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

AFL 19-22
June 10, 2019

Skilled Nursing Facilities (SNF), and General Acute Care Hospitals (GACH) with a SNF Distinct Part (DP)

Enhanced Standard Precautions for Skilled Nursing Facilities, 2019

​All Facilities Letter (AFL) Summary

This AFL supersedes AFL 10-27, and releases updated guidance on Enhanced Standard Precautions for Skilled Nursing Facilities.

NOTE: This AFL has been superseded - Please see AFL 22-21

This AFL supersedes AFL 10-27 and distributes the updated "Enhanced Standard Precautions for Skilled Nursing Facilities, 2019." The updated document includes guidance for SNFs for safely caring for residents with multidrug-resistant organisms (MDRO) in compliance with state and federal regulations. This guidance is intended to be an advisory only and has been developed to assist SNF infection control programs.

Title 22 CCR section 72515 requires SNFs, "accept and retain only those patients for whom they can provide adequate care." Title 42 CFR section 483.80 requires that nursing facilities "must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections." All SNFs in compliance with state statute and federal regulations must be able to provide care for residents with MDROs.

CDPH developed the updated version of "Enhanced Standard Precautions for Skilled Nursing Facilities, 2019" in response to reports of refusals to admit or re-admit residents with MDRO. This updated document incorporates an increased understanding of MDRO in California SNFs, where a high proportion of residents are colonized with MDRO.

The risk of MDRO colonization and transmission is associated with readily identifiable resident characteristics. Transmission can be reduced by infection control measures that are less restrictive than contact precautions and do not require performing active surveillance testing to identify MDRO colonization status, that changes over time. The "Enhanced Standard Precautions for Skilled Nursing Facilities, 2019" provides a practical, resident-centered and activity-based approach to implement measures to prevent MDRO transmission in SNFs. Recommendations for the use of gowns and gloves by health care providers should be based on assessments of a resident's risk for being colonized and likelihood of transmitting MDRO, whether or not the resident is known to be MDRO colonized or infected.

To facilitate implementation of "Enhanced Standard Precautions for SNF, 2019" and assist SNFs in developing their individual policies and procedures, CDPH will provide additional web-based materials, which will be located on the Preventing HAI in California Skilled Nursing Facilities website.  Additional materials will include an infographic illustrating the Moments for Enhanced Standard Precautions that may be used as signage or as teaching tools and a Frequently Asked Questions document that includes scenarios for roommate selection for residents with high risk of MDRO transmission.

Please submit any questions or comments about the guidance to



Original signed by  Heidi W. Steinecker 

Heidi W. Steinecker

Deputy Director

Attachment: Enhancing Standard Precautions for Skilled Nursing Facilities (SNF), 2019 

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