Updated Testing Guidance

In accordance with the Public Health Officer Order – Health Care Work Vaccine Requirement amended September 13, 2022, CDPH is rescinding the requirement for routine diagnostic screening testing for unvaccinated exempt HCP and booster-eligible HCP who have not yet received their booster; however, routine SARS-CoV-2 diagnostic screening testing of SNF HCP may be recommended again during times of high community transmission or surge with a SARS-CoV-2 variant that is capable of evading immunity or causes more severe disease. In addition, post-exposure response testing is still recommended for SNF residents and HCP identified as close contacts during an outbreak. The purpose of this AFL revision is to provide updated testing recommendations for SNF residents and HCP.

SNFs must continue to comply with current federal requirements that may require more stringent testing of staff, including QSO-20-38-NH REVISED (PDF) "Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements" or similar requirements that may be imposed in the future.

Routine Diagnostic Screening Testing of HCP

CDPH no longer requires twice weekly routine diagnostic screening testing for COVID-19 for unvaccinated exempt HCP and booster-eligible HCP who have not yet received their booster in long-term care settings. SNFs must understand that:

• Testing should continue to be performed for HCP with signs or symptoms consistent with COVID-19, regardless of their vaccination status.
• Testing should continue to be performed for HCP with higher-risk exposures to SARS-CoV-2 (i.e., as part of post-exposure or response testing).
  

Testing and Quarantine for Newly Admitted and Readmitted Residents

CDPH has updated testing and quarantine guidance for newly admitted and readmitted residents:

• Newly admitted residents and residents who have left the facility for >24 hours, regardless of vaccination status, should have a series of three viral tests for SARS-COV-2 infection; immediately upon admission and, if negative, again at 3 days and 5 days after their admission.
• Quarantine is not required for newly admitted and readmitted residents, regardless of vaccination status.
• Testing and quarantine are not required for hospitalized residents who tested positive for COVID-19 and met criteria for discontinuation of isolation and precautions prior to SNF admission or readmission and are within 30 days of their infection.
  

Diagnostic Testing for Symptomatic Individuals

Residents or HCP with signs or symptoms potentially consistent with COVID-19 should be tested immediately to identify current infection, regardless of their vaccination status. If antigen testing is used and the first test is negative, the symptomatic HCP should be tested again 48 hours after the first negative test, for a total of at least two tests.

Post-Exposure and Response Testing

CDPH continues to recommend immediate investigation as a potential outbreak when one (or more) COVID-19 positive individuals (resident or HCP) is identified in a facility. SNFs should perform contact tracing within the facility to identify any HCP who have had a higher-risk exposure or residents who may have had high-risk close contact with the individual with SARS-CoV-2 infection:

• All HCP who have had a higher-risk exposure and residents who have had close contacts, regardless of vaccination status, should be tested promptly (but not earlier than 24 hours after the exposure) and, if negative, again at 3 days and at 5 days after the exposure.
• Residents who are close contacts, regardless of vaccination status, should wear source control when outside their room but do not need to be quarantined, restricted to their room, or cared for by HCP using the full personal protective equipment (PPE) recommended for the care of a resident with COVID-19.
• Refer to AFL 21-08.8 for guidance about work restriction for HCP who have higher-risk exposures.
• Post-exposure testing is not generally recommended for HCP or residents who have had SARS-CoV-2 infection in the last 30 days if they remain asymptomatic.
  

If testing of close contacts reveals additional HCP or residents with SARS-CoV-2 infection, contact tracing should be continued to identify residents with close contact or HCP with higher-risk exposures to the newly identified individual(s) with SARS-CoV-2 infection. A facility-wide or group-level (e.g., unit, floor, or other specific area(s) of the facility) approach with quarantine for exposed groups should be considered if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Serial retesting of all residents and HCP who test negative upon the prior round of testing (regardless of their vaccination status) should be performed every 3-7 days until no new cases are identified among residents in sequential rounds of testing over 14 days.

SNFs should continue to ensure residents identified with confirmed COVID-19 are promptly isolated in a designated COVID-19 isolation area. The COVID-19 isolation area may be a designated floor, unit, or wing, or a group of rooms at the end of a unit that is physically separate and ideally includes ventilation measures to prevent transmission to other residents outside the isolation area. SNFs that do not have any residents with COVID-19 and do not have a current need for an isolation area should remain prepared to quickly reestablish the area and provide care for and accept admission of residents with COVID-19.

Symptomatic residents and residents identified as close contacts through individual contact tracing should generally remain in their current room while undergoing testing as described above. Facilities should avoid movement of residents that could lead to new exposures, for example, moving a resident into a room where one of the new roommates is subsequently found to have infection. Other residents on the same unit or wing who were not identified as close contacts through contact tracing are not considered exposed unless the facility is instructed by their local health department (LHD) to take a unit or facility-wide approach to determine exposures.

Refer to AFL 21-08.8 for guidance about work restriction for HCP with exposures and for HCP who test positive.

Procedures for the Duration of Isolation of Residents Who Test Positive:

Residents Who Test Positive for COVID-19

• Residents who test positive and are symptomatic with mild to moderate illness should be isolated (regardless of their vaccination status) until the following conditions are met:
• At least 10 days have passed since symptom onset; AND
• At least 24 hours have passed since resolution of fever without the use of fever-reducing medications; AND
• Any other symptoms have improved
• NOTE: The duration of isolation could be extended to up to 20 days for individuals who had critical illness (e.g., required intensive care) and beyond 20 days for individuals who are moderately to severely immunocompromised (e.g., currently receiving chemotherapy, or recent organ transplant); use of a test-based strategy and (if available) consultation with an infectious disease specialist is recommended to determine when Transmission-based precautions could be discontinued for these individuals.
• Residents who test positive and are asymptomatic throughout their infection should be isolated for 10 days following the date of their positive test.
  

Reporting Test Results

Facilities conducting tests under a Clinical Laboratory Improvement Amendments of 1988 (CLIA) certificate of waiver are subject to regulations that require laboratories to report data for SARS-CoV-2 POSITIVE diagnostic results only. CDPH has updated the requirements for reporting non-positive COVID-19 antigen results (PDF).

During focused infection control surveys, surveyors will be monitoring whether the facility is complying with the CLIA laboratory reporting requirements and reporting any concerns to the CMS Division of Clinical Laboratory Improvement and Quality. In addition to reporting in accordance with CLIA requirements, facilities must continue to report COVID-19 information to the CDC's National Healthcare Safety Network, in accordance with 42 CFR § 483.80(g)(1)–(2). SNFs must demonstrate their compliance with testing requirements by documenting the following information: 

• For symptomatic residents and staff, document the date(s) and time(s) of the identification of signs or symptoms, when testing was conducted, when results were obtained, and the actions the facility took based on the results.
• Upon identification of a new COVID-19 case in the facility (i.e., outbreak), document the date the case was identified, the date that all other residents and staff are tested, the dates that staff and residents who tested negative are retested, and the results of all tests.
• Document the facility's procedures for addressing residents and staff that refuse testing or are unable to be tested, and document any staff or residents who refused or were unable to be tested and how the facility addressed those cases.
• When necessary, such as in emergencies due to testing supply shortages, document that the facility contacted state and local health departments to assist in testing efforts, such as obtaining testing supplies or processing test results.
• When a 48-hour turnaround time for testing cannot be met due to testing supply shortages, the facility should document its efforts to obtain quick turnaround test results with the identified laboratory or laboratories and contact to the local and state health department.
  

Although CDPH is no longer conducting separate mitigation surveys, SNFs should continue use of the strategies developed as part of their SNF Mitigation plans and integrate them into their infection control and emergency preparedness plans. As testing and mitigation strategies change based on updated CDC or CMS guidance, updated plans and policies and procedures will need to be revised.

SNFs must understand that testing does not replace or preclude other infection prevention and control interventions, including monitoring all HCP and residents for signs and symptoms of COVID-19, masking by HCP and residents for source control, use of recommended PPE, and environmental cleaning and disinfection. When testing is performed, a negative test only indicates an individual did not have detectable infection at the time of testing; individuals might have SARS-CoV-2 infection that is still in the incubation period or could have ongoing or future exposures that lead to infection.  

SNFs may submit any questions about infection prevention and control of COVID-19 or this AFL to the CDPH Healthcare-Associated Infections Program via email at CovHAI@cdph.ca.gov.

If you have any questions about state testing prioritization plans, please contact the Testing Taskforce at testing.taskforce@state.ca.gov.

Sincerely,

Original signed by Cassie Dunham

Cassie Dunham

Deputy Director

Resources:

• CDPH Updated Testing Guidance 
• CalREDIE Manual Lab Reporting Module (PDF)
• CMS QSO 20-38 (PDF)
• CDC Duration of Isolation and Precautions for Adults with COVID-19
• CDC Criteria for Return to Work for Healthcare Personnel with SARS-CoV-2 Infection (Interim Guidance)
• AFL 20-52 COVID-19 Mitigation Plan Implementation and Submission Requirements for SNFs and Infection Control Guidance for HCP
• Lab Resources for Testing
• Department of Managed Health Care COVID-19 webpage
• CDC Nursing Homes Testing Recommendations
• CDC Long-Term Care Facility Wide Testing
  
• Nursing Home Preparing for COVID-19
• CDC Guidance on Mitigating Staffing Shortages
  
• CDPH Guidance on the Use of Antigen Tests for Diagnosis of Acute COVID-19
• Public Health Order - Health Care Worker Protections in High-Risk Settings
• Public Health Order - Health Care Worker Vaccine Requirement

[1] People are considered to have completed their primary series for COVID-19: after they have received the second dose in a 2-dose series (Pfizer-BioNTech or Moderna or vaccine authorized by the World Health Organization), or after they have received a single-dose vaccine (Johnson and Johnson [J&J]/Janssen).

[2] CDC Defines quarantine as separate and restrict the movement of people who were exposed to a contagious disease to see if they become sick. CDC Quarantine and Isolation

[3] According to CDC, screening testing is performed to identify persons who may be contagious so that measures can be taken to prevent further transmission, for example in a congregate living setting such as a skilled nursing facility. This was referred to as surveillance testing in prior versions of this AFL. The terminology change aligns with new CDC testing guidance.