Purpose

As part of the COVID-19 mitigation plans described in AFL 20-52 required for all skilled nursing facilities (SNFs), individual facilities are responsible for fulfilling the testing recommendations outlined in AFL 20-53, in addition to other infection control strategies described in the mitigation plan template. The purpose of this toolkit is to provide local SNFs with technical guidance and best practice recommendations to fulfill the State recommendations related to establishing a plan for baseline, surveillance, and response-driven COVID-19 testing of SNF residents and staff.

Roles & Responsibilities

Given these directives from the State, the County of Santa Cruz Public Health Division (Public Health) acknowledges the immense challenge SNFs staff face to meet the requirements. Public Health continues to be committed to finding solutions with SNFs to help meet obligations as directed by State licensing authorities.

Managing outbreaks is a partnership between County Public Health and SNFs.

County Public Health can support SNFs by:

  • Providing SNFs with consultation and recommendations regarding successful workflows and operational approaches for COVID-19 testing at local facilities.
  • Providing technical assistance and training to support SNF with surveillance testing and ongoing preparedness (such as train-the-trainer opportunities, testing toolkit, etc.), continue to conduct case investigations (including containment measures) and contact tracing for individuals who test positive for COVID-19.
  • Facilitating ongoing communications between SNF administrators and medical directors across facilities.
  • Providing Medical Health Operational Area Coordinator (MHOAC) resource requests for PPE and specimen collection materials when supply chain and commercial vendor options are exhausted:

Facilities are responsible for:

  • Staffing for your facility
  • Onsite testing or laboratory services
  • Transportation
  • N95 Fit testing

Specific to COVID-19 testing, California Department of Public Health (CDPH) expects SNFs to:

  • Know how to cover costs for COVID-19 tests (see Financing section below).
  • Include testing strategies informed by the Centers for Disease Control & Prevention (CDC) recommendations in their facility-specific mitigation plan..
  • Develop testing plans in conjunction with Public Health and the California Department of Public Health (CDPH) and report results of COVID-19 baseline testing to CDPH, per AFL 20-55.
  • Implement testing plans that include baseline and surveillance testing of residents and healthcare personnel, admission and readmission testing, and testing of symptomatic or exposed residents (see attached flowcharts).
  • Develop testing plans that include procedures for use and follow-up of test results for both residents and staff.
  • Develop testing plans that include procedures for PPE usage, sample collection, as well as arrangements for laboratory processing of samples (including courier services).
  • Complete and submit daily SNF survey to CDPH.
  • Provide situation status SitStat reports to Health Services Administration Department Operations Center (HSA DOC) and/or MHOAC as requested.

In addition to implementing testing strategies per AFL 20-53, facilities should also follow general preparedness guidance provided in AFL 20-25.2. Given the above responsibilities and expectations, County Public Health staff hopes this testing toolkit provides helpful technical assistance to establish testing plans at local SNFs.

Recommendations & Best Practices

  • General Resources
  • Infrastructure & Administration
    • AFL 20-53 Testing & Response Protocols
      • AFL 20-53 Baseline, Surveillance, Response-Driven Algorithm (attached)
      • CDPH’s All-Facilities Letter 20-53 Flowchart: Baseline, Surveillance, and Response-Driven COVID-19 Testing of SNF Residents and Health Care Personnel (HCP)
      • Potential scenarios and expectations:
        • Symptomatic SNF resident:
          • Implement infection control protocols, including isolation and PPE.
          • Test individual immediately, according to facility protocol.
          • Report to the Communicable Disease Unit (CD Unit) 831-454-4114. Do not wait for results to report the suspect case.
        • Positive resident:
          • Implement infection control measures, including isolation and PPE.
          • Ensure confirmed case has been reported to CD Unit.
          • Create a line list of case’s close contacts and submit to CD Unit.
          • Implement your facility mitigation plan with corresponding cohorting.
          • Follow AFL 20-53 Response-Driven Testing algorithm and guidance.
        • Positive healthcare personnel (HCP):
          • Exclude HCP from work, as per facility protocol.
          • Implement other infection control measures as per facility mitigation plan
          • Report to CD Unit.
          • Create a line list of case’s close contacts and submit to CD Unit.
          • Follow AFL 20-53 Response-Driven Testing algorithm and guidance.
    • Staffing
      • The facility’s Medical Director will serve as the ordering physician for COVID-19 testing for SNF residents.
      • An Administrator should be identified as the point person for managing test results with their contact information provided to CD Unit. Ideally, it should be an individual with clerical skills in information management. This Administrator can also be tasked with monitoring facility’s testing performance and required reporting. It is also recommended that this point of contact participate or designate a representative to attend the County of Santa Cruz Healthcare Coalition (HCC) Monday 2pm meetings, enroll in the California Health Alert Network (CAHAN), and attend CPDH SNF Infection, Prevention, and Control conference calls (Thursdays 12pm).
      • The following key team members are recommended for successful mass testing operations. Facilities should scale teams based on testing volume.
        • Clinical Lead/Swabber – ideally a physician, PA, NP, RN, LVN, respiratory therapist, or MA (with swabbing experience)
        • Back-up/Runner – ideally a CNA or any of the above professionals
        • Clerical assistant to prepare necessary forms, labels
    • Physical Environment
      • If possible, facilities should consider conducting resident testing within each resident’s room for maximum infection control. Allowing each resident to remain in their rooms provides privacy and comfort while reducing unnecessary congregation of individuals queuing at a centralized testing station. If facilities opt for the in-room testing workflow, staff should practice careful infection control when entering and exiting each room. To facilitate a safe workflow, use a COVID-19 test cart and/or assign a CNA “buddy” with each tester.
      • While in-room testing paired with careful workflow practices will provide the highest level of infection control, facilities may opt to set up a centralized testing room to improve efficiency and minimize PPE use.
      • In the event of a positive case, in-room testing is the preferred approach.
      • Refer to the CDC for additional recommendations on COVID-19 testing location.
    • Communications
      • Facilities should carefully consider how positive results of residents or staff will be communicated to other residents, staff, and residents’ family members or responsible parties. It would be beneficial to generate a communication script and FAQ in advance of a positive case.
      • Federal regulations require informing patients, staff, and families of the number of cases in the facility. Facilities must have plans for meeting these regulations. (CDC)
      • Communication with County Public Health:
        • For case and cluster reporting, use the COVID-19 Confidential Morbidity Report (CMR) and contact the Communicable Disease Unit at (831) 454-4114 (phone), (831) 454-5049 (fax), or hsacd@santacruzcounty.us (no Private Health Information (PHI) by email).
        • For support with testing capacity, contact the Public Health call center at (831) 454-4242 and request Testing team to return your call.
    • Information Management
      • According to CDPH AFL 20-55, SNFs will be required to report the aggregate testing data to the State via email.
      • In addition to this required reporting, it would be advantageous for facilities to develop an Excel spreadsheet or other mechanism to track serial test results on residents and staff. Such tracking will be especially helpful for information management and infection control during response-driven testing (when a positive test result prompts weekly testing until no new cases are identified in two sequential rounds of testing).
      • When employers become aware of cases, the OSHA Recordkeeping and Reporting Occupational Injuries and Illness standard (29 CFR 1904), requires certain employers to keep a record of serious work-related injuries and illnesses including work-related COVID-19. (CDC)
      • Public Health Reporting Requirements:
        • According to Title 17 California Code of Regulations, healthcare providers are required to report suspected or confirmed cases of any reportable conditions, including COVID-19, to the local health officer of the jurisdiction where the patient resides.
        • For COVID-19 suspected or confirmed cases, SNF medical directors must immediately submit a COVID-19 Confidential Morbidity Report (CMR) to the CD Unit. As SNF residents are a vulnerable population for severe COVID-19 illness, it is essential that suspect cases with even mild symptoms be isolated, reported to the CD Unit, and tested immediately. SNFs should not wait for test results to report symptomatic patients to CD Unit.
    • Financing
      • For coverage of COVID-19 testing for SNF residents, refer to the Department of Managed Health Care COVID-19 Testing FAQ (PDF)
        • Health plans must cover COVID-19 lab tests without prior authorization and at no cost to the enrollee. This includes serial/sequential tests, such as in SNFs. This includes all health plans, including commercial, Medi-Cal, traditional Medicare, and Medicare Advantage.
      • For COVID-19 testing for SNF healthcare personnel, SNFs can provide their staff with testing, or refer staff to their usual healthcare providers or to the local State-run OptumServe testing site located at Ramsey Park in Watsonville.
    • Patient Privacy and Testing Acceptance
      • Testing should be carried out in a way that protects confidentiality to the extent possible and is consistent with applicable laws and regulations. (CDC)
      • Obtaining Consent:
        • Facilities should ensure their resident admission forms include consent to required lab testing for disease control purposes.
        • Facilities should work with their human resources department to ensure staff are able obtain their routine testing whether it be through their regular healthcare provider, OptumServe, or an occupational health service provider.
      • Handling Refusals
        • Facilities should have a plan in place for handling residents or staff who decline or are unable to be tested. This plan is especially critical in scenarios with a positive case or a person
  • Laboratory Processing
    • Testing Access
      • Polymerase Chain Reaction (PCR) testing for COVID-19 infection is becoming more readily available at hospitals, academic, commercial, and public health laboratories across California. Facilities should refer to AFL 20-44.1 for guidance on expanded access to testing when prioritizing COVID-19 testing for SNF staff and residents. If necessary, County Public Health can assist facilities with acquiring access to testing. Facilities should direct testing inquiries to the HSA DOC Preparedness Branch (contact: Kathleen Conley, kathleen.conley@santacruzcounty.us, 831-400-2348).
      • California Testing Task Force – COVID-19 Testing Taskforce Lab List
      • Facilities should monitor advances and new testing opportunities as they become available.
    • Specimen Collection Supplies
      • Facilities should acquire adequate supplies, but can submit a Medical Health Operational Area Coordinator (MHOAC) resource request when inventory of specimen collection materials is low:
    • Ensure lab requisition forms include date of testing, facility name, and role of the individual tested (i.e., resident, HCP) and any other information required by the individual lab.
    • Consider turnaround times when deciding which lab to contract with.
  • Specimen Collection
    • Swabbing Location: Ideally, specimen collection should be performed one at a time in each resident’s room with the door closed. An airborne infection isolation room is not required. Ideally for rooms with multiple residents, specimen collection should be performed one individual at a time in a room with the door closed and no other individuals present. (CDC)
      • While in-room testing provides the best infection control, facilities may consider conducting testing using a centralized testing room to increase efficiency and minimize PPE use.
    • Facilities should obtain the appropriate specimen based on their lab’s specific requirements. Specificity and sensitivity may vary for each type of specimen across different labs.
    • Ensure that a signed SMO is in place and that staff is following their facility guidance for baseline infection control.
    • Nasopharyngeal (NP) swab is an acceptable specimen for PCR testing. Oropharyngeal (OP) swabs are also acceptable but may not have as high a yield; however, OP swabs should be accompanied by a nasal cavity specimen.
      • Generally, anterior nares and mid-turbinate swabs are also appropriate specimens to collect for PCR testing. Both collection methods are less invasive for the test recipient and reduce the risk of exposure for the test collector. Facilities should consult their labs to confirm specimen collection options.
    • Swabbing Resources:
  • Personal Protective Equipment & Other Equipment
    • All staff performing swabbing or swabbing support within 6 feet of the swabbing area should be trained and proficient in the appropriate use of PPE for COVID-19.
    • PPE Supply Chain:
    • PPE & Other Equipment Resources:
      • PPE List:
        • Face shield or googles
        • N95 or higher respirators
        • Disposable facemasks
        • Disposable isolation gowns
        • Non-sterile gloves
        • Shoe covers
        • Bouffant caps
      • Other Necessary Equipment:
        • Sanitizing wipes (Clorox)
        • Sanitizing wipes (Oxivir-EPA registered)
        • Hand sanitizer
        • Paper towels
        • Tissues
        • Biohazard garbage bags
        • Trash cans
        • Spray bottle (bleach)
      • Hand washing station with hand soap
      • Brown paper bags (small)
      • Brown paper bags (medium)
    • PPE Resources:
  • Infection Control