatory Division, among others.

The guidebook also includes an eighth (8th) module featuring various forms, signage and

instructional resources from federal and state agencies that can be printed and used in

the facility.

The guidebook contains the following modules:

1. Policies, Procedures and/or Processes

2. Screening, Testing and Reporting

3. Personal Protective Equipment

4. Staff Management

5. Resident Management

6. Visitor and Family Management

7. Nursing Home Re-opening

8. Resources

Because the guidebook is modular in nature, a facility that has already completed a

thorough review of one or more topic areas can simply focus their efforts on other

modules or use the entire guidebook as a check on the work they have already done. The

guidebook builds upon the evolution of the regulatory directives, guidance and

COVID-19 DOCUMENTATION GUIDEBOOK


recommendations over the course of time. As such, it should establish a snapshot of a

facility’s considerations and documentation at each stage of that evolution.

Also included with the guidebook is a flow chart depicting in a visual manner how each

facility’s COVID-19 team can use the modules and interface with the QAPI committee.

Before using the guidebook, please note the following:

Each facility will need to tailor its documentation, including its underlying

pandemic plan, assessments, policies and procedures according to its particular

operating characteristics, needs and circumstances.

The guidebook is current as of May 21, 2020. Please note that the regulatory

requirements, guidance and recommendations on which the guidebook is based

are likely to continue to evolve over time as governmental and non-governmental

agencies gain new understanding about the virus, and as public authorities extend

or let expire COVID-19 public health emergency declarations and executive orders.

Accordingly, facilities should pay close attention to the authorities referenced

above to ensure that their decision making and documentation reflect the most

recent developments from these authorities. They also should begin planning the

steps necessary to return their operations to a pre-COVID-19 posture.

Because the modules in the guidebook are reduced to a checklist of items, and thus

may not capture all of the underlying regulatory requirements, guidance and

recommendations, or the nuances thereof, facilities should independently review

these source documents as part of their due diligence.

When completed, the checklists and analysis, if done at the request of the facility’s

Quality Assurance Committee, may constitute confidential quality assurance and

assessment materials that are protected from disclosure to surveyors and

discovery. See 42 U.S.C. § 1395i-3(b)(1)(B). Each facility should therefore carefully

consider how the checklists are prepared and maintained.

The guidebook, including the modules and checklists, should not be construed as

legal advice and is not a substitute for experienced legal counsel to assist with

development of policies, procedures and protocols that reflect the circumstances

of each specific facility and factual situation.

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14933462v3

COVID-19 Team

Policy,

Procedure

and Process

Screening,

Testing &

Reporting

COVID-19 Team Documentation

Staff

Management

Resident

Management

Personal

Protective

Equipment

Visitor and

Family

Management

QAPI Committee

Reopening

the Nursing

Home

COVID-19 DOCUMENTATION GUIDANCE POLICIES, PROCEDURES and/or PROCESSES


Policy Communication Is there documentation to support the following activities? Yes No N/A Comments

The facility’s COVID-19 Team assigns specific team member(s) to be responsible for:

o Obtaining and reviewing new and/or revised federal and state guidance related to COVID-19

CMS CDC OSHA DOL DPH DCH HFRD Other

o Reviewing, revising and/or developing new policies, procedures, processes and/or forms related to COVID-19

Identify policies that may not require revision, but the procedures, processes or forms supporting the policies requires revision

Representative payee policy for ensuring that residents receive federal Economic Impact payments

(5/14/2020 updates to Social Security Administration guide, “Economic Impact Payments for Social Security and SSI Recipients – Steps to Take and Schedule of Payments.”

o Submitting new and/or revised policies, procedures, processes and forms for approval

Identification of multiple methods for communicating new and revised policies, procedures, processes and/or forms to staff, residents, representatives, families and others:

o Post Infection Control signage at all entrances, throughout facility and when appropriate, outside of resident rooms (Refer to Resource Module for possible signage to be used to support policy/procedure/process)

o E-Learning System o In-person education o Competency check-offs



o Listserves, emails or other electronic media o Websites o Newsletters o Flyers o Other

Provide opportunities for staff, residents, representatives, families and others to ask questions and seek clarification related to policy, procedure, process and form changes

Maintain records of reviews, revisions and communication of policies, procedures, processes and forms related to COVID-19

Policies

Is there documentation to support the following activities? Yes No N/A Comments

CDC Preparedness Checklist Completed (2/06/2020-CMS Memo: QSO 20-09)(Refer to Resource Module for tool)

Date of Completion:

CMS COVID-19 Focused Survey Tool completed, per CMS recommendation, as a Facility Self-Assessment (3/04/2020 CMS Memo: QSO-20-12, Updated 3/23/2020-CMS Memo: QSO-20-20, Updated 5/06/2020-CMS Memo: QSO-20-29) (Refer to Resource Module for tool)

Date of Completion:

Pandemic Plan/Policy reviewed and revised, if indicated (2/06/2020 CMS Memo: QSO-20-09)

Date(s): Revisions:

Infection Control Policies reviewed and revised, if indicated: (2/06/2020 CMS Memo: QSO-20-09, 3/04/2020 CMS Memo: QSO-20-14, 3/09/2020 CMS Revised Memo: QSO-20-14, 3/14/2020 CMS Revised Memo: QSO-20-14, 3/23/2020 CMS Memo: QSO 20-20, CMS Blanket Waivers, 4/24/2020 CMS COVID-19 Long Term Care Facility FAQs AND ongoing CDC and DPH guidance)

o Hand-Hygiene o Infection Control Precautions (Standard,

Contact, Enhanced Barrier and Transmission-Based Precautions)

o Respiratory Protection Program, if provided (also refer to PPE documentation guidance checklist)

o Personal Protective Equipment (also refer to PPE documentation guidance checklist)

Optimization and Crisis Capacity Strategies (updated with ongoing CDC guidance)

Date(s): Revisions:



Inventory Management, method of anticipating need, such as the CDC’s PPE Burn Calculator and PPE Re-ordering process (Utilization of DPH’s Process for Request of PPE, if indicated)

Additional Facemask and Respirator Guidance (3/10/20 CMS Memo: QSO-20-17; 3/14/20, 4/3/20, 4/8/20 and 4/24/24 OSHA Enforcement Memos)

o Social Distancing Isolation and/or Cohorting

o COVID-19 Specific Surveillance Activities, including, staff/visitor/resident screening, monitoring, testing and reporting, etc.

o Infection Control Transfer Form (Gov. Kemp’s Executive Order 4/08/2020)

o Other

Reviewed and revised memory care unit infection control and social distancing practices (CDC Guidance-Considerations for Memory Care Units in Long Term Care Facilities)

Human Resource, and workplace safety and health, policies, procedures, processes and forms reviewed and revised, if indicated by the ongoing OSHA, CDC and DPH guidance:

o Staff exposure risk classifications (OSHA Publication 3990-03 2020)

o Job descriptions o Staff work restrictions and return to work

criteria (3/09/2020 CMS Memo: QSO-20-14, ongoing CDC Guidance)

o Staff scheduling adjustments, PBJ and NHSN Reporting (4/24/2020 CMS Memo: QSO-20-28, 5/06/2020 CMS Memo: QSO-20-29, CMS Blanket Waivers)

o Graduate Nurse Licensing, Nurse Aide Certification and Paid Feeding Assistants requirement changes (CMS Blanket Waivers)

o In-service Training (CMS Blanket Waivers)

o PTO

Date(s): Revisions:



o Sick Time o On-Call o Overtime o Bonus o Criminal background checks during extended

grace period for fingerprinting (3/20/2020 Gov. Kemp’s Executive Order)

o Other

Environmental policies, procedures, processes and forms reviewed and revised, if indicated: (3/04/2020 CMS Memo: QSO-20-14, 3/09/2020 CMS Revised Memo: QSO-20-14, 4/08/2020 Gov. Kemp’s Executive Order AND ongoing CDC and DPH guidance):

o Increased/enhanced cleaning and disinfecting, such as cleaning schedule revisions and the utilization of external cleaning, such as the National Guard

o Increased/enhance cleaning of targeted areas, such as high-touch surfaces, electronic devices, etc.

o Increased/enhanced cleaning of shared resident equipment, when resident specific/designated equipment is not available

o Linen cleaning and disinfecting, including how resident laundry is handled differently as a result of COVID-19

o Validating EPA approved disinfectants

Date(s): Revisions:

Other policy, procedures, processes and forms reviewed and revised if indicated: (3/04/2020 CMS Memo: QSO-20-14, 3/09/2020 CMS Revised Memo: QSO-20-14, 3/13/2020 CMS Revised Memo: QSO-20-14, 3/23/2020 CMS Memo: QSO 20-20, CMS Blanket Waivers, 4/24/2020 CMS COVID-19 Long Term Care Facility FAQs, 3/28/2020 DPH Provider Letter, 4/08/2020 Gov. Kemp’s Executive Order and ongoing CDC and DPH guidance)

o Visitor, vendor, non-essential personnel limitations, restrictions, signage and instructions (compassionate care visits, etc.)

o Staff and other essential personnel

limitations, restrictions, signage and

instructions (EMTs, dialysis providers etc.)

o Dialysis (if changed from dialysis being provided outside of facility to being

Date(s): Revisions:



provided inside facility (CMS Blanket Waivers)

o Alternate resident visits, such as virtual visits, phone communications, emails, etc.

o Resident admission, transfer and discharge criteria, including waivers for admissions without a 3 day hospital stay, delay of PASARR screening until after admission, etc. (CMS Blanket Waivers)

o Cancellation of communal dining and group activities and/or dining and group activity changes that provide for social distancing and group limitations, closing common areas and/or designating spaces that support social distancing and group limitations

o Determining and providing for medically necessary appointments where transportation off site is necessary, including use of appropriate PPE during transport

o Providing and arranging for Telehealth provider visits (CMS Blanket Waivers)

o QAPI focus on infection control and adverse events (CMS Blanket Waivers)

o Request for Records Extension (CMS Blanket Waivers)

o MDS Submission Relief (CMS Blanket Waivers)

o Other

COVID-19 Team Is there documentation to support the following activities? Yes No N/A Comments

The COVID-19 team meetings included ongoing review of policies, procedure and processes that support COVID-19 guidance and facility activities.

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COVID-19 DOCUMENTATION GUIDANCE SCREENING, TESTING, NOTIFICATION AND REPORTING


Screening Is there documentation to support the following activities? Yes No N/A Comments

Standardized Screening Tool and/or Screening Log utilized that includes the following criteria:

o Hand hygiene o Traveled internationally within past 14 days

where confirmed COVID-19 present o Worked in location or with someone with

confirmed COVID-19 o Cough o Shortness of breath o Sore throat o History of fever (asked) o Temperature checks o Chills o Repeated shaking with chills o Headache o New loss of taste or smell o Muscle pain o Vomiting o Diarrhea

Because screening criteria have expanded over time, indicate, for each criterion the date each criterion was added to the screening: Criterion: Date

Screening Logs and/or completed Screening Forms are maintained on:

Staff Visitors Residents

Resident Screenings are documented in at least one of the following:

Resident Specific Screening Forms Resident Medical Record Notes Screening Logs which are used for each

resident Screening Logs which are used for multiple

residents

Specify the method in which resident screenings are documented:

Staff Screening

On or before 3/04/2020, require screening of all staff prior to beginning work: (3/04/2020 CMS Memo: QSO-20-12, 3/09/2020 Revised CMS Memo: QSO-20-14, 3/13/2020 Revised CMS Memo: QSO-20-14, 4/19/2020 CMS Memo: QSO-20-20, 3/28/2020 DPH Provider Letter, and CDC Return to Work Criteria)

o Furthermore, require staff to self-monitor/screen and report suspected COVID-19 symptoms immediately

o Additional staff monitoring may be provided based on COVID-19 Exposure Risk



o Prohibiting suspected and/or confirmed COVID-19 positive staff from working

o Permitting staff who were prohibited from working, to return to work when CDC Return to Work Criteria are met

Screen “compassionate care” staff that will be permitted in the facility on a case-by-case basis, as determined by resident need, prior to entering facility. (3/04/2020 CMS Memo: QSO-20-12, 3/04/2020 CMS Memo: QSO-20-14, 3/09/2020 Revised CMS Memo: QSO-20-14, 3/13/2020 Revised CMS Memo: QSO-20-14, 3/28/2020 DPH Provider Letter, and 4/02/2020 Gov. Kemp Executive Order)

o Communicate expectations with compassionate care staff, such as screening requirements, self-reporting, adhering to infection control precautions, PPE required, limiting foot traffic and implementing social distancing, when possible, while in facility.

Screen non-employee essential healthcare personnel who may provide necessary services in the facility prior to entering the facility (lab, radiology, dialysis, EMTs, etc.). (3/04/2020 CMS Memo: QSO-20-12, 3/04/2020 CMS Memo: QSO-20-14, 3/09/2020 Revised CMS Memo: QSO-20-14, 3/13/2020 Revised CMS Memo: QSO-20-14, 3/28/2020 DPH Provider Letter and 4/02/2020 Gov. Kemp Executive Order)

o Communicate expectations with non-employee essential healthcare personnel, such as screening requirements, self-reporting, adhering to infection control precautions, PPE required, limiting foot traffic and implementing social distancing, when possible, while in facility.

Visitor Screening All visitors who screen negative beginning

3/04/2020, are: (3/04/2020 CMS Memo: QSO-20-14, 3/09/2020 CMS Revised Memo: QSO-20-14)

o Limited in facilities that are in counties, or counties adjacent to other counties where a COVID-19 case has occurred.

Limited means the individual should not be allowed to come into the facility, except for certain situations, such as end-of-life or essential for resident’s emotional well-being or care.



o Discouraged in facilities not in those counties referenced above

Discouraged means that the facility allows normal visitation practices, however the facility advises individuals to defer visitation until further notice.

o Establishing an outdoor, covered vendor drop-off location in effort to prevent delivery drivers from the need to enter the facility

o All visitors allowed entry are instructed to limit their movement within the facility to the resident’s room, avoid common areas and practice social distancing when possible.

o Require visitors allowed entry to wear appropriate PPE

o If possible, a “clean room” is established near the facility entrance where visitors can meet with residents (sanitize room after each visit).

Beginning 3/09/2020 and ongoing, advise: (3/09/2020 CMS Revised Memo: QSO-20-14)

o Exposed visitors (contact with COVID-19 positive resident or others prior to admission) to monitor for signs and symptoms of respiratory infection for at least 14 days after last known exposure and if ill to self-isolate at home and contact their healthcare provider.

o All visitors to report to the facility any signs or symptoms of COVID-19 or acute illness within 14 days after visiting the facility.

o Practice social distancing when possible

Was this information provided in writing or orally, explain?

All visitors are restricted from entering the facility on or after 3/13/2020: (3/13/2020 CMS Revised Memo: QSO-20-14, 3/28/2020 DPH Provider Letter and 4/08/2020 Gov. Kemp Executive Order)

o Exception: Compassionate care visitors, who screen negative, may enter facility, as determined on a case-by-case basis, being sure to state the name and relationship to the resident of the visitor as well as the date, time and duration of visit:

Explain how this was communicated to visitors.



Compassionate care visitors are to limit foot traffic, visit with resident in the resident’s room, avoid common areas and practice social distancing, such as refraining from hugging, handholding and kissing.

Visitors are required to perform hand-hygiene upon facility entrance.

Visitors are required to use PPE, such as facemasks, gowns and gloves.

o Documentation of all instances in which visitors were restricted from entering the facility and why.

Resident Screening On or before 3/09/2020, Resident screening and

monitoring of COVID-19 is being conducted on existing and new/re-admission residents (3/09/2020 CMS Memo: QSO-20-14, 3/28/2020 DPH Provider Letter)

On or before 3/13/2020, begin actively taking resident temperature and assess for respiratory symptoms when screening (3/13/2020 CMS Memo: 20-14 and 3/28/2020 DPH Provider Letter)

Date when screening was initiated and frequency of resident screening:

Testing

Is there documentation to support the following activities? Yes No N/A Comments Ensure testing laboratories are in accordance to CDC’s

Interim Testing Guidance in Response to Suspected or Confirmed COVID-19 in Nursing Home Residents and Healthcare Personnel

o Rapid turn-around times (e.g. less than 8 hours

o If testing capacity is limited, direct testing to residents and staff on the same unit or floor of a new confirmed cases

o If testing on the same unit or floor is not possible, direct testing to symptomatic residents and staff who have known exposure

The Department of Public Health (DPH) was notified of testing needs of residents and staff: (Ongoing CDC guidance, DPH website, )

o Document DPH response received, including date(s)

Dates DPH Notified:



Communications with local EMA to place a WebEOC Resource Request for requesting testing to be provided by the Georgia National Guard (DPH and Georgia’s National Guard Testing Strategy)

o Response received, including date(s) o Testing performed by National Guard

Dates of Communication with EMA and National Guard:

Communications made with other (private) testing locations

o Response received, including date(s) o Testing performed, including date(s)

Dates notified and names of other testing locations:

Facility provided advanced notification of anticipated dates, times and other testing information provided to:

o Residents o Staff o Resident representatives

Logs or other forms to track resident testing that includes:

o Resident name o COVID-19 symptomatic o COVID-19 asymptomatic o Date tested o Date test results received o Results o Actions taken and when

Logs or other forms of tracking employee testing that includes:

o Employee name o COVID-19 symptomatic o COVID-19 asymptomatic o Date tested o Date test results received o Results o Actions taken and when

Notification and Reporting

Is there documentation to support the following activities? Yes No N/A Comments Beginning 5/08/20 Inform residents, their

representatives and families by 5 p.m. the next calendar day following the occurrence of: (4/19/2020 CMS Memo: QSO-20-20, 5/06/2020 CMS Memo: QSO-20-29)

o A single confirmed infection of COVID-19 OR

o Three or more residents or staff with new onset of respiratory symptoms that occur within 72 hours of each other

This information must:



o Not include personally identifiable information

o Include information on mitigating actions implemented to prevent or reduce the risk of transmission, including if normal operations of the facility will be altered

o Include any cumulative updates at least weekly or by 5:00 p.m. the next calendar day following the subsequent occurrence of:

A single confirmed infection of COVID-19 is identified OR

Three or more residents or staff with new onset of respiratory symptoms occurring within 72 hours of each other

**Facilities are not expected to make individual calls. Facilities may use general communications platforms easily available to residents, representatives and families such as listservs, website postings, and recorded telephone messages.

Immediate notification to DPH of the following: o Any case of unexplained severe respiratory

illness o Clusters of 2 or more people with respiratory

symptoms o A positive COVID-19 Test

Daily notification to HFRD of the following: o Current Facility Census o Total # COVID-19 Positive Residents

(Cumulative) o # of Resident Tests Pending Results o # of Residents in Quarantine o # of Residents Hospitalized (in the last 24

hours) o # of Residents Hospitalized (in the last week) o # of Resident Deaths o # of Staff (employees assigned to the location) o # of Staff Tested Positive o # of Staff Tests Pending Results

No less than weekly, notification to the CDC’s National Health Safety Network: (4/19/2020 CMS Memo: QSO-20-20, 5/06/2020 CMS Memo: QSO-20-29, NHSN website)

o Residents suspected and confirmed COVID-19 o Staff suspected and confirmed COVID-19 o Resident total deaths and COVID-19 deaths o Staff total deaths and COVID-19 deaths



o Personal Protective Equipment and Hand Hygiene Supplies in facility

o Ventilator capacity and supplies in facility o Resident beds and census o Access to COVID-19 testing while the resident

is in the facility o Staffing shortages o Other information specified

COVID-19 Team Is there documentation to support the following activities? Yes No

N/A Comments

The COVID-19 team meetings included ongoing review of visitor, resident and employee:

o Screening o Testing o Reporting

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COVID-19 DOCUMENTATION GUIDANCE PERSONAL PROTECTIVE EQUIPMENT


PPE Communication Is there documentation to support the following activities? Yes No N/A Comments

Facility implemented a written PPE management plan, that includes, but is not limited to:

o PPE Inventory Control o PPE Optimization o PPE Crisis Capacity

The PPE management plan incorporates OSHA provisions relating to:

o COVID-19 modifications to the facility’s Respiratory Protection Program to account for shortages of N95 respirators, including:

Efforts to secure N95 respirators and alternative classes of NIOSH-approved respirators that provide equal or greater protections compared to an N95 respirator, extended use and reuse of respirators, use of expired previously NIOSH-certified respirators, certain foreign-certified respirators, and alternatives to reduce the need for respirators, such as other engineering controls, modification of work practices, and administrative controls (4/3/20)

Respirator fit-testing (3/14/20; 4/8/20)

Decontamination of filtering face piece respirators (4/24/20)

PPE management plan is updated and communicated to staff, visitors and others, as indicated

o Identify staff responsible for routinely checking the CDC and OSHA websites for PPE updates and communicating changes to pertinent facility leadership

o PPE management plan is continually assessed to determine when a return to standard practice can be considered

Post PPE signage at facility entrances and throughout the facility to remind visitors and staff of PPE requirements (3/04/2020 CMS Memo: QSO-20-12, 3/04/2020 CMS Memo: QSO-20-14, 3/09/2020 CMS Revised Memo: QSO-20-14, 3/13/2020 CMS Revised Memo: QSO-



2014, 4/02/2020 CMS Long Term Facility Guidance and ongoing CDC and DPH guidance)

o Post appropriate PPE signage and PPE supplies outside the rooms of residents rooms who are on isolation based upon infection control precautions required when entering the resident’s room and/or providing resident care (Refer to Resource Module)

Require, instruct on use and provide visitors with hand-hygiene products and appropriate PPE upon facility entrance and to be utilized for the duration of visit, while in the facility (3/04/2020 CMS Memo: QSO-20-12, 3/04/2020 CMS Memo: QSO-20-14, 3/09/2020 CMS Revised Memo: QSO-20-14, 3/13/2020 CMS Revised Memo: QSO-2014, 4/02/2020 CMS Long Term Facility Guidance and ongoing CDC and DPH guidance)

Staff are made aware of methods to obtain additional PPE and hand-hygiene products when needed

Communicate and coordinate PPE needs to appropriate State and Local Health Departments, as indicated (4/02/2020 CMS LTC Facility Guidance and ongoing DPH guidance)

o On or before 3/24/2020, PPE requests are made to DPH for PPE via the ReadyOp website

Completed COVID-19 Survey for Nursing Home tool as a PPE self-assessment: standard and transmission based precautions and PPE (3/23/2020 CMS Memo, QSO-20-20 and 5/6/20 CMS Memo QSO-20-20)

At least weekly, reporting PPE supplies (N95 masks, medical/surgical masks, eye protection, gowns, gloves and alcohol-based hand sanitizer) to NHSN (refer to Screening, Testing, and Reporting Module).

PPE Inventory Control Is there documentation to support the following activities? Yes No N/A Comments

Beginning on or before 2/06/2020, review of the appropriate PPE use and availability (2/06/2020 CMS Memo: QSO 20-09 3/04/2020 CMS Memo: QSO-20-12, 3/04/2020 CMS Memo: QSO-20-14, 3/09/2020 CMS Revised Memo: QSO-20-14, 3/13/2020 CMS Revised Memo: QSO-2014, 4/02/2020 CMS Long Term Facility Guidance and ongoing CDC and DPH guidance)



o Ensure PPE measures and protocols are in the emergency plans/policies, including the event of potential surge situations (refer to Policies, Procedures and Processes Checklist)

Increased frequency, (such as 3 x/week, every other day, daily, every shift, etc.), PPE inventory count which includes counts completed for:

o Surgical/medical masks o Respirators o Gloves o Gowns o Goggles o Face Shields o Hand Sanitizer o EPA-Approved COVID-19 Disinfectants o Other

Dates/times of PPE vendor contacts, orders placed (and response), back-orders and deliveries

Utilization of the CDC’s PPE Burn-Rate Calculator or other structured method of anticipating PPE usage over time

Communicate and coordinate PPE needs to appropriate State and Local Health Departments, as indicated (3/24/2020 DPH guidance, 4/02/2020 CMS LTC Facility Guidance)

o On or before 3/24/2020, PPE requests are made to DPH for PPE via the ReadyOp website

PPE locations are identified and accessible for staff to obtain PPE and hand-hygiene products where resident care is provided (consider the use a floor plan that identifies PPE storage locations)

o Evidence of increased monitoring of PPE locations is being conducted

PPE is secured PPE restocked as needed

o PPE disposal receptacles are near exits inside the resident’s room

Hand-sanitizer dispensers are in place at entrances, high traffic/common areas, and other convenient locations throughout the facility, ideally inside or outside of each resident’s room (consider the use a floor plan that identifies locations of hand-sanitizer dispensers)



o Evidence of increased monitoring of dispensers is being conducted and dispensers are being refilled as needed

Soap, paper towels and disposal receptacles are provided at all facility sinks for staff, residents and others to use in hand-hygiene activities

o Evidence of increased monitoring of soap and paper towels is being conducted and supplies are refilled as needed

If available and if requested, provision of PPE to state regulatory personnel upon facility entrance. Communicate to regulatory personnel if unable to provide PPE prior to their facility entrance (3/04/2020 CMS Memo, QSO-20-12)

PPE Optimization (Strategies for PPE Optimization may change daily standard practices but may not have any significant impact on the care delivered to

the patient or the safety of healthcare personnel (HCP). These practices may be used temporarily during periods of expected PPE shortages).

Is there documentation to support the following activities? Yes No N/A Comments Assessment and installation of engineering controls,

such as plexi-glass barriers, outdoor mail boxes, etc.

Assessment and implementation of altering work practices to minimize resident contact for staff with non-direct care duties, such as getting direct care staff to obtain resident signatures, deliver mail, etc.

Cancellation of elective and non-urgent medical appointments

Implementation of telehealth provider visits Cancellation of group activities and communal dining

o Implementation of social distancing

Re-evaluation of staff exposure risk classifications to identify PPE needs based upon job role and functions

o Identification of residents with suspected or confirmed COVID-19 or who have aerosol generating treatments that may require staff to use an N95 respirator

On or before 3/28/2020 implementation of universal face-masking of all staff, while in the facility (4/02/2020 CMS Long Term Facility Guidance, 3/28/2020 DPH Provider Letter, 4/08/2020 Gov. Kemp’s Executive Order, and ongoing Executive Orders)

o If different types of facemasks are used for specific resident care activities from the universal face-masking, then inform staff and visitors of such and provide different facemasks accordingly



o Also refer to Gov. Kemp Executive Order 4/08/2020 to implement universal and correct use of facemasks for all employees and use of additional PPE when interacting with residents with respiratory symptoms, including the use of Standard, Contact and Droplet precautions with eye protection when care for residents with undiagnosed respiratory infection (unless the suspected diagnosis requires Airborne Precautions, such as TB).

Implementation of full PPE for the care of any resident with known or suspected COVID-19 per CDC guidance on conservation of PPE

o If COVID-19 transmission occurs in the facility, implementation of full PPE for the care of all residents irrespective of COVID-19 diagnosis or symptoms

On or before 3/09/2020, for residents with suspected or confirmed COVID-19, residents are to wear facemask prior to leaving their room and during transport (3/09/2020 CMS Revised Memo: 20-14 and ongoing CDC guidance)

o Follow CDC recommendations for those residents who should not wear a face covering

On or before 4/02/2020, implementation of resident facemasks, whether they have COVID-19 symptoms or not, to cover their mouth and nose when: (4/02/2020 CMS Long Term Facility Guidance)

o Staff are in their room providing care o Anytime the resident is outside of their

room o When medical/surgical facemask availability

is limited, restrict resident facemask use and use alternative measures for source control of respiratory secretions, such as tissues or cloth facemask.

Following the CDC’s recommendations for “Strategies for Optimizing PPE, develop and implement protocols for cleaning, storage and disposal process for reuse PPE (CDC PPE Reuse Strategies)

o Steps are in place to avoid contamination of reuse PPE between residents

o Assignment of PPE to employees for reuse



o When N95 or other respirators are considered for reuse, ensure compliance to OSHA and the CDC’s guidance on decontamination and reuse of filtering facemasks

Utilize respirator cleaning vendors, if indicated

Staff training on: o Protocols for use and reuse of PPE o Inspection and checks of reuse PPE, prior to

reusing o When to and where to dispose of PPE o PPE cleaning and storing process o Donning and doffing PPE to prevent

contamination, including competency check-off

o Requesting additional reuse PPE

PPE Crisis Capacity (Strategies that are not commensurate with U.S. standards of care. These measures, or a combination of these measures, together with

PPE Optimization may need to be considered during periods of PPE shortages and/or unavailability).

Is there documentation to support the following activities? Yes No N/A Comments Consideration of using PPE that is beyond the

manufacturer-designated shelf-life for resident care activities

Good faith efforts to obtain alternatives to PPE to protect workers

o Alternative filtering face piece respirators, reusable elastomeric respirators, or powered, air-purifying respirators where an N95 filtering face piece respirators would be used

Prioritize PPE use for selected care activities, including the use of eye protection, gloves and gowns with:

o The use of medical/surgical facemasks and during care activities where splashes and sprays are anticipated.

o The use of medical/surgical facemasks during activities where prolonged face-to-face or close contact with a potentially infectious patient is unavoidable.

o N95 respirator use with COVID-19 positive resident requiring nebulizer treatments or suctioning. If N95 respirators are not available: Use of medical/surgical facemasks when performing aerosol generating procedures.



14996293v3

When PPE supply has been exhausted (the facility is unable to follow the CDC PPE guidance) alternative PPE processes have been developed and implemented:

o Use of cloth face masks with face shields when surgical/medical facemasks or N95 respirators are no longer available

o Use a face shield that covers the entire front (that extends to the chin or below) and sides of the face with no facemask

o Use of cloth gowns, raincoats or other garments when paper gowns are no longer available, including laundering/cleaning process

o Exclusion of staff at higher risk for severe illness from COVID-19 from contact with known or suspected COVID-19 residents, such as those of older age, those with chronic medical conditions, or those who may be pregnant, from caring for residents with confirmed or suspected COVID-19 infection.

o Designate staff who have clinically recovered from COVID-19 to preferentially provide care for residents with confirmed or suspected COVID-19.


The COVID-19 Team meetings include ongoing review of PPE management plan, including PPE availability, staff awareness, compliance with PPE protocols and PPE optimization strategies.

COVID-19 DOCUMENTATION GUIDANCE STAFF MANAGEMENT


Staffing Communication

Is there documentation to support the following activities? Yes No N/A Comments Development and implementation of strategies

for communicating the facility’s staffing plan and required staff training related to COVID-19

o Evidence of ongoing communications with staff regarding staffing plan updates and ongoing staff training requirements

Identification and implementation of multiple methods to communicate staffing plan and required training to staff:

o Posting of information and signage at facility entrances, staff bulletin boards, and other locations within facility (Refer to Resource Module for possible signage to use)

o Staff meetings (staggered or virtual to limit numbers and maintain social distancing.

o E-learning systems o In-person education programs o Competency check-offs o Listservs, emails and other electronic

media o Newsletters o Other

Provide opportunities for staff to ask questions and seek clarification regarding staffing plan

Maintain records of ongoing staffing plan communication and staff training requirements

Staffing Plan Is there documentation to support the following activities? Yes No N/A Comments

Written staffing plan in place o Evidence of ongoing updates

Date(s): Updates:

Determine the ability for certain staff members to work remotely or to tele-working, i.e. billing (4/02/2020 Gov. Kemp Executive Order)

Conduct staff meetings, and staff gatherings (4/02/2020 Gov. Kemp Executive Order)

o Virtually, when possible o In-person, limiting number of staff present

and maintaining social distancing o Avoiding close contact between staff

members, i.e. hugging, handshaking, etc.



Provide additional work supplies (pads, pens, electronic devices, etc.) in effort to avoid sharing, as indicated.(3/09/2020 CMS Revised Memo: QSO-20-14)

Identify staff and require them to report when they work in more than one healthcare facility

o If possible, attempt to make arrangements for such staff members to only work in one facility during the pandemic period (4/08/2020 Gov. Kemp’s Executive Order)

Review CMS Emergency Declaration Blanket Waivers that may support staffing time, additional staff and flexibilities and include in the staffing plan, if indicated: (CMS Blanket Waivers, DPH-HFRD Guidance and 3/23/2020 Gov. Kemp’s Executive Orders)

o Temporary Nurse Aide Training Program o Graduate nurse licensing waiver o Additional licensed staff waivers that may

be applicable o PBJ extended staffing data submissions o MDS timeframe submission requirements o Delay in providing 12 hour annual CNA in-

service training o Implementation of Telehealth Provider

visits o Extending resident request for records

receipt from 2 working days to 10 working days

Possible cancellations of staff elective time off (vacations) and other non-emergency time off/leave of absences during the pandemic period, if permitted

Revise staffing schedules to adjust for: (4/02/2020 CMS Long Term Care Guidance)

o Consistent staffing, separate for COVID-19 suspected or positive tested residents vs. non-suspected or negative tested residents

o Designated COVID-19 units/halls for existing, newly admitted and/or readmitted residents

o Higher intensity of care and time required to care for suspected cases or positive-tested residents

o Consideration of eliminating non-infection control duties performed by the Infection Preventionist, in effort to focus full-time on infection control activities



o Other

Review of job exposure risk classifications (including protocols of screening for, monitoring or, and reporting of symptoms) (CDC, OSHA Healthcare Personnel Risk Assessment)

Establish enhanced on-call with multiple layers of staff responding and working related to:

o Staff absences due to suspected or confirmed COVID-19

o Increased staffing need due to staffing changes, i.e. consistent staffing, designated staffing for COVID-19 units or halls, etc.

o Increase staffing need due to resident increased acuity

Establish or review staffing agency contracts, needs and compliance with all requirements

Review and revise hiring and orientation processes in effort to increase staff volume in a shorter time, by expediting processes:

o Ensure appropriate background checks are obtained during extended grace period for fingerprinting (3/20/2020 Gov. Kemp’s Executive Order, DCH-HFRD COVID-19 Information)

o Contact local schools and colleges to identify potential staff

o Utilize Social Media and other media to recruit and advertise staffing needs

o Other

Utilization of corporate, regional staff and others employed within the organization to supplement staffing where appropriate

From 4/10/2020 through 5/25/2020 - Follow protocols for recording staff injuries and illnesses, with COVID-19 being a recordable illness on the OSHA 300 log when the below criteria are met: (4/10/2020 OSHA Enforcement Memo)

o OSHA recordkeeping requirements at 29 CFR Part 1904 mandate covered employers record certain work-related injuries and illnesses on their OSHA 300 log.

o COVID-19 can be a recordable illness if a worker is infected as a result of performing their work-related duties. However, employers are only responsible for recording



cases of COVID-19 if all of the following are true:

The case is a confirmed case of COVID-19 (see CDC information on persons under investigation and presumptive positive and laboratory-confirmed cases of COVID-19);

The case is work-related (as defined by 29 CFR 1904.5); and

The case involves one or more of the general recording criteria set forth in 29 CFR 1904.7 (e.g., medical treatment beyond first aid, days away from work).

From 5/26/20, record cases of COVID-19 among employees in accordance with the following protocols: (5/19/2020 OSHA Enforcement Memo)

o The case is a confirmed case of COVID-19 o The case is work-related as defined by 29

CFR § 1904.5 Facility undertakes a reasonable

and good faith investigation into work-relatedness

Asking employee his/her thoughts

Asking employee about work and away-from-work activities that may have led to illness

Review of work environment

Work-relatedness determination based on information reasonably available to the employer at the time

Evidence for and against work-relatedness

Other cases in the facility

Proximity of illness to lengthy, close exposure to residents or other employees with the illness

Job duties with frequent, close exposure to



individuals in an area with ongoing community transmission

Not likely work related if close, frequent association outside the workplace with someone (not a coworker) having COVID-19

o The case involves one or more of the general recording criteria of 29 CFR § 1904.7

Implementation of staff benefit enhancements: o Child Care (connect with local YMCA and

other external programs providing child care for essential healthcare workers)

o Payroll Bonuses o Sick Time o Appreciation and Recognition

Soliciting Thank-You notes and cards from the community

Staff meals, snacks, candy, drinks, etc.

Staff raffles, gifts cards Recognition of staff on social

media, bulletin boards, etc. Other

o Hotel or other housing provided o Emergency Assistance o Transportation o Other

Addressing staff stress and burnout through: o Offering counseling o Providing coping techniques (taking breaks,

eating healthy, exercising, etc.) o Establishing a staff “quiet room” o Establishing a staff buddy system to check

on each other and provide support o Other

Review resident care needs for possible staff adjustments in an effort to limit the number of times and number of staff that enter a resident’s room while ensuring resident care needs continue to be met

Review and revise job functions to provide direct care staff with more time to perform essential direct care services:



o Moving non-clinical functions normally performed by clinical staff, to being performed by non-clinical staff (restocking linen carts and supplies, delivering water, meals and snacks, assisting residents to and from baths, as appropriate and where indicated, taking menu orders, responding to call lights, staying with resident while in the bathroom until clinical staff can come, providing 1-to-1 for residents with behavior or social concerns, applying/removing glasses/hearing aids, bed making etc.)

o Cancellation of group and concurrent therapy and revision of resident therapy plans to free up therapy time to assist in providing direct care when appropriate, such as, ADL care, feeding and toileting assistance, and restorative, functional, and mobility maintenance programs

o Other

If appropriate, review medication and treatment orders with providers to determine whether licensed nurse time can be reduced safely without compromising residents’ care needs:

o Discontinue non-critical medications (vitamins, etc.), if appropriate

o Discontinue or reduce blood sugar checks and conversion of sliding scale insulin to daily long-acting insulin, if appropriate

o Discontinue non-use or infrequent use of PRN medications, ensuring there is not a delay in re-ordering and receiving if needed by the resident, if appropriate

o Routine scheduling of frequently used PRN medications or other medication adjustments to improve licensed nurse efficiencies, if appropriate

o Decrease frequency of vital signs checks, if appropriate

o Change in dressings types to reduce frequency of changing, if appropriate

o Other

On or before 3/04/20, requiring staff COVID-19 screening, monitoring, testing (when applicable), and self-reporting prior to beginning work (refer to Screening, Monitoring and Testing module and Return to Normal Operations below):



(3/04/2020 CMS Memo: QSO-20-14, 3/09/2020 Revised CMS Memo: QSO-20-14, 3/13/2020 Revised CMS Memo: QSO-20-14, 4/19/2020 CMS Memo: QSO-20-20, 5/18/20 CMS Memo: QSO-20-30, 5/14/2020 OSHA alert, 3/28/2020 DPH Provider Memo, and CDC Return to Work Criteria)

o Consideration of additional staff monitoring based on COVID-19 Exposure Risk

o Screen employees for symptoms before each shift

o Prohibiting suspected and/or confirmed COVID-19 positive staff from working

o Send staff home or to seek medical care

o Permitting staff who were prohibited from working, and to return to work when CDC Return to Work Criteria are met

o Maintain at least 6 feet between workers, residents, and visitors to the extent possible, including while workers perform their duties and during breaks

o Stagger break periods to avoid crowding in breakrooms

o Consider alternatives to in-person staff meetings

o Encourage staff to report any safety and health concerns

o Reporting staff who are under suspicion and/or tested positive for COVID-19 to external agencies as required (Department of Public Health, HFRD, NHSN-4/19/2020 CMS Memo: QSO-20-20 and 5/06/2020 CMS Memo: QSO-20-29, 4/02/2020 Gov. Kemp Executive Order)

Identify/define “compassionate care” staff that will be permitted in the facility on a case-by-case basis, as determined by resident need.

o Establish screening process for compassionate care staff prior to entering the facility and protocols for time spent on facility property

o Communicate expectations (screening, use of infection control precautions and PPE, in writing with compassion care staff and agencies (hospice agencies, etc.) (3/04/2020 CMS Memo: QSO-20-12, 3/04/2020 CMS Memo: QSO-20-14,



3/09/2020 Revised CMS Memo: QSO-20-14, 3/14/2020 Revised CMS Memo: QSO-20-14, 3/28/2020 DPH Provider Memo, and 4/02/2020 Gov. Kemp Executive Order)

Identify/define non-employee essential healthcare personnel who may provide necessary services in the facility (lab, radiology, dialysis, EMTs, etc.). This may be done on a resident-by-resident basis, as determined by resident need.

o Establish screening process for non-employed healthcare personnel prior to entering the facility and protocols for time spent on facility property

o Communicate expectations (screening, use of infection control precautions and PPE, in writing with appropriate agencies providing non-employee healthcare services) (3/04/2020 CMS Memo: QSO-20-12, 3/04/2020 CMS Memo: QSO-20-14, 3/09/2020 Revised CMS Memo: QSO-20-14, 3/14/2020 Revised CMS Memo: QSO-20-14, 3/28/2020 DPH Provider Memo, and 4/02/2020 Gov. Kemp Executive Order)

Review the CDC’s Strategies to Mitigated Healthcare Personnel Staffing Shortages, and incorporate appropriate strategies into staffing plan, if indicated.

Training/Education

Is there documentation to support the following activities? Yes No N/A Comments

Identification of staff member(s) responsible to provide staff training related to COVID-19

ALL staff, including contract staff, received training on: (2/06/2020 CMS Memo: QSO-20-09, 3/04/2020 CMS Memo: QSO-20-12, 3/04/2020 CMS Memo: QSO-20-14, 3/09/2020 CMS Revised Memo: QSO-20-14, 3/10/2020 CMS Memo: QSO-20-17, 3/13/2020 Revised CMS Revised Memo: QSO-20-14, 3/23/2020 CMS Memo: 20-20, 3/28/2020 DPH Provider Memo AND ongoing CDC guidance)

o Policy Changes (refer to Policies, Procedures and Process checklist)

Pandemic Infection Control Human Resources Other

Dates Training Provided: Topic:



o COVID-19, including signs and symptoms

o Staff Exposure Risk Classifications o Infection Control Precautions (Standard,

Contact, Enhanced Barrier, and Transmission-Based)

o Hand-Hygiene (use of alcohol based hand sanitizers and washing with soap and water for 20 seconds)

o Cough Etiquette o Personal Protective Equipment (refer to

PPE checklist for more detail) Type of PPE required for

different infection control precautions necessary for residents who are non-COVID-19 positive, under suspicion for COVID-19 and positive COVID-19

Universal (All Staff) masking at all times while in facility (4/02/2020 CMS Long Term Care Facility Guidance)

How to obtain or request PPE Optimizing and reuse of PPE Inspection of reuse PPE prior to

use Donning and doffing PPE Cleaning and disinfecting reuse

PPE o Respiratory Program (if facility has)

Including respiratory-N95, fit-testing

o Social Distancing o Staff screening requirements prior to

beginning work o Staff monitoring, testing and self-

reporting o Staff Quarantining and Return to Work

Requirements o Staff scheduling changes, such as

consistent assignment o Other



PPE Donning/Doffing competencies and check-offs are completed for staff requiring PPE

o On-going monitoring of staff utilizing and donning/doffing of PPE correctly (Refer to Resource Module for PPE signage)


The COVID-19 team meetings include an ongoing review of the staffing plan, staff training/education and staffing activities.

14994856v3

COVID-19 DOCUMENTATION GUIDANCE

RESIDENT MANAGEMENT


Resident Communication Plan

Is there documentation to support the following activities? Yes No N/A Comments Facility implemented an ongoing written communication

plan of COVID-19 actions taken. o Evidence of ongoing communications to

residents for the duration of the pandemic

Date plan initiated and dates updated:

The communication plan includes method(s), written and verbal, that the facility utilized in communicating actions taken to the residents

o Posting of information and signage at facility entrances and other locations

o Electronic media (social media, emails, website, etc.)

o Newsletters o Designated phone line/messages o Other

Dates and types of communication methods used:

The communication plan includes the following (5/06/2020 CMS Memo: QSO-20-29), effective 5/08/2020:

o Inform residents by 5 p.m. the next calendar day following the occurrence of:

A single confirmed infection of COVID-19; OR

Three or more residents or staff with new onset of respiratory symptoms that occur within 72 hours

o This information must: Not include personally identifiable

information Include information on mitigating

actions implemented to prevent or reduce the risk of transmission, including if normal operations of the facility will be altered

Include any cumulative updates at least weekly or by 5:00 p.m. the next calendar day following the occurrence of:

A single confirmed infection of COVID-19 is identified; OR


Dates of reporting:


RESIDENT MANAGEMENT


**Facilities are not expected to make individual calls. Rather, they may use general communications platforms easily available to residents, representatives and families such as listservs, website postings, paper notices and recorded telephone messages.

The communication plan allows for the opportunity for resident to provide feedback and ask questions.

Resident Specific Actions Is there documentation to support the following activities? Yes No N/A Comments

On or before 3/09/2020, Resident screening and monitoring of COVID-19 is being conducted on existing and new/re-admissions residents (also refer to Screening, Testing and Reporting Module) (3/09/2020 CMS Memo: QSO-20-14, 3/28/2020 DPH Provider Letter)

Screening should be conducted at least daily

On or before 3/13/2020, begin actively taking resident temperature and assess for respiratory symptoms when screening (3/13/2020 CMS Memo: QSO-20-14)

Consideration of adding pulse oximetry to resident screening

Date when screening was initiated and frequency of resident screening:

Increased monitoring established for residents with suspected or confirmed COVID-19.

o Provide a minimum of every shift monitoring, or more frequently based on resident condition

o Include pulse oximetry and all vital signs in resident monitoring activities

o Include assessment of respiratory system in resident monitoring activities

On or before 3/13/2020, the facility implemented the following actions (3/09/2020 CMS Memo: QSO-20-14, 3/13/2020 Revised CMS Memo: QSO-20-14, 3/23/2020 CMS Memo: QSO-20-20, 4/24/2020 CMS COVID-19 Long Term Care Facility FAQs, 3/28/2020 DPH Provider Letter, Gov. Kemp’s Executive Orders on 3/23/2020, 4/02/2020 and 4/08/2020)

o Visitor restrictions with exception of “compassionate care” visits (in resident room or other designated “clean” space)

o Cancellation of communal dining and group activities and/or dining and group activity changes that provide for social distancing and group limitations, closing common areas and/or designating spaces that support social distancing and group limitations (see below)

Dates and method(s) by which communications with Residents occurred:


RESIDENT MANAGEMENT


o Residents to practice social distancing o Residents to utilize cough etiquette o Residents to perform frequent hand hygiene

On or before 3/09/2020, alternate visitation methods established for residents/visitors: (3/09/2020 CMS Memo: QSO-20-14, 3/13/2020 CMS Memo: QSO-20-14, 4/24/2020 CMS Long Term Care Facility FAQs.)

o Virtual visits (Face Time, Skype, etc.) o Phone visits o Window visits o Other

List dates and type of visitation methods established:

Alternatives to group activities established which support social distancing:

o Virtual/televised in-room activities for all Residents who can participate

o Window activities o Hallway door bingo, exercises o Outdoor time o Other

List dates and types of alternate group activities established:

Reviewed and revised memory care unit infection control and social distancing practices (CDC Guidance-Considerations for Memory Care Units in Long Term Care Facilities)

On or before 3/09/2020, for residents with suspected or confirmed COVID-19, residents are to wear facemask prior to leaving their room and during transport (3/09/2020 CMS Revised Memo: 20-14 and ongoing CDC guidance)


On or before 4/02/2020, implementation of resident facemasks, whether they have COVID-19 symptoms or not, to cover their mouth and nose when:

o Staff are in their room providing care o Anytime the resident is outside of their

room o When medical/surgical facemask availability

is limited, restrict resident facemask use and use alternative measures for source control of respiratory secretions, such as tissues or cloth facemask



RESIDENT MANAGEMENT


Provide residents with tissues and appropriate disposal receptacles

(4/02/2020 CMS Long Term Care Facility Guidance and CDC Face Mask and Cloth Face Mask Guidance)

Provide resident information regarding the right to access the Ombudsman via phone or other means if in-person access is restricted per infection control visitor guidance (3/09/2020 CMS Memo: QSO-20-14, 3/13/2020 Revised CMS Memo: QSO-20-14, 4/24/2020 Long Term Care Facility FAQs)

Post appropriate infection control signage outside suspected COVID-19 and confirmed positive COVID-19 resident rooms, to alert all who enter to use appropriate infection control precautions and PPE (3/09/2020 CMS Memo: QSO-20-14, 3/13/2020 Revised CMS Memo: QSO-20-14, 3/23/2020 CMS Memo: QSO-20-20)

Notify residents of facility access limitations and the ability to leave and re-enter the facility, as well as any requirements and procedures for placement in alternative facilities for COVID-19 positive or unknown status. (4/02/2020 CMS Long Term Care Facility Guidance)

In accordance with CMS COVID-19 Blanket Waivers, the facility will provide the resident/resident representative notification of transfer, as soon as practicable when:

o There is a need to relocate the resident within the facility, in accordance with the facility’s cohorting plan

o Any requirements, procedures and need for placement in alternative facilities for COVID-19 positive or unknown status residents

When a resident desires to leave the facility against medical advice, in addition to established facility policy criteria, the facility will: (4/24/2020 CMS Long Term Care Facility FAQs)

o Strongly discourage the resident from leaving the facility

o Encourage the resident to wear a facemask while out in the community

o Discuss the importance of handwashing and offering hand sanitizer to the resident, if available

o Explain the risks of leaving the facility during a pandemic


RESIDENT MANAGEMENT


Identify residents who receive aerosol generating procedures and need for staff to utilize N95 respirators. (3/04/2020 CMS Memo: QSO-20-12, 3/10/2020 CMS Memo: 20-17 and ongoing CDC and OSHA respirator guidance). See Personal Protective Equipment Module for more details.

o Staff are to use N95 respirators when administering treatments or are present for such treatments involving residents under suspicion of or positive for COVID-19

Establish telehealth visits for residents with their physicians, and/or other providers (CMS COVID-19 Blanket Waivers)

Assess resident need for “medically-necessary” medical appointments and coordinate with providers for:

o Possible options, such as providing dialysis or chemo treatments in the facility, telehealth visits, etc.

o The need for additional precautions to be implemented during transport and while away for medically-necessary appointments, such as the resident wearing a facemask while out of facility and performing hand-hygiene prior to entering facility, etc.

o Consideration of increased resident screening when medically-necessary appointments are essential to resident care and well-being

Provide resident monitoring for psychosocial and/or behavior symptoms related to changes in routine, isolation, trauma, worry, anxiety and/or other symptoms resulting from COVID-19

o Notify physician and resident representative, and/or provide appropriate interventions, if indicated

o Provide resident telehealth visits with psychosocial providers, if indicated

Update resident care plans to include individualized care related to COVID-19 activities. These may include, but not be limited to:

o Resident COVID-19 screening and testing o Management of COVID-19 symptoms o Psychosocial and/or behavior monitoring

and interventions as a result of COVID-19


RESIDENT MANAGEMENT


o Updated activity choices and interventions as a result of COVID-19

Results and interventions related to psychosocial and/or behavior monitoring

Psychosocial provider telehealth or in-person visits

Additions and/or changes in psychoactive medication use

In-room and doorway (social distancing) activity participation and choices

Virtual, window and other visits with family

Other o Infection control precautions and PPE

necessary for resident care o In accordance with CMS COVID-19 Blanket

Waivers, the facility does not have to provide the resident with post-acute care provider discharge data for resident’s use in selecting a provider upon discharge, such as home health.

In accordance with the CMS COVID-19 Blanket Waivers, when a resident requests a copy of their medical record, the facility will inform the resident that it will be provided within 10 working days of the request rather than 2 working days.

Other Is there documentation to support the following activities? Yes No N/A Comments

Review and revise resident admission, transfer and discharge criteria related to COVID-19 (also refer to Policies, Procedures and Processes Module): (3/09/2020 CMS Memo: QSO-20-14, 3/13/2020 CMS Revised Memo: QSO-20-14, 4/13/2020 CMS Memo: QSO-20-25, CMS COVID-19 Blanket Waivers)

o Establish transfer agreements to transfer or accept COVID-19 residents, if indicated, in furtherance of an inter-facility cohorting plan

o Implement CDC Infection Control Form or comparable form for all resident transfers (Refer to Resource Module for form)

o In accordance with the CMS COVID-19 Blanket Waivers, the 3-day hospital stay for skilled care admissions/readmissions for residents affected by COVID-19 have been eliminated


RESIDENT MANAGEMENT


o In accordance with the CMS COVID-19 Blanket Waivers, the facility may admit new residents who have not received a Level 1 or Level 2 PASARR screening. Level 1 assessments may be performed post-admission; on or before the 30th day of admission, new residents with a mental illness or intellectual disability should be referred promptly by the facility to the State PASARR program for Level 2 resident review.

Establish a Cohorting Plan (In-Facility Cohorting and Inter-Facility Cohorting), when feasible: (3/04/2020 CMS Memo: QSO-20-14, 3/09/2020 CMS Revised Memo: QSO-20-14, 3/13/2020 CMS Revised Memo: QSO-20-14, 4/14/2020 CMS Memo: 20-25, 3/28/2020 DPH Provider Letter, 4/08/2020 Gov. Kemp’s Executive Order and ongoing CDC guidance)

o Hallways or Units are established for residents under suspicion of having COVID-19 or are COVID-19 positive

o In accordance with CMS COVID-19 Blanket Waivers, the facility may identify temporary rooms not normally used as resident’s rooms to accommodate COVID-19 beds and resident care

o Residents under suspicion of having COVID-19 or are COVID-19 positive are moved to designated COVID-19 rooms

Ensure ongoing resident infection control activities are monitored and included in COVID-19 surveillance activities (also refer to Policies, Procedures and Processes Module): (3/04/2020 CMS Memo: QSO-20-12, 3/09/2020 Revised CMS Memo: QSO-20-14, 3/14/2020/CMS Revised Memo: QS-20-14, 4/19/2020 CMS Memo: QSO-20-20, CMS COVID-19 Focused Survey for Nursing Homes Tool and ongoing CDC guidance)

o Resident screening, monitoring and testing o Tracking the spread of cases (suspected or

confirmed) through the facility. Consider utilization of facility floor plans as a tracking visual)

o Staff compliance with infection control precautions, such as hand-hygiene, use of PPE, etc.

o Cleaning and disinfecting practices o Other


RESIDENT MANAGEMENT


Facility may apply to state for CMP funds for programs to purchase communication devices, such as tablets or web-cams, to increase the ability for nursing homes to help residents stay connected to their loved ones. (CMS COVID-19 Blanket Waivers, 4/24/2020 Long Term Care Facility-FAQs))


The COVID-19 team meetings included ongoing review of actions taken that directly impact resident care and services.

14995929v3


VISITOR AND FAMILY MANAGEMENT


Visitor and Family Communication Plan Is there documentation to support the following activities? Yes No N/A Comments

Facility implemented an ongoing written communication plan of COVID-19 actions taken:

o Evidence of ongoing communications to visitors and resident families for the duration of the pandemic

** Note: specific communications may not be applicable to all visitors or all family members. In addition, the facility must adhere to privacy regulations when communicating COVID-19 information. ** Note: for purposes of this module, the term family (or families) is inclusive of resident representatives.

Date plan initiated and dates updated:

The communication plan includes written and verbal methods utilized in communicating actions taken which impact visitors and families: (3/09/2020 CMS Revised Memo: QSO-20-14, 3/13/2020 CMS Revised Memo: QSO-20-14 )

o Posting of information and signage at facility entrances and other locations

o Electronic media (social media, emails, websites, listservs, etc.)

o Newsletters o Designated phone line/messages

Assigning staff as primary contact for inbound calls and conduct regular outbound calls to keep families up to date

Offering phone line with a voice recording updated at set times (e.g. daily)

o Other

Dates and types of communication methods used:

The communication plan includes the following (5/06/2020 CMS Memo: QSO-20-29):

o Inform residents/resident representative/family by 5 p.m. the next calendar day following the occurrence of:

A single confirmed infection of COVID-19; OR


o This information must: Not include personally

identifiable information

Dates of reporting:




Include information on

mitigating actions implemented to prevent or reduce the risk of transmission, including if normal operations of the facility will be altered

Include any cumulative updates at least weekly or by 5:00 p.m. the next calendar day following the subsequent occurrence of:

A single confirmed infection of COVID-19 is identified; OR


**Facilities are not expected to make individual calls. Rather, they may use general communications platforms easily available to residents, representatives and families such as listservs, website postings, paper notices and recorded telephone messages.

The communication plan includes the opportunity for visitor feedback and questions.

Visitor and Family: Actions Taken Is there documentation to support the following activities? Yes No N/A Comments

On or before, 3/04/2020, the facility will screen all visitors: (3/04/2020 CMS Memo: QSO-20-12, 3/09/2020 CMS Memo: QSO-20-14, 3/13/2020 CMS Revised Memo: QSO-20-14, 3/23/2020 CMS Memo: QSO-20-20, 4/02/2020 Long Term Care Facility COVID-19 Guidance, and ongoing CDC guidance)

o For visitors with positive screens, the facility may limit visitation rights for reasonable clinical or safety reasons or such visitors may be restricted from entering the facility (also refer to Screening, Testing and Reporting Module)

o Post signage at all entrances to notify visitors of screening requirements (may consider limiting entry points)

Dates Posted: Signage Message Posted:




o Place hand-sanitizer at all entrances with instructions for visitors to perform hand-hygiene upon entrance to the facility

All visitors who screen negative beginning 3/04/2020, are: (3/04/2020 CMS Memo: QSO-20-14, 3/09/2020 CMS Revised Memo: QSO-20-14, 3/13/2020 CMS Revised Memo: QSO-20-14)

o Limited in facilities that are in counties, or counties adjacent to other counties where a COVID-19 case has occurred.

Limited means the individual should not be allowed to come into the facility, except for certain situations, such as end-of-life or essential for resident’s emotional well-being or care.

o Discouraged in facilities not in those counties referenced above

Discouraged means that the facility allows normal visitation practices, however the facility advises individuals to defer visitation until further notice.

o Establishing an outdoor, covered vendor drop-off location in effort to prevent delivery drivers from the need to enter the facility

o All visitors allowed entry are instructed to limit their movement within the facility to the resident’s room, avoid common areas and practice social distancing when possible.

o Require visitors allowed entry to wear appropriate PPE

o If possible, a “clean room” establish near the facility entrance where visitors can meet with residents (sanitize room after each visit).

Copies of visitor screens maintained OR screening logs maintained.

Beginning 3/09/2020 and ongoing, advise: (3/09/2020 CMS Revised Memo: QSO-20-14)

o Exposed visitors (those having contact with COVID-19 positive resident or others prior to admission) to monitor for signs and symptoms of respiratory

Was this information provided in writing or orally, explain?




infection for at least 14 days after last known exposure and if ill to self-isolate at home and contact their healthcare provider.

o All visitors to report to the facility any signs or symptoms of COVID-19 or acute illness within 14 days after visiting the facility.

o Practice social distancing when possible

All visitors are restricted from entering the facility on or after 3/13/2020: (3/13/2020 CMS Revised Memo: QSO-20-14, 4/08/2020 Gov. Kemp’s Executive Order)

o Exception: Compassionate care visitors, who screen negative, may enter facility, as determined on a case-by-case basis, being sure to state the name of such visitors, the relationship to the resident, and the date, time and duration of visits:

Compassionate care visitors are to limit foot traffic, visit with resident in the resident’s room, avoid common areas and practice social distancing, refraining from hugging, handholding, kissing, and the like.

Visitors are required to perform hand-hygiene upon facility entrance.

Visitors are required to use PPE, such as facemasks, gowns and gloves.

o Documentation of all instances in which visitors were restricted from entering the facility and why.

Explain how this was communicated to visitors

On or before 3/09/2020, alternate visitation methods established for residents/visitors: (3/09/2020 Revised CMS Memo: QSO-20-14, 3/13/2020 CMS Revised Memo: QSO-20-14, 4/24/2020 CMS Long Term Care Facility FAQs)

o Virtual visits (Face Time, Skype, etc.) o Phone visits o Window visits o Other

Dates and types of alternate visitation methods established. Explain how visitors notified.




14995784v3


The COVID-19 team meetings include an ongoing review of actions taken regarding visitors, outcomes and updates.

DOCUMENTATION GUIDANCE REOPENING NURSING HOME


Reopening Communication Plan

Is there documentation to support the following activities? Yes No N/A Comments The pandemic COVID-19 plan has been updated to reflect

the facility’s “Reopening” (5/18/20 CMS Memo: QSO-20-30)

o Phased-in approach Waiting until all state facilities have met

entrance criteria for a given phase, OR Allowing facilities in a certain region (e.g.

counties) within a state to enter each phase at the same time, OR

Permitting individual nursing homes to move through the phases based on each nursing home’s status for meeting the criteria for entering a phase

***This module reflects recommendations from the Centers for Medicare and Medicaid Services (CMS) for reopening nursing homes. Individual states may implement all or some of the CMS recommendations, or establish and implement their own reopening phases, the triggers for progression through the phases, and the requirements applicable to nursing homes within each phase of reopening.

The Reopening strategies have been effectively communicated to:

o Residents o Families other visitors o Staff

Reopening Factors Is there documentation to support the following activities? Yes No N/A Comments The facility utilizes the following factors when making decisions about relaxing restrictions (5/18/20 CMS Memo: QSO-20-30 and 5/12/20 Gov. Kemp’s Executive Order)

Case status in community: State-based criteria to determine the level of community transmission and guides progression from one phase to another

Case status in nursing home(s): Absence of any new nursing home onset of COVID-19 cases (resident or staff), such as resident acquiring COVID-19 in the nursing home

Adequate staffing: NO staffing shortages and the facility is not under a contingency staff plan

Access to adequate testing: The facility should have a testing plan in place on contingencies informed by the CDC. At a minimum, the plan should consider for the following components:

o Resident and staff COVID-19 test consents/declinations are obtained prior to testing



o The capacity for all residents to receive a single baseline COVID-19 test.

Similarly, the capacity for all residents to be tested upon identification of an individual with symptoms consistent with COVID-19.

Capacity for continuance of weekly re-testing of all residents until all residents test negative.

o The capacity for all staff (including volunteers and

vendors who are in the facility on a weekly basis) to receive a single baseline COVID-19 test,

Re-testing for all staff continuing every week

State and local leaders may adjust the requirement for weekly testing of staff based on data about the circulation of the virus in their community

o Written screening protocols for: All staff-each shift Each resident-daily All persons entering the facility, such as

vendors, volunteers, and visitors o An arrangement with laboratories to process

tests. The test used should be able to detect

SARS-CoV-2 virus (e.g., polymerase chain reaction (PCR)) with greater than 95% sensitivity, greater than 90% specificity,

Results within 48 hours Antibody test results should not be used

to diagnose someone with an active SARS-CoV-2 infection

o A procedure for addressing residents or staff that decline or are unable to be tested (e.g., symptomatic resident refusing testing in a facility with positive COVID-19 cases should be treated as positive

Universal source control: o Residents and visitors wear a cloth face covering

or facemask. If a visitor is unable or unwilling to

maintain these precautions (such as young children), consider restricting their ability to enter the facility

All visitors should maintain social distancing and perform hand washing or sanitizing upon entry to the facility



Access to adequate Personal Protective Equipment (PPE) for staff: (CDC Guidance at Strategies to Optimize the Supply of PPE and Equipment)

o Contingency capacity strategy is allowable (facility’s PPE Crisis capacity strategy would not constitute adequate access to PPE)

o All staff wear all appropriate PPE when indicated o Staff wear cloth face covering if facemask is not

indicated, such as administrative staff

Local hospital capacity: o Ability for the local hospital to accept transfers

from nursing homes

Phase 1 Reopening (Current State: Significant Mitigation)

Is there documentation to support the following activities? Yes No N/A Comments Phase 1: In a posture that can be described as the facility’s highest level of vigilance, regardless of transmission within their communities

Visitation generally prohibited, except for compassionate care situations

Restricted entry of non-essential healthcare personnel Communal dining limited (for COVID-19 negative or

asymptomatic residents only), o Residents may eat in the same room with social

distancing (limited number of people at tables and spaced at least 6 feet)

Non-medically necessary trips outside the building should be avoided

Restrict group activities, but some activities may be conducted (for COVID-19 negative or asymptomatic residents only) with:

o Social distancing, o Hand hygiene, and o Use of a cloth face covering or facemask

For medically necessary trips away from the facility o Residents must wear a cloth face covering or

facemask; and o The facility must share the resident’s COVID-19

status with the transportation service and entity with whom the resident has the appointment (Ga. facilities utilize Infection Control Transfer Form, Refer to Resource Module)

100% screening of all persons entering the facility and all staff at the beginning of each shift:

o Temperature checks



o Ensure all outside persons entering building have cloth face covering or facemask

o Questionnaire about symptoms and potential exposure

o Observation of any signs or symptoms

100% screening (at least daily) of all residents o Temperature checks o Questions about and observation for other signs

and symptoms of COVID-19

Universal source control for everyone in the facility o Residents and visitors entering for compassionate

care wear cloth face covering or facemask

All staff wear appropriate PPE when they are interacting with residents, to the extent PPE is available and consistent with CDC guidance on optimization of PPE

o Staff wear cloth face covering if facemask is not indicated

All staff are tested weekly o All residents are tested upon identification of an

individual with symptoms consistent with COVID-19, OR

o If staff have tested positive for COVID-19 o Weekly testing continues until all residents test

negative

Dedicated space in facility for cohorting and managing care for residents with COVID-19;

o Plan to manage new/readmissions with an unknown COVID-19 status and residents who develop symptoms

Phase 2-Reopening Is there documentation to support the following activities? Yes No N/A Comments

Facility does not begin to de-escalate or relax restrictions until their surrounding community satisfies gating criteria and enters phase 2 Reopening

Case status in community has met the criteria for entry into phase 2 (no rebound in cases after 14 days in phase 1)

There have been no new, onset COVID-19 cases in the nursing home for 14 days

The nursing home is not experiencing staff shortages

The nursing home has adequate supplies of PPE and essential cleaning and disinfection supplies to care for residents

The nursing home has adequate access to testing for COVID-19

Referral hospital(s) have bed capacity on wards and intensive care units

Visitation generally prohibited, except for compassionate care situations



o In those limited situations, visitors are screened and additional precautions are taken, including social distancing and hand hygiene

o All visitors must wear a cloth face covering or facemask for the duration of their visit

Allow entry of limited numbers of non-essential healthcare personnel/contractors as determined necessary by the facility,

o With screening, and o Additional precautions including social distancing,

hand hygiene and cloth face covering or facemask

Communal dining limited (for COVID-19 negative or asymptomatic residents only)

o Residents may eat in the same room with social distancing (limited number of people at tables and spaced by at least 6 feet)

Group activities, including outings limited for asymptomatic or COVID-19 negative residents only with no more than 10 people, and

o Social distancing among residents, o Hand hygiene, and o Use of a cloth face covering or facemask

For medically necessary trips outside of the facility: o The resident must wear a cloth face covering or



100% screening of all persons entering the facility and all staff at the beginning of each shift:

o Temperature checks o Ensure all outside persons entering building have

cloth face covering or facemask o Questionnaire about symptoms and potential

exposure o Observation of any signs or symptoms



Universal source control for everyone in the facility o Staff wear cloth face covering if facemask is not


Test: o All staff weekly



o All residents upon identification of an individual with symptoms consistent with COVID-19, OR if staff have tested positive for COVID-19

o Weekly testing continues until all residents test negative

Dedicated space in facility for cohorting and managing care for residents with COVID-19


Universal source control for everyone in the facility o Residents and visitors wear cloth face covering or

facemask

All staff wear all appropriate PPE when indicated o Staff wear cloth face covering if facemask is not


All staff are tested weekly o All residents are tested upon identification of an



negative

Phase 3-Reopening Is there documentation to support the following activities? Yes No N/A Comments

Community case status meets criteria for entry to phase 3 (no rebound in cases during phase 2)

There have been non new, nursing home onset COVID-19 cases in the nursing home for 28 days (through phases 1 and 2)

The nursing home is not experiencing staff shortages

The nursing home has adequate supplies of PPE and essential cleaning and disinfection supplies to care for residents

The nursing home has adequate access to testing for COVID-19

Referral hospital(s) have bed capacity on wards and intensive care units

Visitation allowed with screening, and o Ensuring social distancing and hand hygiene o All visitors must wear a cloth face covering or

facemask for the duration of their visit

Allow entry of non-essential healthcare personnel/contractors as determined necessary by facility, with

o Screening o Social distancing o Hand hygiene



o Cloth face covering or facemask

Communal dining limited (for COVID-19 negative or asymptomatic residents only)

o Residents may eat in the same room with social distancing (limited number of people at table and spaced at least 6 feet apart

Group activities, including outings, allowed (for asymptomatic or COVID-19 negative residents only), with

o No more than the number of people where social distancing among residents can be maintained

o Hand hygiene, and o Use of a cloth face covering or facemask

Allow entry of volunteers, with screening and additional precautions, including:

o Social distancing o Hand hygiene o Cloth face covering or facemask

For medically necessary trips outside of the facility o The resident must wear a cloth face covering or



100% screening of all persons entering the facility and all staff at the beginning of each shift, including:

o Temperature checks o Ensure all outside persons entering the facility

have cloth face covering or facemask o Questionnaire about symptoms and potential

exposure o Observation of any signs or symptoms



Test all staff weekly o Test all residents upon identification of an



negative

Dedicated space in facility for cohorting and managing care for residents with COVID-19




Other-Reopening Is there documentation to support the following activities? Yes No N/A Comments

Facility should spend a minimum of 14 days in a given phase, prior to advancing to the next phase

o With no new onset of resident or staff COVID-19 cases

If the facility identifies a new onset of COVID-19 case (resident or staff), while in any phase, that facility goes back to the highest level of mitigation, and starts over (even if facility is in phase 3)

Continue to report testing results to (Refer to Screening, Testing and Reporting Module):

o NHSN-at least weekly o Department of Public Health-Daily o Health Facility Regulatory Department-Daily


The COVID-19 team meetings included ongoing review of reopening actions and evaluation.

15025921v1

Infection Control Transfer Form This form must be filled out for transfer to accepting facility with information communicated prior to or with transfer. Please attach copies of latest culture reports with susceptibilities if available.

Sending Healthcare Facility: Apply Label Here

Sending Facility Contacts Contact Name Phone

Physician & Infection Preventionist

Does the person* currently have an infection, colonization OR a history of positive culture of a multidrug-resistant organism (MDRO) or other potentially transmissible infectious organism?

Colonization or history (Check if YES)

Active infection on Treatment (Check if YES)

Acinetobacter, multidrug-resistant Yes No

Candida auris Yes No

Carbapenem-resistant Enterobacteriaceae (CRE) Yes No

Clostridioides difficile Yes No

COVID-19 Yes No

Ebola Yes No

Enterobacteriaceae (e.g., E. coli, Klebsiella, Proteus) producing- Extended Spectrum Beta-Lactamase (ESBL)

Yes No

H1N1 Yes No

Influenza Yes No

Methicillin-resistant Staphylococcus aureus (MRSA) Yes No

Pseudomonas aeruginosa, multidrug-resistant Yes No

Vancomycin-resistant Enterococcus (VRE) Yes No

Other, specify (e.g., lice, scabies, norovirus, influenza): Yes No

Is the person* currently in isolation? Yes No

Is the person* currently on Transmission-Based Precautions and if so, why? Reason:

Yes No

Type of Precautions (check all that apply) Contact Droplet Airborne

Does the person* currently have any of the following? (check all that apply)

Cough or requires suctioning Diarrhea Vomiting Incontinent of urine or stool

Open wounds or wounds requiring dressing change Drainage (source): Hemodialysis catheter

Central line/PICC (Approx. date inserted) Urinary catheter (Approx. date inserted) Suprapubic catheter

Percutaneous gastrostomy tube Tracheostomy

COVID-19 Test Completed Yes No

Date Completed:

Results Negative Positive

Report given to: ______________________________ Date & Time:_____________________________

Name of staff completing form (print): ______________________ Signature: _____________________

COVID-19 Focused Survey for Nursing Homes

Infection Control This survey tool must be used to investigate compliance at F880, F884 (CMS Federal surveyors only), F885, and E0024. Surveyors must determine whether the facility is implementing proper infection prevention and control practices to prevent the development and transmission of COVID-19 and other communicable diseases and infections. Entry and screening procedures as well as resident care guidance has varied over the progression of COVID-19 transmission in facilities. Facilities are expected to be in compliance with CMS requirements and surveyors will use guidance that is in effect at the time of the survey. Refer to QSO memos released at: https://www.cms.gov/Medicare/Provider-Enrollment- and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to- States-and-Regions.

This survey tool provides a focused review of the critical elements associated with the transmission of COVID-19, will help surveyors to prioritize survey activities while onsite, and identify those survey activities which can be accomplished offsite. These efficiencies will decrease the potential for transmission of COVID-19, as well as lessen disruptions to the facility and minimize exposure of the surveyor. Surveyors should be mindful to ensure their activities do not interfere with the active treatment or prevention of transmission of COVID-19.

If citing for noncompliance related to COVID-19, the surveyor(s) must include the following language at the beginning of the Deficient Practice Statement or other place determined appropriate on the Form CMS-2567: “Based on [observations/interviews/record review], the facility failed to [properly prevent and/or contain – or other appropriate statement] COVID-19.”

If surveyors see concerns related to compliance with other requirements, they should investigate them in accordance with the existing guidance in Appendix PP of the State Operations Manual and related survey instructions. Surveyors may also need to consider investigating concerns related to Emergency Preparedness in accordance with the guidance in Appendix Z of the State Operations Manual (e.g., for emergency staffing).

For the purpose of this survey tool, “staff” includes employees, consultants, contractors, volunteers, and others who provide care and services to residents on behalf of the facility. The Infection Prevention and Control Program (IPCP) must be facility-wide and include all departments and contracted services.

Critical Element #8 is only for consideration by CMS Federal Survey staff. Information to determine the facility’s compliance at F884 is only reported to each of the 10 CMS locations.

Surveyor(s) reviews for:

• The overall effectiveness of the Infection Prevention and Control Program (IPCP) including IPCP policies and procedures; • Standard and Transmission-Based Precautions;

• Quality of resident care practices, including those with COVID-19 (laboratory-positive case), if applicable; • The surveillance plan;

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• Visitor entry and facility screening practices; • Education, monitoring, and screening practices of staff; • Facility policies and procedures to address staffing issues during emergencies, such as transmission of COVID-19; and • How the facility informs residents, their representatives, and families of suspected or confirmed COVID-19 cases in the facility.

1. Standard and Transmission-Based Precautions (TBPs) CMS is aware that there is a scarcity of some supplies in certain areas of the country. State and Federal surveyors should not cite facilities for not having certain supplies (e.g., PPE such as gowns, N95 respirators, surgical masks) if they are having difficulty obtaining these supplies for reasons outside of their control. However, we do expect facilities to take actions to mitigate any resource shortages and show they are taking all appropriate steps to obtain the necessary supplies as soon as possible. For example, if there is a shortage of PPE (e.g., due to supplier(s) shortage which may be a regional or national issue), the facility should contact their health department or healthcare coalition for assistance (https://www.phe.gov/Preparedness/planning/hpp/Pages/find-hc-coalition.aspx), follow national and/or local guidelines for optimizing their current supply or identify the next best option to care for residents. Among other practices, optimizing their current supply may mean prioritizing use of gowns based on risk of exposure to infectious organisms, blood or body fluids, splashes or sprays, high contact procedures, or aerosol generating procedures (AGPs), as well as possibly extending use of PPE (follow national and/or local guidelines). Current CDC guidance for healthcare professionals is located at: https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html and healthcare facilities is located at: https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/index.html. Guidance on strategies for optimizing PPE supply is located at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html. If a surveyor believes a facility should be cited for not having or providing the necessary supplies, the State Agency should contact the CMS Regional Location.

General Standard Precautions: Are staff performing the following appropriately: • Respiratory hygiene/cough etiquette, • Environmental cleaning and disinfection, and • Reprocessing of reusable resident medical equipment (e.g., cleaning and disinfection of glucometers per device and disinfectant manufacturer’s instructions for use)?

Hand Hygiene: Are staff performing hand hygiene when indicated? If alcohol-based hand rub (ABHR) is available, is it readily accessible and preferentially used by staff for hand hygiene?

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https://www.phe.gov/Preparedness/planning/hpp/Pages/find-hc-coalition.aspx

https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html

https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/index.html

https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html

COVID-19 Focused Survey for Nursing Homes If there are shortages of ABHR, are staff performing hand hygiene using soap and water instead? Are staff washing hands with soap and water when their hands are visibly soiled (e.g., blood, body fluids)? Do staff perform hand hygiene (even if gloves are used) in the following situations: • Before and after contact with the resident; • After contact with blood, body fluids, or visibly contaminated surfaces; • After contact with objects and surfaces in the resident’s environment; • After removing personal protective equipment (e.g., gloves, gown, facemask); and • Before performing a procedure such as an aseptic task (e.g., insertion of an invasive device such as a urinary catheter, manipulation of a central venous catheter, and/or dressing care)?

When being assisted by staff, is resident hand hygiene performed after toileting and before meals? Interview appropriate staff to determine if hand hygiene supplies (e.g., ABHR, soap, paper towels) are readily available and who they contact for replacement supplies.

Personal Protective Equipment (PPE): Determine if staff appropriately use PPE including, but not limited to, the following: • Gloves are worn if potential contact with blood or body fluid, mucous membranes, or non-intact skin; • Gloves are removed after contact with blood or body fluids, mucous membranes, or non-intact skin; • Gloves are changed and hand hygiene is performed before moving from a contaminated body site to a clean body site during resident care; and

• An isolation gown is worn for direct resident contact if the resident has uncontained secretions or excretions. Is PPE appropriately removed and discarded after resident care, prior to leaving room (except in the case of extended use of PPE per national/local recommendations), followed by hand hygiene? If PPE use is extended/reused, is it done according to national and/or local guidelines? If it is reused, is it cleaned/decontaminated/maintained after and/or between uses? Interview appropriate staff to determine if PPE is available, accessible and used by staff. • Are there sufficient PPE supplies available to follow infection prevention and control guidelines? In the event of PPE shortages, what procedures is the facility taking to address this issue?

• Do staff know how to obtain PPE supplies before providing care? • Do they know who to contact for replacement supplies?

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Transmission-Based Precautions (Note: PPE use is based on availability and latest CDC guidance. See note on Pages 1-2): Determine if appropriate Transmission-Based Precautions are implemented: • For a resident on Contact Precautions: staff don gloves and isolation gown before contact with the resident and/or his/herenvironment; • For a resident on Droplet Precautions: staff don a facemask within six feet of a resident; • For a resident on Airborne Precautions: staff don an N95 or higher level respirator prior to room entry of aresident; • For a resident with an undiagnosed respiratory infection: staff follow Standard, Contact, and Droplet Precautions (i.e., facemask, gloves, isolation gown) with eye protection when caring for a resident unless the suspected diagnosis requires Airborne Precautions (e.g., tuberculosis);

• For a resident with known or suspected COVID-19: staff wear gloves, isolation gown, eye protection and an N95 or higher-levelrespirator if available. A facemask is an acceptable alternative if a respirator is not available. Additionally, if there are COVID-19 cases in the facility or sustained community transmission, staff implement universal use of facemasks while in the facility (based on availability). When COVID-19 is identified in the facility, staff wear all recommended PPE (i.e., gloves, gown, eye protection and respirator or facemask) for the care of all residents on the unit (or facility-wide based on the location of affected residents), regardless of symptoms (based on availability).

o Some procedures performed on residents with known or suspected COVID-19 could generate infectious aerosols (i.e., aerosol- generating procedures (AGPs)). In particular, procedures that are likely to induce coughing (e.g., sputum induction, open suctioning of airways) should be performed cautiously. If performed, the following should occur: Staff in the room should wear an N95 or higher-level respirator, eye protection, gloves, and an isolation gown. The number of staff present during the procedure should be limited to only those essential for resident care and procedure support.

AGPs should ideally take place in an airborne infection isolation room (AIIR). If an AIIR is not available and the procedure is medically necessary, then it should take place in a private room with the door closed.

Clean and disinfect the room surfaces promptly and with appropriate disinfectant. Use disinfectants on List N of the EPA website for EPA-registered disinfectants that have qualified under EPA’s emerging viral pathogens program for use against SARS-COV-2 or other national recommendations;

• Dedicated or disposable noncritical resident-care equipment (e.g., blood pressure cuffs, blood glucose monitor equipment) is used, or if not available, then equipment is cleaned and disinfected according to manufacturers’ instructions using an EPA-registered disinfectant for healthcare setting prior to use on another resident;

• Objects and environmental surfaces that are touched frequently and in close proximity to the resident (e.g., bed rails, over-bed table, bedside commode, lavatory surfaces in resident bathrooms) are cleaned and disinfected with an EPA-registered disinfectant for healthcare setting (effective against the organism identified if known) at least daily and when visibly soiled; and

• Is signage on the use of specific PPE (for staff) posted in appropriate locations in the facility (e.g., outside of a resident’s room, wing, or facility-wide)?

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COVID-19 Focused Survey for Nursing Homes Interview appropriate staff to determine if they are aware of processes/protocols for Transmission-Based Precautions and how staff is monitored for compliance. If concerns are identified, expand the sample to include more residents on Transmission-Based Precautions.

1. Did staff implement appropriate Standard (e.g., hand hygiene, appropriate use of PPE, environmental cleaning and disinfection,and reprocessing of reusable resident medical equipment) and Transmission-Based Precautions (if applicable)? Yes No F880

2. Resident Care If there is sustained community transmission or case(s) of COVID-19 in the facility, is the facility restricting residents (to the extent possible) to their rooms except for medically necessary purposes? If there is a case in the facility, and residents have to leave their room, are they wearing a facemask, performing hand hygiene, limiting their movement in the facility, and performing social distancing (efforts are made to keep them at least 6 feet away from others). If PPE shortage is an issue, facemasks should be limited to residents diagnosed with or having signs/symptoms of respiratory illness or COVID-19. Has the facility cancelled group outings, group activities, and communal dining? Has the facility isolated residents with known or suspected COVID-19 in a private room (if available), or taken other actions based on national (e.g., CDC), state, or local public health authority recommendations? For the resident who develops severe symptoms of illness and requires transfer to a hospital for a higher level of care, did the facility alert emergency medical services and the receiving facility of the resident’s diagnosis (suspected or confirmed COVID-19) and precautions to be taken by transferring and receiving staff as well as place a facemask on the resident during transfer (as supply allows)? For residents who need to leave the facility for care (e.g. dialysis, etc.), did the facility notify the transportation and receiving health care team of the resident’s suspected or confirmed COVID-19 status? Does the facility have residents who must leave the facility regularly for medically necessary purposes (e.g., residents receiving hemodialysis and chemotherapy) wear a facemask (if available) whenever they leave their room, including for procedures outside of the facility?

2. Did staff provide appropriate resident care? Yes No F880

3. IPCP Standards, Policies and Procedures Did the facility establish a facility-wide IPCP including standards, policies, and procedures that are current and based on national standards for undiagnosed respiratory illness and COVID-19?

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COVID-19 Focused Survey for Nursing Homes Does the facility’s policies or procedures include when to notify local/state public health officials if there are clusters of respiratory illness or cases of COVID-19 that are identified or suspected? Concerns must be corroborated as applicable including the review of pertinent policies/procedures as necessary.

3. Does the facility have a facility-wide IPCP including standards, policies, and procedures that are current and based onnationalstandards for undiagnosed respiratory illness and COVID-19? Yes No F880

4. Infection Surveillance

How many residents and staff in the facility have fever, respiratory signs/symptoms, or other signs/symptoms related to COVID-19? How many residents and staff have been diagnosed with COVID-19 and when was the first case confirmed? How many residents and staff have been tested for COVID-19? What is the protocol for determining when residents and staff should be tested? Has the facility established/implemented a surveillance plan, based on a facility assessment, for identifying (i.e., screening), tracking, monitoring and/or reporting of fever (at a minimum, temperature is taken per shift), respiratory illness, and/or other signs/symptoms of COVID-19 and immediately isolate anyone who is symptomatic? Does the plan include early detection, management of a potentially infectious, symptomatic resident that may require laboratory testing and/or Transmission-Based Precautions/PPE (the plan may include tracking this information in an infectious disease log)? Does the facility have a process for communicating the diagnosis, treatment, and laboratory test results when transferring a resident to an acute care hospital or other healthcare provider; and obtaining pertinent notes such as discharge summary, lab results, current diagnoses, and infection or multidrug-resistant organism colonization status when residents are transferred back from acute care hospitals? Can appropriate staff (e.g., nursing and unit managers) identify/describe the communication protocol with local/state public health officials? Interview appropriate staff to determine if infection control concerns are identified, reported, and acted upon.

4. Did the facility provide appropriate infection surveillance? Yes No F880

5. Visitor Entry

Review for compliance of: • Screening processes and criteria (i.e., screening questions and assessment of illness); • Restriction criteria; and

05/08/2020 Page 6


• Signage posted at facility entrances for screening and restrictions as well as a communication plan to alert visitors ofnew procedures/restrictions.

For those permitted entry, are they instructed to frequently perform hand hygiene; limit their interactions with others in the facility and surfaces touched; restrict their visit to the resident’s room or other location designated by the facility; and offered PPE (e.g., facemask) as supply allows? What is the facility’s process for communicating this information? For those permitted entry, are they advised to monitor for signs and symptoms of COVID-19 and appropriate actions to take if signs and/or symptoms occur?

5. Did the facility perform appropriate screening, restriction, and education of visitors? Yes No F880

6. Education, Monitoring, and Screening of Staff

Is there evidence the facility has provided education to staff on COVID-19 (e.g., symptoms, how it is transmitted, screening criteria, work exclusions)? How does the facility convey updates on COVID-19 to all staff? Is the facility screening all staff at the beginning of their shift for fever and signs/symptoms of illness? Is the facility actively taking their temperature and documenting absence of illness (or signs/symptoms of COVID-19 as more information becomes available)? If staff develop symptoms at work (as stated above), does the facility: • Place them in a facemask and have them return home; • Inform the facility’s infection preventionist and include information on individuals, equipment, and locations the person came in contact with; and

• Follow current guidance about returning to work (e.g., local health department, CDC: https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/hcp-return-work.html).

6. Did the facility provide appropriate education, monitoring, and screening of staff? Yes No F880

7. Reporting to Residents, Representatives, and Families

Identify the mechanism(s) the facility is using to inform residents, their representatives, and families (e.g., newsletter, email, website, recorded voice message) Did the facility inform all residents, their representatives, and families by 5 PM the next calendar day following the occurrence of a single confirmed COVID-19 infection or of three or more residents or staff with new onset of respiratory symptoms that occurred within 72 hours of each other?

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COVID-19 Focused Survey for Nursing Homes Did the information include mitigating actions taken by the facility to prevent or reduce the risk of transmission, including if normal operations in the nursing home will be altered (e.g., restrictions to visitation or group activities)? Did the information include personally identifiable information? Is the facility providing cumulative updates to residents, their representatives, and families at least weekly or by 5 PM the next calendar day following the subsequent occurrence of either: each time a confirmed COVID-19 infection is identified, or whenever three or more residents or staff with new onset of respiratory symptoms occur within 72 hours of each other? Interview a resident and a resident representative or family member to determine whether they are receiving timely notifications.

7. Did the facility inform residents, their representatives, and families of suspected or confirmed COVID-19 cases in the facility along with mitigating actions in a timely manner? Yes No F885

8. Reporting to the Centers for Disease Control and Prevention (CDC) – Performed Offsite by CMS. For consideration by CMS Federal Surveyors only.

Review CDC data files provided to CMS to determine if the facility is reporting at least once a week. Review data files to determine if all data elements required in the National Healthcare Safety Network (NHSN) COVID-19 Module are completed.

8. Did the facility report at least once a week to CDC on all of the data elements required in the NHSN COVID-19 Module? Yes No F884

9. Emergency Preparedness – Staffing in Emergencies

Policy development: Does the facility have a policy and procedure for ensuring staffing to meet the needs of the residents when needed during an emergency, such as COVID-19 outbreak? Policy implementation: In an emergency, did the facility implement its planned strategy for ensuring staffing to meet the needs of the residents? (N/A if an emergency staff was not needed).

9. Did the facility develop and implement policies and procedures for staffing strategies during an emergency? Yes No E0024 N/A

05/08/2020 Page 8


Section 3087 of the 21st Century Cures Act, signed into law in December 2016, added subsection (f) to section 319 of the Public Health Service Act. This new subsection gives the HHS Secretary the authority to waive Paperwork Reduction Act (PRA) (44 USC 3501 et seq.) requirements with respect to voluntary collection of information during a public health emergency (PHE), as declared by the Secretary, or when a disease or disorder is significantly likely to become a public health emergency (SLPHE). Under this new authority, the HHS Secretary may waive PRA requirements for the voluntary collection of information if the Secretary determines that: (1) a PHE exists according to section 319(a) of the PHS Act or determines that a disease or disorder, including a novel and emerging public health threat, is a SLPHE under section 319(f) of the PHS Act; and (2) the PHE/SLPHE, including the specific preparation for and response to it, necessitates a waiver of the PRA requirements. The Office of the Assistant Secretary for Planning and Evaluation (ASPE) has been designated as the office that will coordinate the process for the Secretary to approve or reject each request.

The information collection requirements contained in this information collection request have been submitted and approved under a PRA Waiver granted by the Secretary of Health and Human Services. The waiver can be viewed at https://aspe.hhs.gov/public-health-emergency-declaration-pra-waivers.

05/08/2020 Page 9

https://aspe.hhs.gov/public-health-emergency-declaration

19 CORONAVIRUS DISEASE

C V DI SYMPTOMS OF CORONAVIRUS DISEASE 2019

Patients with COVID-19 have experienced mild to severe respiratory illness.

Symptoms* can include FEVER

COUGH

SHORTNESS OF BREATH

*Symptoms may appear 2-14days after exposure.

Seek medical advice if you develop symptoms, and have been in close

contact with a person known to have COVID-19 or if you live in or

have recently been in an area with ongoing spread of COVID-19.

For more information: www.cdc.gov/COVID19-symptoms CS 315252-A 03/03/2020

www.cdc.gov/COVID19-symptoms

What You Can do if You are at Higher Risk of Severe Illness from COVID-19

Based on what we know now, those at high-risk for severe illness from COVID-19 are: • People aged 65 years and older

• People who live in a nursing home or long-term care facility

People of all ages with underlying medical conditions, particularly if not well controlled, including: • People with chronic lung disease or moderate to severe asthma

• People who have serious heart conditions

• People who are immunocompromised - Many conditions can cause a person to be immunocompromised, including cancer treatment, smoking, bone marrow or organ transplantation, immune deficiencies, poorly controlled HIV or AIDS, and prolonged use of corticosteroids and other immune weakening medications.

• People with severe obesity (body mass index [BMI] of 40 or higher)

• People with diabetes

• People with chronic kidney disease undergoing dialysis

• People with liver disease

Are You at Higher Risk for Severe Illness?

Stay home if possible.

Wash your hands often.

Avoid close contact(6 feet, which is about two arm lengths) with people who are sick.

Clean and disinfect frequently touched surfaces.

Avoid all cruise travel and non-essential air travel.

316216A April 3, 2020 10:14 AM

cdc.gov/coronavirus

Call your healthcare professional if you are sick.

For more information on steps you can take to protect yourself, see CDC’s How to Protect Yourself.

Here’s What You Can do to Help Protect Yourself

https://www.cdc.gov/coronavirus/2019-ncov/prepare/prevention.html

CS316248A 04/01/2020

cdc.gov/coronavirus

Cleaning And Disinfecting Your Facility

Everyday Steps, Steps When Someone is Sick, and Considerations for Employers

How to clean and disinfectWear disposable gloves to clean and disinfect.

Clean• Clean surfaces using

soap and water. Practice routine cleaning of frequently touched surfaces.

High touch surfaces include:

Tables, doorknobs, light switches, countertops, handles, desks, phones, keyboards, toilets, faucets, sinks, etc.

Disinfect• Clean the area or item with soap and

water or another detergent if it is dirty. Then, use a household disinfectant.

• Recommend use of EPA-registered household disinfectant. Follow the instructions on the label to ensure safe and effective use of the product.

Many products recommend:

- Keeping surface wet for a period of time (see product label)

- Precautions such as wearing gloves and making sure you have good ventilation during use of the product.

• Diluted household bleach solutions may also be used if appropriate for the surface. Check to ensure the product is not past its expiration date. Unexpired household bleach will be effective against coronaviruses when properly diluted. Follow manufacturer’s instructions for application and proper ventilation. Never mix household bleach with ammonia or any other cleanser.

Leave solution on the surface for at least 1 minute

To make a bleach solution, mix:

- 5 tablespoons (1/3rd cup) bleach per gallon of water OR

- 4 teaspoons bleach per quart of water

• Alcohol solutions with at least 70% alcohol.

Soft surfacesFor soft surfaces such as carpeted floor, rugs, and drapes

• Clean the surface using soap and water or with cleaners appropriate for use on these surfaces.

http://www.cdc.gov/coronavirus

https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2


• Launder items (if possible) according to the manufacturer’s instructions. Use the warmest appropriate water setting and dry items completely.

OR

• Disinfect with an EPA-registered household disinfectant. These disinfectants meet EPA’s criteria for use against COVID-19.

Electronics• For electronics, such as

tablets, touch screens, keyboards, remote controls, and ATM machines

• Consider putting a wipeable cover on electronics.

• Follow manufacturer’s instruction for cleaning and dinfecting.

- If no guidance, use alcohol-based wipes or sprays containing at least 70% alcohol. Dry surface thoroughly.

LaundryFor clothing, towels, linens and other items

• Wear disposable gloves.

• Wash hands with soap and water as soon as you remove the gloves.

• Do not shake dirty laundry.

• Launder items according to the manufacturer’s instructions. Use the warmest appropriate water setting and dry items completely.

• Dirty laundry from a sick person can be washed with other people’s items.

• Clean and disinfect clothes hampers according to guidance above for surfaces.

Page 2 of 3

HOT

Cleaning and disinfecting your building or facility if someone is sick

• Close off areas used by the sick person.

• Open outside doors and windows to increase air circulation in the area. Wait 24 hours before you clean or disinfect. If 24 hours is not feasible, wait as long as possible.

• Clean and disinfect all areas used by the sick person, such as offices, bathrooms, common areas, shared electronic equipment like tablets, touch screens, keyboards, remote controls, and ATM machines.

• If more than 7 days since the sick person visited or used the facility, additional cleaning and disinfection is not necessary.

- Continue routing cleaning and disinfection

When cleaning• Wear disposable gloves and

gowns for all tasks in the cleaning process, including handling trash.

- Additional personal protective equipment (PPE) might be required based on the cleaning/disinfectant products being used and whether there is a risk of splash.

- Gloves and gowns should be removed carefully to avoid contamination of the wearer and the surrounding area.

• Wash your hands often with soap and water for 20 seconds.

- Always wash immediately after removing gloves and after contact with a sick person.

.



- Hand sanitizer: If soap and water are not available and hands are not visibly dirty, an alcohol-based hand sanitizer that contains at least 60% alcohol may be used. However, if hands are visibly dirty, always wash hands with soap and water.

• Additional key times to wash hands include:

- After blowing one’s nose, coughing, or sneezing.

- After using the restroom.

- Before eating or preparing food.

- After contact with animals or pets.

- Before and after providing routine care for another person who needs assistance (e.g., a child).

Additional Considerations for Employers

• Educate workers performing cleaning, laundry, and trash pick-up to recognize the symptoms of COVID-19.

• Provide instructions on what to do if they develop symptoms within 14 days after their last possible exposure to the virus.

• Develop policies for worker protection and provide training to all cleaning staff on site prior to providing cleaning tasks.

- Training should include when to use PPE, what PPE is necessary, how to properly don (put on), use, and doff (take off) PPE, and how to properly dispose of PPE.

• Ensure workers are trained on the hazards of the cleaning chemicals used in the workplace in accordance with OSHA’s Hazard Communication standard (29 CFR 1910.1200).

• Comply with OSHA’s standards on Bloodborne Pathogens (29 CFR 1910.1030), including proper disposal of regulated waste, and PPE (29 CFR 1910.132).

For facilities that house people overnight: • Follow CDC’s guidance for colleges and universities. Work with state and local health officials to

determine the best way to isolate people who are sick and if temporary housing is needed.

• For guidance on cleaning and disinfecting a sick person’s bedroom/bathroom, review CDC’s guidance on disinfecting your home if someone is sick.

COVID-19

Page 3 of 3

https://www.cdc.gov/

https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1200




https://www.cdc.gov/coronavirus/2019-ncov/community/guidance-ihe-response.html

https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/disinfecting-your-home.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fprepare%2Fdisinfecting-your-home.html

CS 315495-A 03/12/2020

For more information: www.cdc.gov/COVID19

Healthcare personnel (HCP) are on the front lines of caring for patients with confirmed or possible infection with coronavirus disease 2019 (COVID-19) and therefore have an increased risk of exposure to this virus. HCPs can minimize their risk of exposure when caring for confirmed or possible COVID-19 patients by following Interim Infection Prevention and Control Recommendations for Patients with Confirmed (COVID-19) or Persons Under Investigation for COVID-19 in Healthcare Settings.

What healthcare personnel should know about caring for patients with confirmed or possible coronavirus disease 2019 (COVID-19)

How COVID-19 Spreads There is much to learn about the newly emerged COVID-19, including how and how easily it spreads. Based on what is currently known about COVID-19 and what is known about other coronaviruses, spread is thought to occur mostly from person-to-person via respiratory droplets among close contacts.

Close contact can occur while caring for a patient, including:

• being within approximately 6 feet (2 meters) of a patient with COVID-19 for a prolonged period of time.

• having direct contact with infectious secretions from a patient with COVID-19. Infectious secretions may include sputum, serum, blood, and respiratory droplets.

If close contact occurs while not wearing all recommended personal protective equipment personal protective equipment (PPE), healthcare personnel may be at risk of infection.

How You Can Protect Yourself Healthcare personnel caring for patients with confrmed or possible COVID-19 should adhere to CDC recommendations for infection prevention and control (IPC):

• Assess and triage these patients with acute respiratory symp-toms and risk factors for COVID-19 to minimize chances of exposure, including placing a facemask on the patient and placing them in an examination room with the door closed in an Airborne Infection Isolation Room (AIIR), if available.

• Use Standard Precautions , Contact Precautions, and Airborne Precautions and eye protection when caring for patients with confirmed or possible COVID-19.

• Perform hand hygiene with alcohol-based hand rub before and after all patient contact, contact with potentially infectious material, and before putting on and upon removal of PPE, including gloves. Use soap and water if hands are visibly soiled.

• Practice how to properly don, use, and doff PPE in a manner to prevent self-contamination.

• Perform aerosol-generating procedures, in an AIIR, while following appropriate IPC practices, including use of appropriate PPE.

Environmental Cleaning and Disinfection Routine cleaning and disinfection procedures are appropriate for SARS-CoV-2 in healthcare settings, including those patient-care areas in which aerosol-generating procedures are performed. Products with EPA-approved emerging viral pathogens claims are recommended for use against SARS-CoV-2. Management of laundry, food service utensils, and medical waste should also be performed in accordance with routine procedures.

When to Contact Occupational Health ServicesIf you have an unprotected exposure (i.e., not wearing recommended PPE) to a confirmed or possible COVID-19 patient, contact your supervisor or occupational health immediately.

If you develop symptoms consistent with COVID-19 (fever, cough, or difficulty breathing), do not report to work. Contact your occupational health services.

For more information for healthcare personnel, visit: https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html

http://www.cdc.gov/COVID19

https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html


https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Finfection-control.html

https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html

https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html

https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html

https://www.cdc.gov/hai/pdfs/ppe/PPE-Sequence.pdf




https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html

Stay home when you are sick,except to get medical care.

Wash your hands often with soap and water for at least 20 seconds.

Cover your cough or sneeze with a tissue, then throw the tissue in the trash.

Clean and disinfect frequently touched objects and surfaces.

Avoid touching your eyes, nose, and mouth.

CS314915-A

STOP THE SPREAD OF GERMS

For more information: www.cdc.gov/COVID19

Avoid close contact with people who are sick.

Help prevent the spread of respiratory diseases like COVID-19.


Symptoms of Coronavirus (COVID-19)

cdc.gov/coronavirus317142-A May 20, 2020 10:44 AM

Know the symptoms of COVID-19, which can include the following:

*Seek medical care immediately if someone has emergency warning signs of COVID-19.

• Trouble breathing• Persistent pain or pressure

in the chest• New confusion

• Inability to wake or stay awake

• Bluish lips or face

Cough Chills Muscle pain

Shortness of breath or difficulty breathing*

New loss of taste or smell

Sore throat

Symptoms can range from mild to severe illness, and appear 2-14 days after you are exposed to the virus that causes COVID-19.

This list is not all possible symptoms. Please call your medical provider for any other symptoms that are severe or concerning to you.

Fever

CS 316439-A 04/14/2020

Share facts about COVID-19Know the facts about coronavirus (COVID-19) and help stop the spread of rumors.

FACT

1

Someone who has completed quarantine or has been released from isolation does not pose a risk of infection to other people.

FACT

5You can help stop COVID-19 by knowing the signs and symptoms, which can include:

FACT

4There are simple things you can do to help keep yourself and others healthy.

FACT

2

Diseases can make anyone sick regardless of their race or ethnicity.

• Fever• Cough

• Shortness of breath

Seek medical attention immediately if you or someone you love has emergency warning signs, including: • Trouble breathing• Persistent pain or pressure in the chest• New confusion or not able to be woken• Bluish lips or face

This list is not all inclusive. Please consult your medical provider for any other symptoms that are severe or concerning.

For up-to-date information, visit CDC’s coronavirus disease 2019 web page.

For most people, the immediate risk of becoming seriously ill from the virus that causes COVID-19 is thought to be low.

Fear and anxiety about COVID-19 can cause people to avoid or reject others even though they are not at risk for spreading the virus.

Older adults and people of any age who have serious underlying medical conditions may be at higher risk for more serious complications from COVID-19.

• Wash your hands often with soap and water for at least 20 seconds, especially after blowing your nose, coughing, or sneezing; going to the bathroom; and before eating or preparing food.

• When in public, wear a cloth face covering that covers your mouth and nose.

• Avoid touching your eyes, nose, and mouth with unwashed hands.

• Stay home when you are sick.

• Cover your cough or sneeze with a tissue, then throw the tissue in the trash.

FACT

3

cdc.gov/coronavirus

http://cdc.gov/coronavirus

If you have these symptoms, please see the front desk immediately.

Patients with COVID-19 may have these symptoms:

FeverCough

Shortness of breath

We may ask you to wear a mask or use tissues to cover your cough, and offer you a separate space to wait.

For more information: cdc.gov/COVID19

315894 March 13, 2020 12:06 PM

Thank you for helping us protect other patients and staff.

If you have these symptoms, please see the front desk immediately.

6 ft

Stay at least 6 feet (about 2 arms’ length)

from other people.

Stay home when you are sick, except to get medical care.

Clean and disinfect frequently touched

objects and surfaces.

Cover your cough or sneeze with a tissue, then throw the tissue in the

trash and wash your hands.

Wash your hands often with soap and water for at least 20 seconds.

Stop the Spread of Germs

cdc.gov/coronavirus316917-A May 13, 2020 11:00 AM

Help prevent the spread of respiratory diseases like COVID-19.

Do not touch your eyes, nose, and mouth.

When in public, wear a cloth face covering over your nose and mouth.

http://cdc.gov/coronavirus

CS 316158-A 04/20/2020

Coronavirus Disease 2019 (COVID-19)Keeping Patients on Dialysis Safe

What is COVID-19?COVID-19 is a respiratory illness that can spread from person to person, similar to influenza.

Take Everyday Precautions • Wash your hands often with soap and water for at least 20 seconds or use hand sanitizer

with at least 60% alcohol.• Avoid touching your face.• Everyone should wear a cloth face cover in public setting where other social distancing

measures are difficult to maintain.• Avoid close contact with people who are sick.• Avoid crowds and keep at least six feet of space between yourself

and others if COVID-19 is spreading in your community. • If you are in a private setting and do not have on your cloth face

covering, remember to always cover your mouth and nose with a tissue when you cough or sneeze or use the inside of your elbow.

» Throw used tissues in the trash and immediately clean your hands.• Routinely clean and disinfect surfaces you often touch, such as cell

phones, computers, countertops, handles, and light switches.

Preparing the Facility You may see changes as the dialysis facility prepares to keep you safe during treatment.This may include:

• Signs with special instructions for patients with symptoms of COVID-19.• Additional education about hand hygiene and cough etiquette. • Waiting areas will be divided for patients with symptoms and patients

without symptoms. • A change in patient chair locations, treatment times, or days. • A change in the gowns, facemasks, and eye protection that the

staff wear. • Patients, visitors and staff will all be wearing a cloth face covering

or facemask the entire time they are in the facility.

Monitoring Symptoms Symptoms of COVID-19 can range from mild symptoms to severe illness.

• Fever• New cough• Sore throat• Tiredness• Shortness of breath• Muscle aches

If you feel sick or think you may have been exposed to COVID-19, call your facility right away to let them know. This allows the facility to plan for your arrival or direct you to the hospital.

Always inform staff of fever or COVID-19 symptoms before entering the treatment area.

If you are on dialysis, you should NOT postpone your treatments.

COVID-19 in the CommunityIf COVID-19 is spreading in your community:

• Take extra measures to put distance between yourself and other people and wear a cloth face covering when you leave your house.

• Talk with your family and caregivers to create a plan for if you get sick.• Know contact information for your dialysis facility and care providers. • Make sure you have access to several weeks of medications and

supplies in case you need to stay home.

Speak Up: Questions for StaffDon’t be afraid to use your voice and ask questions such as:

• How is the facility preparing for COVID-19?• Will there be any changes that may affect my treatment?• What can I do to protect myself and others?

Everyone has a role to play in staying healthy. Help protect yourself and your community from getting and spreading respiratory illnesses like COVID-19 by following CDC guidance. www.cdc.gov/coronavirus/2019-ncov/community

cdc.gov/coronavirus

CS 316651-A 05/04/2020

Important Information About Your Cloth Face CoveringsAs COVID-19 continues to spread within the United States, CDC has recommended additional measures to prevent the spread of SARS-CoV-2, the virus that causes COVID-19. In the context of community transmission, CDC recommends that you:

Stay at home as much as possible

Practice social distancing (remaining at least 6 feet away from others)

6 ft Clean your hands often

In addition, CDC also recommends that everyone wear cloth face coverings when leaving their homes, regardless of whether they have fever or symptoms of COVID-19. This is because of evidence that people with COVID-19 can spread the disease, even when they don’t have any symptoms. Cloth face coverings should not be placed on young children under age 2, anyone who has trouble breathing, or is unconscious, incapacitated, or otherwise unable to remove the mask without assistance.

How cloth face coverings workCloth face coverings prevent the person wearing the mask from spreading respiratory droplets when talking, sneezing, or coughing. If everyone wears a cloth face covering when out in public, such as going to the grocery store, the risk of exposure to SARS-CoV-2 can be reduced for the community. Since people can spread the virus before symptoms start, or even if people never have symptoms, wearing a cloth face covering can protect others around you. Face coverings worn by others protect you from getting the virus from people carrying the virus.

How cloth face coverings are different from other types of masksCloth face coverings are NOT the same as the medical facemasks, surgical masks, or respirators (such as N95 respirators) worn by healthcare personnel, first responders, and workers in other industries. These masks and respirators are personal protective equipment (PPE). Medical PPE should be used by healthcare personnel and first responders for their protection. Healthcare personnel and first responders should not wear cloth face coverings instead of PPE when respirators or facemasks are indicated. N95 respirator Cloth covering

General considerations for the use of cloth face coveringsWhen using a cloth face covering, make sure:

• The mouth and nose are fully covered• The covering fits snugly against the

sides of the face so there are no gaps• You do not have any difficulty

breathing while wearing the cloth face covering

• The cloth face covering can be tied or otherwise secured to prevent slipping

Avoid touching your face as much as possible. Keep the covering clean. Clean hands with soap and water or alcohol-based hand

sanitizer immediately, before putting on, after touching or adjusting, and after removing the cloth face covering. Don’t share it with anyone else unless it’s washed and dried first. You should be the only person handling your covering. Laundry instructions will depend on the cloth used to make the face covering. In general, cloth face coverings should

be washed regularly (e.g., daily and whenever soiled) using water and a mild detergent, dried completely in a hot dryer, and

stored in a clean container or bag.

For more information, go to: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cloth-face-cover-faq.html

cdc.gov/coronavirus

https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cloth-face-cover-faq.html


How to Safely Wear and Take Off a Cloth Face Covering

cdc.gov/coronavirusCS 316439A 05/18/2020

PHARMACY

CLOTH B

ARR

IER

For instructions on making a cloth face covering, see:

Cloth face coverings are not surgical masks or N-95 respirators, both of which should be saved for health care workers and other medical first responders.

WEAR YOUR FACE COVERING CORRECTLY

USE THE FACE COVERING TO PROTECT OTHERS

FOLLOW EVERYDAY HEALTH HABITS

TAKE OFF YOUR CLOTH FACE COVERING CAREFULLY, WHEN YOU’RE HOME

• Wash your hands before putting on your face covering• Put it over your nose and mouth and secure it under your chin• Try to fit it snugly against the sides of your face • Make sure you can breathe easily• Do not place a mask on a child younger than 2

• Wear a face covering to protect others in case you’re infected but don’t have symptoms• Keep the covering on your face the entire time you’re in public• Don’t put the covering around your neck or up on your forehead• Don’t touch the face covering, and, if you do, clean your hands

• Stay at least 6 feet away from others• Avoid contact with people who are sick• Wash your hands often, with soap and water, for at least 20 seconds each time• Use hand sanitizer if soap and water are not available

• Untie the strings behind your head or stretch the ear loops• Handle only by the ear loops or ties• Fold outside corners together• Place covering in the washing machine• Wash your hands with soap and water

Accessible: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/diy-cloth-face-coverings.html

https://www.cdc.gov/coronavirus

https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/diy-cloth-face-coverings.html

CS 316291A 05/05/2020

cdc.gov/coronavirus

How to Protect Yourself and OthersKnow how it spreads

• There is currently no vaccine to prevent coronavirus disease 2019 (COVID-19).

• The best way to prevent illness is to avoid being exposed to this virus.• The virus is thought to spread mainly from person-to-person.

» Between people who are in close contact with one another (within about 6 feet).

» Through respiratory droplets produced when an infected person coughs, sneezes or talks.

» These droplets can land in the mouths or noses of people who are nearby or possibly be inhaled into the lungs.

» Some recent studies have suggested that COVID-19 may be spread by people who are not showing symptoms.

Everyone should Clean your hands often

• Wash your hands often with soap and water for at least 20 seconds especially after you have been in a public place, or after blowing your nose, coughing, or sneezing.

• If soap and water are not readily available, use a hand sanitizer that contains at least 60% alcohol. Cover all surfaces of your hands and rub them together until they feel dry.


Avoid close contact

• Stay home if you are sick.• Avoid close contact with people who are sick.

• Put distance between yourself and other people. » Remember that some people without symptoms may be able to spread virus.

» This is especially important for people who are at higher risk of getting very sick. www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-at-higher-risk.html

• You could spread COVID-19 to others even if you do not feel sick.

• Everyone should wear a cloth face cover when they have to go out in public, for example to the grocery store or to pick up other necessities.

» Cloth face coverings should not be placed on young children under age 2, anyone who has trouble breathing, or is unconscious, incapacitated or otherwise unable to remove the mask without assistance.

• The cloth face cover is meant to protect other people in case you are infected.

• Do NOT use a facemask meant for a healthcare worker.

• Continue to keep about 6 feet between yourself and others. The cloth face cover is not a substitute for social distancing.

Cover coughs and sneezes

• If you are in a private setting and do not have on your cloth face covering, remember to always cover your mouth and nose with a tissue when you cough or sneeze or use the inside of your elbow.

• Throw used tissues in the trash.

• Immediately wash your hands with soap and water for at least 20 seconds. If soap and water are not readily available, clean your hands with a hand sanitizer that contains at least 60% alcohol.

Clean and disinfect

• Clean AND disinfect frequently touched surfaces daily. This includes tables, doorknobs, light switches, countertops, handles, desks, phones, keyboards, toilets, faucets, and sinks. www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/disinfecting-your-home.html

• If surfaces are dirty, clean them: Use detergent or soap and water prior to disinfection.

• Then, use a household disinfectant. You can see a list of EPA-registered household disinfectants here.

Cover your mouth and nose with a cloth face cover when around others

cdc.gov/coronavirus

Call ahead before visiting your doctor. • Call ahead. Many medical visits for routine

care are being postponed or done by phone or telemedicine.

• If you have a medical appointment that cannot be postponed, call your doctor’s office. This will help the office protect themselves and other patients.

If you are sick, wear a cloth covering over your nose and mouth.• You should wear a cloth face covering over your

nose and mouth if you must be around other people or animals, including pets (even at home).

• You don’t need to wear the cloth face covering if you are alone. If you can’t put on a cloth face covering (because of trouble breathing for example), cover your coughs and sneezes in some other way. Try to stay at least 6 feet away from other people. This will help protect the people around you.

Note: During the COVID-19 pandemic, medical grade facemasks are reserved for healthcare workers and some first responders. You may need to make a cloth face covering using a scarf or bandana.

If you develop emergency warning signs for COVID-19 get medical attention immediately. Emergency warning signs include*:

• Trouble breathing

• Persistent pain or pressure in the chest

• New confusion or not able to be woken

• Bluish lips or face

*This list is not all inclusive. Please consult your medical provider for any other symptoms that are severe or concerning to you.

Call 911 if you have a medical emergency. If you have a medical emergency and need to call 911, notify the operator that you have or think you might have, COVID-19. If possible, put on a facemask before medical help arrives.

CS 316120-A 05/03/2020

cdc.gov/coronavirus

Prevent the spread of COVID-19 if you are sickAccessible version: https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/steps-when-sick.html

If you are sick with COVID-19 or think you might have COVID-19, follow the steps below to help protect other people in your home and community.

Stay home except to get medical care. • Stay home. Most people with COVID-19

have mild illness and are able to recover at home without medical care. Do not leave your home, except to get medical care. Do not visit public areas.

• Take care of yourself. Get rest and stay hydrated.

• Get medical care when needed. Call your doctor before you go to their office for care. But, if you have trouble breathing or other concerning symptoms, call 911 for immediate help.

• Avoid public transportation, ride-sharing, or taxis.

Separate yourself from other people and pets in your home. • As much as possible, stay in a specific room and

away from other people and pets in your home. Also, you should use a separate bathroom, if available. If you need to be around other people or animals in or outside of the home, wear a cloth face covering.

ɞ See COVID-19 and Animals if you have questions about pets: https://www.cdc.gov/coronavirus/2019-ncov/faq.html#COVID19animals

Monitor your symptoms.• Common symptoms of COVID-19 include fever and

cough. Trouble breathing is a more serious symptom that means you should get medical attention.

• Follow care instructions from your healthcare provider and local health department. Your local health authorities will give instructions on checking your symptoms and reporting information.

http://cdc.gov/COVID19

https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/steps-when-sick.html

https://www.cdc.gov/coronavirus/2019-ncov/faq.html#COVID19animals

https://www.cdc.gov/coronavirus/2019-ncov/faq.html#COVID19animals

Cover your coughs and sneezes.• Cover your mouth and nose with a tissue when

you cough or sneeze.

• Throw used tissues in a lined trash can.

• Immediately wash your hands with soap and water for at least 20 seconds. If soap and water are not available, clean your hands with an alcohol-based hand sanitizer that contains at least 60% alcohol.

Clean your hands often.• Wash your hands often with soap and water

for at least 20 seconds. This is especially important after blowing your nose, coughing, or sneezing; going to the bathroom; and before eating or preparing food.

• Use hand sanitizer if soap and water are not available. Use an alcohol-based hand sanitizer with at least 60% alcohol, covering all surfaces of your hands and rubbing them together until they feel dry.

• Soap and water are the best option, especially if your hands are visibly dirty.


Avoid sharing personal household items.• Do not share dishes, drinking glasses, cups,

eating utensils, towels, or bedding with other people in your home.

• Wash these items thoroughly after using them with soap and water or put them in the dishwasher.

Clean all “high-touch” surfaces everyday.• Clean and disinfect high-touch surfaces

in your “sick room” and bathroom. Let someone else clean and disinfect surfaces in common areas, but not your bedroom and bathroom.

• If a caregiver or other person needs to clean and disinfect a sick person’s bedroom or bathroom, they should do so on an as-needed basis. The caregiver/other person should wear a mask and wait as long as possible after the sick person has used the bathroom.

High-touch surfaces include phones, remote controls, counters, tabletops, doorknobs, bathroom fixtures, toilets, keyboards, tablets, and bedside tables.

• Clean and disinfect areas that may have blood, stool, or body fluids on them.

• Use household cleaners and disinfectants. Clean the area or item with soap and water or another detergent if it is dirty. Then use a household disinfectant.

ɞ Be sure to follow the instructions on the label to ensure safe and effective use of the product. Many products recommend keeping the surface wet for several minutes to ensure germs are killed. Many also recommend precautions such as wearing gloves and making sure you have good ventilation during use of the product.

ɞ Most EPA-registered household disinfectants should be effective.

How to discontinue home isolation• People with COVID-19 who have stayed home

(home isolated) can stop home isolation under the following conditions:

ɞ If you will not have a test to determine if you are still contagious, you can leave home after these three things have happened:

§ You have had no fever for at least 72 hours (that is three full days of no fever without the use of medicine that reduces fevers) AND

§ other symptoms have improved (for example, when your cough or shortness of breath has improved) AND

§ at least 10 days have passed since your symptoms first appeared.

ɞ If you will be tested to determine if you are still contagious, you can leave home after these three things have happened:

§ You no longer have a fever (without the use of medicine that reduces fevers) AND

§ other symptoms have improved (for example, when your cough or shortness of breath has improved) AND

§ you received two negative tests in a row, 24 hours apart. Your doctor will follow CDC guidelines.

In all cases, follow the guidance of your healthcare provider and local health department. The decision to stop home isolation should be made in consultation with your healthcare provider and state and local health departments. Local decisions depend on local circumstances.

CS 314937A 04/15/2020

cdc.gov/coronavirus

What you should know about COVID-19 to protect yourself and others

Know about COVID-19• Coronavirus (COVID-19) is an illness caused

by a virus that can spread from person to person.

• The virus that causes COVID-19 is a new coronavirus that has spread throughout the world.

• COVID-19 symptoms can range from mild (or no symptoms) to severe illness.

Know how COVID-19 is spread• You can become infected by coming into

close contact (about 6 feet or two arm lengths) with a person who has COVID-19. COVID-19 is primarily spread from person to person.

• You can become infected from respiratory droplets when an infected person coughs, sneezes, or talks.

• You may also be able to get it by touching a surface or object that has the virus on it, and then by touching your mouth, nose, or eyes.

Protect yourself and others from COVID-19• There is currently no vaccine to protect

against COVID-19. The best way to protect yourself is to avoid being exposed to the virus that causes COVID-19.

• Stay home as much as possible and avoid close contact with others.

• Wear a cloth face covering that covers your nose and mouth in public settings.

• Clean and disinfect frequently touched surfaces.

• Wash your hands often with soap and water for at least 20 seconds, or use an alcohol-based hand sanitizer that contains at least 60% alcohol.

milk Practice social distancing• Buy groceries and medicine,

go to the doctor, and complete banking activities online when possible.

• If you must go in person, stay at least 6 feet away from others and disinfect items you must touch.

• Get deliveries and takeout, and limit in-person contact as much as possible.

Prevent the spread of COVID-19 if you are sick• Stay home if you are sick,

except to get medical care.

• Avoid public transportation, ride-sharing, or taxis.

• Separate yourself from other people and pets in your home.

• There is no specific treatment for COVID-19, but you can seek medical care to help relieve your symptoms.

• If you need medical attention, call ahead.

Know your risk for severe illness• Everyone is at risk of

getting COVID-19.

• Older adults and people of any age who have serious underlying medical conditions may be at higher risk for more severe illness.


SEQUENCE FOR PUTTING ON PERSONAL PROTECTIVE EQUIPMENT (PPE)

CS250672-E

ThetypeofPPEusedwillvarybasedonthelevelofprecautionsrequired,suchasstandardandcontact,dropletorairborneinfectionisolationprecautions.TheprocedureforputtingonandremovingPPEshouldbetailoredtothespecifictypeofPPE.

1. GOWN• Fullycovertorsofromnecktoknees,armstoendofwrists,andwraparoundtheback

• Fasteninbackofneckandwaist

2. MASK OR RESPIRATOR• Securetiesorelasticbandsatmiddleofheadandneck

• Fitflexiblebandtonosebridge• Fitsnugtofaceandbelowchin• Fit-checkrespirator

3. GOGGLES OR FACE SHIELD• Placeoverfaceandeyesandadjusttofit

4. GLOVES• Extendtocoverwristofisolationgown

USE SAFE WORK PRACTICES TO PROTECT YOURSELF AND LIMIT THE SPREAD OF CONTAMINATION

• Keephandsawayfromface• Limitsurfacestouched• Changegloveswhentornorheavilycontaminated• Performhandhygiene

HOW TO SAFELY REMOVE PERSONAL PROTECTIVE EQUIPMENT (PPE) EXAMPLE 1ThereareavarietyofwaystosafelyremovePPEwithoutcontaminatingyourclothing,skin,ormucousmembraneswithpotentiallyinfectiousmaterials.Hereisoneexample.Remove all PPE before exiting the patient roomexceptarespirator,ifworn.Removetherespiratorafterleavingthepatientroomandclosingthedoor.RemovePPEinthefollowingsequence:

1. GLOVES• Outsideofglovesarecontaminated!• Ifyourhandsgetcontaminatedduringgloveremoval,immediately

washyourhandsoruseanalcohol-basedhandsanitizer• Usingaglovedhand,graspthepalmareaoftheotherglovedhand

andpeelofffirstglove• Holdremovedgloveinglovedhand• Slidefingersofunglovedhandunderremaininggloveatwristand

peeloffsecondgloveoverfirstglove• Discardglovesinawastecontainer

2. GOGGLES OR FACE SHIELD• Outsideofgogglesorfaceshieldarecontaminated!• Ifyourhandsgetcontaminatedduringgoggleorfaceshieldremoval,

immediatelywashyourhandsoruseanalcohol-basedhandsanitizer• Removegogglesorfaceshieldfromthebackbyliftingheadbandor

earpieces• Iftheitemisreusable,placeindesignatedreceptaclefor

reprocessing.Otherwise,discardinawastecontainer

3. GOWN• Gownfrontandsleevesarecontaminated!• Ifyourhandsgetcontaminatedduringgownremoval,immediately

washyourhandsoruseanalcohol-basedhandsanitizer• Unfastengownties,takingcarethatsleevesdon’tcontactyourbody

whenreachingforties• Pullgownawayfromneckandshoulders,touchinginsideofgownonly• Turngowninsideout• Foldorrollintoabundleanddiscardinawastecontainer

4. MASK OR RESPIRATOR• Frontofmask/respiratoriscontaminated—DONOTTOUCH!• Ifyourhandsgetcontaminatedduringmask/respiratorremoval,

immediatelywashyourhandsoruseanalcohol-basedhandsanitizer• Graspbottomtiesorelasticsofthemask/respirator,thentheonesat

thetop,andremovewithouttouchingthefront• Discardinawastecontainer

CS250672-E

OR5. WASH HANDS OR USE AN

ALCOHOL-BASED HAND SANITIZER IMMEDIATELY AFTER REMOVING ALL PPE

PERFORM HAND HYGIENE BETWEEN STEPS IF HANDS BECOME CONTAMINATED AND IMMEDIATELY AFTER REMOVING ALL PPE

HOW TO SAFELY REMOVE PERSONAL PROTECTIVE EQUIPMENT (PPE) EXAMPLE 2

HereisanotherwaytosafelyremovePPEwithoutcontaminatingyourclothing,skin,ormucousmembraneswithpotentiallyinfectiousmaterials.Remove all PPE before exiting the patient room exceptarespirator,ifworn.Removetherespirator after leavingthepatientroomandclosingthedoor.RemovePPEinthefollowingsequence:

1. GOWN AND GLOVES• Gownfrontandsleevesandtheoutsideofglovesare

contaminated!• Ifyourhandsgetcontaminatedduringgownorgloveremoval,

immediatelywashyourhandsoruseanalcohol-basedhandsanitizer

• Graspthegowninthefrontandpullawayfromyourbodysothatthetiesbreak,touchingoutsideofgownonlywithglovedhands

• Whileremovingthegown,foldorrollthegowninside-outintoabundle

• Asyouareremovingthegown,peeloffyourglovesatthesametime,onlytouchingtheinsideoftheglovesandgownwithyourbarehands.Placethegownandglovesintoawastecontainer

CS250672-E

A B

D E

C

2. GOGGLES OR FACE SHIELD• Outsideofgogglesorfaceshieldarecontaminated!• Ifyourhandsgetcontaminatedduringgoggleorfaceshieldremoval,

immediatelywashyourhandsoruseanalcohol-basedhandsanitizer• Removegogglesorfaceshieldfromthebackbyliftingheadbandand

withouttouchingthefrontofthegogglesorfaceshield• Iftheitemisreusable,placeindesignatedreceptaclefor

reprocessing.Otherwise,discardinawastecontainer

3. MASK OR RESPIRATOR• Frontofmask/respiratoriscontaminated—DONOTTOUCH!• Ifyourhandsgetcontaminatedduringmask/respiratorremoval,

immediatelywashyourhandsoruseanalcohol-basedhandsanitizer• Graspbottomtiesorelasticsofthemask/respirator,thentheonesat

thetop,andremovewithouttouchingthefront• Discardinawastecontainer

OR

4. WASH HANDS OR USE AN ALCOHOL-BASED HAND SANITIZER IMMEDIATELY AFTER REMOVING ALL PPE

PERFORM HAND HYGIENE BETWEEN STEPS IF HANDS BECOME CONTAMINATED AND IMMEDIATELY AFTER REMOVING ALL PPE

CS 315838-C 03/23/2020

cdc.gov/COVID19

COVID-19 Personal Protective Equipment (PPE) for Healthcare Personnel

Acceptable Alternative PPE – Use FacemaskPreferred PPE – Use N95 or Higher Respirator

N95 or higher respiratorWhen respirators are not available, use the best available alternative, like a facemask.

FacemaskN95 or higher respirators are preferred but facemasks are an acceptable alternative.

Isolation gownIsolation gown

One pair of clean, non-sterile gloves


Face shieldor goggles

Face shieldor goggles

CS 316124-A 03/30/2020

www.cdc.gov/coronavirus

Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19Before caring for patients with confirmed or suspected COVID-19, healthcare personnel (HCP) must:• Receive comprehensive training on when and what PPE is necessary, how to don (put on) and doff (take off) PPE, limitations of

PPE, and proper care, maintenance, and disposal of PPE.

• Demonstrate competency in performing appropriate infection control practices and procedures.

CS 315838-A 03/20/2020

cdc.gov/COVID19


Preferred PPE – Use N95 or Higher Respirator

N95 or higher respiratorWhen respirators are not available, use the best available alternative, like a facemask.


Face shield or goggles

Isolation gown

CS 315838-B 03/20/2020

cdc.gov/COVID19


Acceptable Alternative PPE – Use Facemask

FacemaskN95 or higher respirators are preferred but facemasks are an acceptable alternative.


Face shield or goggles

Isolation gown

Remember:• PPE must be donned correctly before entering the patient area (e.g., isolation room, unit if cohorting).

• PPE must remain in place and be worn correctly for the duration of work in potentially contaminated areas. PPE should not be adjusted (e.g., retying gown, adjusting respirator/facemask) during patient care.

• PPE must be removed slowly and deliberately in a sequence that prevents self-contamination. A step-by-step process should be developed and used during training and patient care.

Donning (putting on the gear):More than one donning method may be acceptable. Training and practice using your healthcare facility’s procedure is critical. Below is one example of donning.

1. Identify and gather the proper PPE to don. Ensure choice of gown size is correct (based on training).

2. Perform hand hygiene using hand sanitizer.

3. Put on isolation gown. Tie all of the ties on the gown. Assistance may be needed by another HCP.

4. Put on NIOSH-approved N95 filtering facepiece respirator or higher (use a facemask if a respirator is not available). If the respirator has a nosepiece, it should be fitted to the nose with both hands, not bent or tented. Do not pinch the nosepiece with one hand. Respirator/facemask should be extended under chin. Both your mouth and nose should be protected. Do not wear respirator/facemask under your chin or store in scrubs pocket between patients.*

» Respirator: Respirator straps should be placed on crown of head (top strap) and base of neck (bottom strap). Perform a user seal check each time you put on the respirator.

» Facemask: Mask ties should be secured on crown of head (top tie) and base of neck (bottom tie). If mask has loops, hook them appropriately around your ears.

5. Put on face shield or goggles. Face shields provide full face coverage. Goggles also provide excellent protection for eyes, but fogging is common.

6. Perform hand hygiene before putting on gloves. Gloves should cover the cuff (wrist) of gown.

7. HCP may now enter patient room.

Doffing (taking off the gear):More than one doffing method may be acceptable. Training and practice using your healthcare facility’s procedure is critical. Below is one example of doffing.

1. Remove gloves. Ensure glove removal does not cause additional contamination of hands. Gloves can be removed using more than one technique (e.g., glove-in-glove or bird beak).

2. Remove gown. Untie all ties (or unsnap all buttons). Some gown ties can be broken rather than untied. Do so in gentle manner, avoiding a forceful movement. Reach up to the shoulders and carefully pull gown down and away from the body. Rolling the gown down is an acceptable approach. Dispose in trash receptacle.*

3. HCP may now exit patient room.

4. Perform hand hygiene.

5. Remove face shield or goggles. Carefully remove face shield or goggles by grabbing the strap and pulling upwards and away from head. Do not touch the front of face shield or goggles.

6. Remove and discard respirator (or facemask if used instead of respirator).* Do not touch the front of the respirator or facemask.

» Respirator: Remove the bottom strap by touching only the strap and bring it carefully over the head. Grasp the top strap and bring it carefully over the head, and then pull the respirator away from the face without touching the front of the respirator.

» Facemask: Carefully untie (or unhook from the ears) and pull away from face without touching the front.

7. Perform hand hygiene after removing the respirator/facemask and before putting it on again if your workplace is practicing reuse.

*Facilities implementing reuse or extended use of PPE will need to adjust their donning and doffing procedures to accommodate those practices.


CONTACTPRECAUTIONS

EVERYONE MUST:Clean their hands, including before entering and when leaving the room.

Put on gloves before room entry.Discard gloves before room exit.

Put on gown before room entry.Discard gown before room exit.Do not wear the same gown and gloves for the care of more than one person.

Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person.

PROVIDERS AND STAFF MUST ALSO:

ABHR

CS19

-30614

9-A

ENHANCEDBARRIER

PRECAUTIONSEVERYONE MUST:

Clean their hands, including before entering and when leaving the room.

Wear gloves and a gown for the following High-Contact Resident Care Activities.

Do not wear the same gown and gloves for the care of more than one person.

PROVIDERS AND STAFF MUST ALSO:

DressingBathing/ShoweringTransferringChanging LinensProviding HygieneChanging briefs or assisting with toiletingDevice care or use: central line, urinary catheter, feeding tube, tracheostomyWound Care: any skin opening requiring a dressing

ABHR

CS19

-30614

9-A

DROPLETPRECAUTIONS

EVERYONE MUST:Clean their hands, including before

entering and when leaving the room.

Make sure their eyes, nose and mouth are fully covered before room entry.

Remove face protection before room exit.

or

ABHR

CS19

-30614

9-A

AIRBORNEPRECAUTIONS

EVERYONE MUST:

Clean their hands, including before entering and when leaving the room.

Put on a fit-tested N-95 or higher level respirator before room entry.Remove respirator after exiting the room and closing the door.

Door to room must remain closed.

N-95NIOSH

ABHR

CS19

-30614

9-A

Stop the spread of germs that can make you and others sick!

You may be asked to put on a facemask to protect others.

If you don’t have a tissue, cough or sneeze into your upper sleeve or elbow, not your hands.

Wash hands often with soap and warm water for 20 seconds. If soap and water are not available, use an alcohol-based hand rub.

Cover your mouth and nose with a tissue when you cough or sneeze.Put your used tissue in the waste basket.

CS208322

CL AN Y UI HAND

WHY: WHEN: v Stay healthy V Before and after visiting

someone 's hospital room V Prevent colds

V Before eating V Prevent flu

V Mter using restroom V Prevent diarrhea

V Mter coughing or sneezing V Prevent spread of other

sicknesses and diseases V Mter being near someone sick or someone coughing or sneezing

V Mter touching trash

HOW: V Use an alcohol hand rub .

Rub hands until dry OR

V Wash with soap and water

www.publichealth.va.gov/lnfectionDontPassltOn VAl",fi,;.. HEALTH EXCEl.1.ENCE CARE in the 21St Century

Hands 4 - All

www.publichealth.va.gov/lnfectionDontPassltOn

Help keep COVID-19 out of our facility

DO NOT VISIT IF YOU ARE SICK

If you have cold, cough, runny nose, sore throat, muscle aches or fever, please do not come into the facility

CLEAN YOUR HANDS

Clean hands before entering and after leaving with hand sanitizer

VISIT ONE RESIDENT ONLY

Do not visit multiple people in this visit

Help keep our residents safe

Healthcare Professional Preparedness Checklist For Transport and Arrival of Patients With Confirmed or Possible COVID-19

U.S. Department of Health and Human Services Centers for Disease Control and Prevention

Front-line healthcare personnel in the United States should be prepared to evaluate patients for coronavirus disease 2019 (COVID-19). The following checklist highlights key steps for healthcare personnel in preparation for transport and arrival of patients with confirmed or possible COVID-19.

Stay up to date on the latest information about signs and symptoms, diagnostic testing, and case definitions for coronavirus disease 2019.

Review your infection prevention and control policies and CDC infection control recommendations for COVID-19 for:

� Assessment and triage of patients with acute respiratory symptoms

� Patient placement

� Implementation of Standard, Contact, and Airborne Precautions, including the use of eye protection

� Visitor management and exclusion

� Source control measures for patients (e.g., put facemask on suspect patients)

� Requirements for performing aerosol generating procedures

� Be alert for patients who meet the persons under investigation (PUI) definition

� Know how to report a potential COVID-19 case or exposure to facility infection control leads and public health officials.

� Know who, when, and how to seek evaluation by occupational health following an unprotected exposure (i.e., not wearing recommended PPE) to a suspected or confirmed coronavirus disease 2019 patient.

� Remain at home, and notify occupational health services, if you are ill.

� Know how to contact and receive information from your state or local public health agency.

www.cdc.gov/COVID19

https://www.cdc.gov/coronavirus/2019-nCoV/summary.html



https://www.cdc.gov/coronavirus/2019-nCoV/hcp/clinical-criteria.html


www.cdc.gov/COVID19

Coronavirus Disease 2019 (COVID-19) Preparedness Checklist for Nursing Homes and other Long-Term Care Settings

U.S. Department of Health and Human Services Centers for Disease Control and Prevention

Nursing homes and other long-term care facilities can take steps to assess and improve their preparedness for responding to coronavirus disease 2019 (COVID-19). Each facility will need to adapt this checklist to meet its needs and circumstances based on differences among facilities (e.g., patient/resident characteristics, facility size, scope of services, hospital affiliation). This checklist should be used as one tool in developing a comprehensive COVID-19 response plan. Additional information can be found at www.cdc.gov/COVID-19. Information from state, local, tribal, and territorial health departments, emergency management agencies/authorities, and trade organizations should be incorporated into the facility’s COVID-19 plan. Comprehensive COVID-19 planning can also help facilities plan for other emergency situations.

This checklist identifies key areas that long-term care facilities should consider in their COVID-19 planning. Long-term care facilities can use this tool to self-assess the strengths and weaknesses of current preparedness efforts. Additional information is provided via links to websites throughout this document. However, it will be necessary to actively obtain information from state, local, tribal, and territorial resources to ensure that the facility’s plan complements other community and regional planning efforts. This checklist does not describe mandatory requirements or standards; rather, it highlights important areas to review to prepare for the possibility of residents with COVID-19.

A preparedness checklist for hospitals, including long-term acute care hospitals is available. https://www.cdc.gov/coronavirus/2019-ncov/downloads/hospital-preparedness-checklist.pdf

Interim Infection Prevention and Control Recommendations for Patients with Confirmed Coronavirus Disease 2019 (COVID-19) or Persons Under Investigation for COVID-19 in Healthcare Settings:https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html

Strategies to Prevent the Spread of COVID-19 in Long-Term Care Facilities (LTCF): https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/prevent-spread-in-long-term-care-facilities.html

1. Structure for planning and decision making

� COVID-19 has been incorporated into emergency management planning for the facility.

� A multidisciplinary planning committee or team* has been created to specifically address COVID-19 preparedness planning.

List committee’s or team’s name:

*An existing emergency or disaster preparedness team may be assigned this responsibility.

continue on next page

Completed In Progress Not Started

1

https://www.cdc.gov/coronavirus/2019-ncov/index.html

https://www.cdc.gov/coronavirus/2019-ncov/downloads/hospital-preparedness-checklist.pdf


cont.

� People assigned responsibility for coordinating preparedness planning, hereafter referred to as the COVID-19 response coordinator.

Insert name(s), title(s), and contact information:

� Members of the planning committee include the following: (Develop a list of committee members with the name, title, and contact information for each personnel category checked below and attach to this checklist.) � Facility administration � Medical director � Director of Nursing � Infection control � Occupational health � Staff training and orientation � Engineering/maintenance services � Environmental (housekeeping) services � Dietary (food) services � Pharmacy services � Occupational/rehabilitation/physical therapy services � Transportation services � Purchasing agent � Facility staff representative � Other member(s) as appropriate (e.g., clergy, community representatives,

department heads, resident and family representatives, risk managers, quality improvement, direct care staff including consultant services, union representatives)

� The facility’s COVID-19 response coordinator has contacted local or regional planning groups to obtain information on coordinating the facility’s plan with other COVID-19 plans.

Insert groups and contact information:

2. Development of a written COVID-19 plan.

� A copy of the COVID-19 preparedness plan is available at the facility and accessible by staff.

� Relevant sections of federal, state, regional, or local plans for COVID-19 or pandemic influenza are reviewed for incorporation into the facility’s plan.

� The facility plan includes the Elements listed in #3 below.

� The plan identifies the person(s) authorized to implement the plan and the organizational structure that will be used.structure that will be used.



2


3. Elements of a COVID-19 plan.General:

� A plan is in place for protecting residents, healthcare personnel, and visitors from respiratory infections, including COVID-19, that addresses the elements that follow.

� A person has been assigned responsibility for monitoring public health advisories (federal and state) and updating the COVID-19 response coordinator and members of the COVID-19 planning committee when COVID-19 is in the geographic area. For more information, see https://www.cdc.gov/coronavirus/2019-ncov/index.html.

Insert name, title, and contact information of person responsible.

� The facility has a process for inter-facility transfers that includes notifying transport personnel and receiving facilities about a resident’s suspected or confirmed diagnosis (e.g., presence of respiratory symptoms or known COVID-19) prior to transfer.

� The facility has a system to monitor for, and internally review, development of COVID-19 among residents and healthcare personnel (HCP) in the facility. Information from this monitoring system is used to implement prevention interventions (e.g., isolation, cohorting), see CDC guidance on respiratory surveillance: https://www.cdc.gov/longtermcare/pdfs/LTC-Resp-OutbreakResources-P.pdf.

� The facility has infection control policies that outline the recommended Transmission-Based Precautions that should be used when caring for residents with respiratory infection. (In general, for undiagnosed respiratory infection, Standard, Contact, and Droplet Precautions with eye protection are recommended unless the suspected diagnosis requires Airborne Precautions; see: https://www.cdc.gov/infectioncontrol/guidelines/isolation/appendix/type-duration-precautions.html.) For recommended Transmission-Based Precautions for residents with suspected or confirmed COVID-19, the policies refer to CDC guidance; see: https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html.

� The facility periodically reviews specific IPC guidance for healthcare facilities caring for residents with suspected or confirmed COVID-19 (available here: https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html)and additional long-term care guidance (available here: https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/prevent-spread-in-long-term-care-facilities.html).

Facility Communications: � Key public health points of contact during a COVID-19 outbreak have been identified. (Insert name, title, and contact information for each.)

Local health department contact:

State health department contact:

State long-term care professional/trade association:


3

https://www.cdc.gov/coronavirus/2019-ncov/index.html

https://www.cdc.gov/longtermcare/pdfs/LTC-Resp-OutbreakResources-P.pdf

https://www.cdc.gov/longtermcare/pdfs/LTC-Resp-OutbreakResources-P.pdf

https://www.cdc.gov/infectioncontrol/guidelines/isolation/appendix/type-duration-precautions.html

https://www.cdc.gov/infectioncontrol/guidelines/isolation/appendix/type-duration-precautions.html





https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/prevent-spread-in-long-term-care-facilities.html



Completed In Progress Not Startedcont. � A person has been assigned responsibility for communications with public health authorities during a COVID-19 outbreak.

Insert name and contact information:

� Key preparedness (e.g., Healthcare coalition) points of contact during a COVID-19 outbreak have been identified.

Insert name, title, and contact information for each:

� A person has been assigned responsibility for communications with staff, residents, and their families regarding the status and impact of COVID-19 in the facility. (Having one voice that speaks for the facility during an outbreak will help ensure the delivery of timely and accurate information.)

� Contact information for family members or guardians of facility residents is up to date.

� Communication plans include how signs, phone trees, and other methods of communication will be used to inform staff, family members, visitors, and other persons coming into the facility (e.g., consultants, sales and delivery people) about the status of COVID-19 in the facility.

� A list has been created of other healthcare entities and their points of contact (e.g., other long-term care and residential facilities, local hospitals and hospital emergency medical services, relevant community organizations—including those involved with disaster preparedness) with whom it will be necessary to maintain communication during an outbreak. Attach a copy of contact list.

� A facility representative(s) has been involved in the discussion of local plans for inter-facility communication during an outbreak.

Supplies and resources: The facility provides supplies necessary to adhere to recommended IPC practices including:

� Alcohol-based hand sanitizer for hand hygiene is available in every resident room (ideally both inside and outside of the room) and other resident care and common areas (e.g., outside dining hall, in therapy gym).

� Sinks are well-stocked with soap and paper towels for hand washing.

� Signs are posted immediately outside of resident rooms indicating appropriate IPC precautions and required personal protective equipment (PPE).

� Facility provides tissues and facemasks for coughing people near entrances and in common areas with no-touch receptacles for disposal.

� Necessary PPE is available immediately outside of the resident room and in other areas where resident care is provided. continue on next page

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Completed In Progress Not Startedcont. � Facilities should have supplies of facemasks, respirators (if available and the facility has a respiratory protection program with trained, medically cleared, and fit-tested HCP), gowns, gloves, and eye protection (i.e., face shield or goggles).

� 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.

� Facility ensures HCP have access to EPA-registered hospital-grade disinfectants to allow for frequent cleaning of high-touch surfaces and shared resident care equipment. � Products with EPA-approved emerging viral pathogens claims are recommended for use

against COVID-19. If there are no available EPA-registered products that have an approved emerging viral pathogen claim for COVID-19, products with label claims against human coronaviruses should be used according to label instructions.

� The facility has a process to monitor supply levels.

� The facility has a contingency plan, that includes engaging their health department and healthcare coalition when they experience (or anticipate experiencing) supply shortages. Contact information for healthcare coalitions is available here: https://www.phe.gov/Preparedness/planning/hpp/Pages/find-hc-coalition.aspx

Identification and Management of Ill Residents: � The facility has a process to identify and manage residents with symptoms of respiratory infection (e.g., cough, fever, sore throat) upon admission and daily during their stay in the facility, which include implementation of appropriate Transmission-Based Precautions.

� The facility has criteria and a protocol for initiating active surveillance for respiratory infection among residents and healthcare personnel. CDC has resources for performing respiratory surveillance in long-term care facilities during an outbreak, see: https://www.cdc.gov/longtermcare/pdfs/LTC-Resp-OutbreakResources-P.pdf

� Plans developed on how to immediately notify the health department for clusters of respiratory infections, severe respiratory infections, or suspected COVID-19.

� The facility has criteria and a protocol for: limiting symptomatic and exposed residents to their room, halting group activities and communal dining, and closing units or the entire facility to new admissions.

� The facility has criteria and a process for cohorting residents with symptoms of respiratory infection, including dedicating HCP to work only on affected units.

Considerations about Visitors: � The facility has plans and material developed to post signs at the entrances to the facility instructing visitors not to visit if they have fever or symptoms of a respiratory infection.

� The facility has criteria and protocol for when visitors will be limited or restricted from the facility. continue on next page

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Completed In Progress Not Startedcont. � Should visitor restrictions be implemented, the facility has a process to allow for remote communication between the resident and visitor (e.g., video-call applications on cell phones or tablets) and has policies addressing when visitor restrictions will be lifted (e.g., end of life situation).

For more information about managing visitor access and movement in the facility see: https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html

Occupational Health: � The facility has sick leave policies that are non-punitive, flexible, and consistent with public health policies that allow ill healthcare personnel (HCP) to stay home.

� The facility instructs HCP (including consultant personnel) to regularly monitor themselves for fever and symptoms of respiratory infection, as a part of routine practice.

� The facility has a process to actively screen HCP for fever and symptoms when they report to work.

� The facility has a process to identify and manage HCP with fever and symptoms of respiratory infection.

� The facility has a plan for monitoring and assigning work restrictions for ill and exposed HCP. (See: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html)

� The facility has a respiratory protection plan that includes medical evaluation, training, and fit testing of employees.

Education and Training: � The facility has plans to provide education and training to HCP, residents, and family members of residents to help them understand the implications of, and basic prevention and control measures for, COVID-19. Consultant HCP should be included in education and training activities.

� A person has been designated with responsibility for coordinating education and training on COVID-19 (e.g., identifies and facilitates access to available programs, maintains a record of personnel attendance).

Insert name, title, and contact information:

� Language and reading-level appropriate materials have been identified to supplement and support education and training programs to HCP, residents, and family members of residents (e.g., available through state and federal public health agencies such and through professional organizations), and a plan is in place for obtaining these materials.


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https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html)

https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html)

Completed In Progress Not Startedcont. � Plans and material developed for education and job-specific training of HCP which includes information on recommended infection control measures to prevent the spread of COVID-19, including: � Signs and symptoms of respiratory illness, including COVID-19. � How to monitor residents for signs and symptoms of respiratory illness. � How to keep residents, visitors, and HCP safe by using correct infection control practices

including proper hand hygiene and selection and use of PPE. Training should include return demonstrations to document competency.

� Staying home when ill. � HCP sick leave policies and recommended actions for unprotected exposures (e.g., not

using recommended PPE, an unrecognized infectious patient contact).

� See: “Strategies to prevent the spread of COVID-19 in long-term care facilities,’ available at: https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/prevent-spread-in-long-term-care-facilities.html

� The facility has a plan for expediting the credentialing and training of non-facility HCP brought in from other locations to provide resident care when the facility reaches a staffing crisis.

� Informational materials (e.g., brochures, posters) on COVID-19 and relevant policies (e.g., suspension of visitation, where to obtain facility or family member information) have been developed or identified for residents and their families. These materials are language and reading-level appropriate, and a plan is in place to disseminate these materials in advance of the actual pandemic.

Surge Capacity:Staffing

� A contingency staffing plan has been developed that identifies the minimum staffing needs and prioritizes critical and non-essential services based on residents’ health status, functional limitations, disabilities, and essential facility operations.

� A person has been assigned responsibility for conducting a daily assessment of staffing status and needs during a COVID-19 outbreak.

Insert name, title, and contact information:

� Legal counsel and state health department contacts have been consulted to determine the applicability of declaring a facility “staffing crisis” and appropriate emergency staffing alternatives, consistent with state law.

� The staffing plan includes strategies for collaborating with local and regional planning and response groups to address widespread healthcare staffing shortages during a crisis.


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https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/prevent-spread-in-long-term-care-fac

https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/prevent-spread-in-long-term-care-fac

Completed In Progress Not Startedcont.

Consumables and durable medical equipment and supplies � Estimates have been made of the quantities of essential resident care materials and equipment (e.g., intravenous pumps and ventilators, pharmaceuticals) and personal protective equipment (e.g., masks, respirators, gowns, gloves, and hand hygiene products), that would be needed during an eight-week outbreak.

� Estimates have been shared with local, regional, and tribal planning groups to better plan stockpiling agreements.

� A plan has been developed to address likely supply shortages (e.g., personal protective equipment), including strategies for using normal and alternative channels for procuring needed resources.

� A strategy has been developed for how priorities would be made in the event there is a need to allocate limited resident care equipment, pharmaceuticals, and other resources.

� A process is in place to track and report available quantities of consumable medical supplies including PPE.

Postmortem care: � A contingency plan has been developed for managing an increased need for postmortem care and disposition of deceased residents.

� An area in the facility that could be used as a temporary morgue has been identified.

� Local plans for expanding morgue capacity have been discussed with local and regional planning contacts.

www.cdc.gov/COVID198

Documents

COVID-19 DOCUMENTATION GUIDEBOOK Introduction COVID-19 Documentation...The facility’s COVID-19 Team assigns specific team member(s) to be responsible for: o Obtaining and reviewing