Strategy for Skilled Nursing Facilities: Targeted COVID-19 Testing and Cohorting Plan

The California Department of Public Health's Center for Health Care Quality (CHCQ) requires all skilled nursing facilities (SNFs) to develop a plan, in conjunction with CHCQ and their local health department, for regular testing of SNF residents and health care workers (HCWs) to limit exposure and prevent the spread of COVID-19 within SNFs. The plan includes strategies for baseline, screening, and response-driven testing and how test results will be used to inform resident and HCW cohorting. A testing and cohorting plan is one of six elements included in the required SNF COVID-19 Mitigation Plans, as listed in All Facilities Letter 20-52. All Facilities Letter 20-53.3 expands upon the testing elements of those plans.

Baseline testing of all residents and HCWs was conducted in SNFs that did not currently have a positive case. This testing provided a point-in-time snapshot to detect cases in SNFs quickly, stop transmission, and implement effective infection prevention and control actions. All SNFs completed baseline testing by June 30, 2020, as listed in All Facilities Letter 20-55 and the final data is provided in the “Skilled Nursing Facilities – Baseline Testing, September 1, 2020 (.xlsx)” file posted below.

Screening testing of all HCWs is conducted at a minimum of weekly in SNFs that do not currently have any positive resident or HCW cases. SNFs in counties with a positivity rate greater than 10% (>10%) are required to test twice weekly per the Centers for Medicare and Medicaid Services. SNFs should consider implementing weekly screening testing and cohorting for residents that regularly leave for dialysis or other services, as well as screening testing for newly admitted and readmitted residents following hospitalization or an Emergency Department visit. In addition, all CHCQ Surveyors completed baseline testing and also complete weekly screening testing to further prevent the spread of infection in SNFs and protect vulnerable populations.

Response-driven testing is conducted in SNFs as soon as possible after one or more positive resident or HCW cases are identified. SNFs should conduct serial retesting every seven days for all residents and HCWs who test negative upon the prior round of testing until no new cases are identified among residents in two sequential rounds of testing. SNFs may resume regular screening testing for HCWs after two sequential rounds of negative response testing among residents is achieved.

Testing instruments used for COVID-19 testing in SNFs should be an authorized nucleic acid or antigen detection assay as recommended by the Centers for Disease Control and Prevention, with results obtained rapidly (e.g., within 48 hours). SNFs may use the Point-of-Care (POC) rapid response antigen tests distributed by the Department of Health and Human Services for testing residents and HCWs. Authorized POC antigen tests provide results in approximately 15 minutes to quickly identify and isolate contagious individuals.

Cohorting in SNFs consists of housing residents in separate color-coded designated areas within the facility based on test results. The “red” area houses residents with positive test results for the duration of the resident’s isolation period. The “yellow-exposed” area houses residents with negative test results who were exposed within the last 14 days. The “yellow observation” area houses newly admitted or readmitted residents for 14 days from the date of last potential exposure and then retested. The “green” area houses residents with negative test results without known exposure within the last 14 days and recovered residents who have completed their isolation period.

“Red” area cohorted residents who test positive should be housed in a separate area (building, unit, or wing) within the facility. SNFs must ensure that HCWs providing care for COVID-positive residents are not also providing care for residents in other cohorts in order to minimize transmission risk and protect vulnerable populations.

The SNF Testing Survey Dashboard below provides COVID-19 testing data reported by SNFs weekly for both resident and HCWs beginning the week of July 19, 2020.

All data in the dashboard is provided to offer a snapshot of COVID-19 screening and response-driven testing in SNFs in California and does not imply wrongdoing on the part of the facilities.

Skilled Nursing Facilities -- Baseline Testing, September 1, 2020 (.xslx)