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

AFL 22-21
October 5, 2022

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

Enhanced Standard Precautions for Skilled Nursing Facilities, 2022
(This AFL Supersedes AFL 19-22)

​All Facilities Letter Summary

This AFL supersedes AFL 19-22, and releases updated guidance on Enhanced Standard Precautions for Skilled Nursing Facilities.

​This AFL distributes the updated “Enhanced Standard Precautions for Skilled Nursing Facilities, 2022" (PDF). The document includes updated guidance to SNFs for safely caring for residents with medical devices and unhealed wounds who are at increased risk for transmission of multidrug-resistant organisms (MDRO) in compliance with state and federal regulations. This guidance is intended to be 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.

The California Department of Public Health (CDPH) updated Enhanced Standard Precautions (ESP) guidance in 2022 to simplify and facilitate implementation, and reflect substantial changes in the epidemiology of MDRO in California SNFs since its previous publication in 2019. Increased MDRO prevalence and large, sustained, regional outbreaks of previously novel or rare MDRO, including Candida auris, highlight the role of ESP as a prevention strategy before transmission and outbreaks occur, as well as a need for new guidance for transitioning from Contact Precautions to ESP as part of long-term outbreak mitigation and management. 

Enhanced Standard Precautions for Skilled Nursing Facilities, 2022” (PDF) provides a practical, resident-centered and activity-based approach to implement measures to prevent MDRO transmission that are less restrictive than Contact Precautions. Recommendations for the use of gowns and gloves by health care providers are 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. 

Please submit any questions or comments about the guidance to the CDPH Healthcare-Associated Infections Program via email at


Original signed by Cassie Dunham

Cassie Dunham
Deputy Director


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