Asymptomatic and Presymptomatic SARS-CoV-2 Infections in Residents of a Long-Term Care Skilled Nursing Facility — King County, Washington, March 2020

Early Release / March 27, 2020 / 69

Summary

What is already known about this topic?

Once SARS-CoV-2 is introduced in a long-term care skilled nursing facility (SNF), rapid transmission can occur.

What is added by this report?

Following identification of a case of coronavirus disease 2019 (COVID-19) in a health care worker, 76 of 82 residents of an SNF were tested for SARS-CoV-2; 23 (30.3%) had positive test results, approximately half of whom were asymptomatic or presymptomatic on the day of testing.

What are the implications for public health practice?

Symptom-based screening of SNF residents might fail to identify all SARS-CoV-2 infections. Asymptomatic and presymptomatic SNF residents might contribute to SARS-CoV-2 transmission. Once a facility has confirmed a COVID-19 case, all residents should be cared for using CDC-recommended personal protective equipment (PPE), with considerations for extended use or reuse of PPE as needed.

Training Offering Overview

Training Name: COVID-19 LTC-Surveyor Training (COVID19LTC)

Activity Code: 0CMSCOVID19_LTC

Training Description: A brief training related to a focused COVID-19 survey for Nursing Homes surveyors. This is not mandatory, but is recommended for LTC surveyors.

Memorandum Summary

• On Friday, March 13, 2020, the President declared a national emergency, which triggers the Secretary’s ability to authorize waivers or modifications of certain requirements pursuant to section 1135 of the Social Security Act (the Act). Under section 1135(b)(5) of the Act, CMS is prioritizing surveys by authorizing modification of timetables and deadlines for the performance of certain required activities, delaying revisit surveys, and generally exercising enforcement discretion for three weeks.
• During this three-week time frame, only the following types of surveys will be prioritized and conducted:

• Complaint/facility-reported incident surveys: State survey agencies (SSAs) will conduct surveys related to complaints and facility-reported incidents (FRIs) that are triaged at the Immediate Jeopardy (IJ) level. A streamlined Infection Control review tool will also be utilized during these surveys, regardless of the Immediate Jeopardy allegation.
• Targeted Infection Control Surveys: Federal CMS and State surveyors will conduct targeted Infection Control surveys of providers identified through collaboration with the Centers for Disease Control and Prevention (CDC) and the HHS Assistant Secretary for Preparedness and Response (ASPR). They will use a streamlined review checklist to minimize the impact on provider activities, while ensuring providers are implementing actions to protect the health and safety of individuals to respond to the COVID-19 pandemic.
• Self-assessments: The Infection Control checklist referenced above will also be shared with all providers and suppliers to allow for voluntary self-assessment of their Infection Control plan and protections

• During the prioritization period, the following surveys will not be authorized: Standard surveys for long term care facilities (nursing homes), hospitals, home health agencies (HHAs), intermediate care facilities for individuals with intellectual disabilities (ICF/IIDs), and hospices. This includes the life safety code and Emergency Preparedness elements of those standard surveys; and revisits that are not associated with IJ.
• Furthermore, for Clinical Laboratory Improvement Amendments (CLIA), we intend to prioritize immediate jeopardy situations over recertification surveys, and generally intend to use enforcement discretion, unless immediate jeopardy situations arise.
• Finally, initial certification surveys will continue to be authorized in accordance within current guidance and prioritization.

 Additional Instructions for Nursing Homes

We are disseminating the Infection Control survey developed by CMS and CDC so facilities can educate themselves on the latest practices and expectations. We expect facilities to use this new process, in conjunction with the latest guidance from CDC, to perform a voluntary self-assessment of their ability to prevent the transmission of COVID-19. This document may be requested by surveyors, if an onsite investigation takes place. We also encourage nursing homes to voluntarily share the results of this assessment with their state or local health department Healthcare-Associated Infections (HAI) Program. Contact information for each state’s health departments is identified on the Centers for Disease Control & Prevention’s (CDC’s) website at:https://www.cdc.gov/HAI/state-based/index.html.

Furthermore, we remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility, and when and to whom possible incidents of communicable disease or infections should be reported (42 CFR 483.80(a)(2)(i) and (ii)). CDC recommends that nursing homes notify their health department about residents with severe respiratory infection, or a cluster of respiratory illness (e.g., > or = 3 residents or HCP with new-onset respiratory symptoms within 72 hours). Local and state reporting guidelines or requirements may vary. Monitor the CDC website for information and resources to help prevent the introduction and spread of COVID-19 in nursing homes (CDC Preparing for COVID-19: Long-term Care Facilities, Nursing Homes:https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/prevent-spread-in-long-term-care-facilities.html ).

We urge providers to review the tools and implement actions to protect the health and safety of individuals to respond to the COVID-19 pandemic.

Based on currently available information and clinical expertise, older adults and people of any age who have serious underlying medical conditions might be at higher risk for severe illness from COVID-19.

Based upon available information to date, those at high-risk for severe illness from COVID-19 include:

During this COCA call, presenters will focus on current information about people who are higher risk for COVID-19 complications because of their age or underlying medical conditions, particularly those that are not well-controlled. 

Due to the high demand we anticipate for this COCA Call, we encourage participants to consider viewing on Facebook. To see the call live, please click on COCA's Facebook Page. 

There will only be a few slides for this COCA Call. Slides will not advance during the presentation portion of this webinar. You can find the slides under the "Call Materials" tab here.

Advanced registration is not required.

When: Wednesday, March 25, 2020, 2 p.m. to 3 p.m. (Eastern Time)

During this COCA Call, presenters will provide a COVID-19 update and discuss strategies for healthcare facilities to optimize personal protective equipment (PPE) supplies such as eye protection, isolation gowns, facemasks, and N95 respirators.

Understanding how to put on (don) and remove (doff) personal protective equipment (PPE) will be critical in mitigating risk for COVID-19.

The CDC offers basic instructions.

Nebraska Medicine and the University of Nebraska Medical Center, which have been providing care for COVID-19 quarantined cruise ship passengers, offer additional guidance:

 Personal protective equipment (PPE):

PPE for the Care of Patients Infected or Suspected with COVID-19 [VIDEO] (updated 03/12/2020)

PPE for COVID-19 infographic (updated 03/06/2020)

Donning: Step-by-step process (updated 03/06/2020)

Doffing: Step-by-step process (updated 03/12/2020)

Coronavirus Disease 2019 (COVID-19) Update and Information for Long-term Care Facilities

During this COCA Call, presenters will focus on current information about COVID-19 as it relates to long-term care facilities, including nursing homes. Topics will include infection prevention and control guidance, steps facilities should take to prepare, and available resources.

Special Request: Due to the high demand we anticipate for this COCA Call, we kindly ask participants to access it in a group format, if possible, to allow for the maximum number of people to participate.

Watch on Facebook: You may also participate in this COCA Call by joining COCA's Facebook Live.  

Advanced registration is not required.

Continuing Education will not be offered for this COCA Call. 

There will only be a few slides for this COCA Call. Slides will not advance during the presentation portion of this webinar. You can find the slides under the "Call Materials" tab here.   

Date: Tuesday, March 17, 2020

Time: 2:00pm–3:00pm (ET)

Please click the link below to join:
https://zoom.us/j/148725646

Or iPhone one-tap:
US: +16468769923,,148725646# or +16699006833,,148725646#   

Or Telephone:
US: +1 646 876 9923 or +1 669 900 6833 

Webinar ID: 148 725 646

International numbers available: https://zoom.us/u/anixAVglV

If you are unable to attend this live COCA Call, it will be available to view on-demand a few hours after the call. 

On Mar 13, 2020, the Centers for Medicare & Medicaid Services (CMS) announced critical new measures designed to keep America’s nursing home residents safe from the 2019 Novel Coronavirus (COVID-19). 

CMS has again revised the QSO memorandum Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes based on the newest recommendations from the Centers for Disease Control and Prevention (CDC). It directs nursing homes to significantly restrict visitors and nonessential personnel, as well as restrict communal activities inside nursing homes. The new measures are CMS’s latest action to protect America’s seniors, who are at highest risk for complications from COVID-19. While visitor restrictions may be difficult for residents and families, it is an important temporary measure for their protection.

“As we learn more about the Coronavirus from experts on the ground, we’ve learned that seniors with multiple conditions are at highest risk for infection and complications, so CMS is using every tool at our disposal to keep nursing homes free from infection,” said CMS Administrator Seema Verma. “Temporarily restricting visitors and nonessential workers will help reduce the risk of Coronavirus spread in nursing homes, keeping residents safe. The Trump Administration is working around the clock to ensure the continued safety of America’s health care system, particularly nursing homes.”

The new measures CMS announced on March 13, which supersede prior CMS guidance, constitute the agency’s most aggressive and decisive recommendations with respect to nursing home safety in the face of the spread of COVID-19. They include:

• Restricting all visitors, effective immediately, with exceptions for compassionate care, such as end-of-life situations;
• Restricting all volunteers and nonessential health care personnel and other personnel (i.e. barbers);
• Cancelling all group activities and communal dining; and
• Implementing active screening of residents and health care personnel for fever and respiratory symptoms.

The guidance directs nursing homes to restrict visitation except in certain compassionate cases, like end-of-life. In those cases, visitors will be equipped with personal protective equipment (PPE) like masks, and the visit will be limited to a specific room only.

CMS’s guidance is based upon CDC recommendations informed by real-time information being gathered from experts on the ground in areas with large numbers of COVID-19 cases, like Washington and California. According to CDC, seniors with multiple health conditions are at highest risk for complications. With large congregations of that particularly vulnerable population, nursing homes are extremely susceptible to quick spread of the virus. There have already been reports of large numbers of cases of COVID-19 spreading quickly through nursing homes, such as the Life Care Center in Kirkland, Washington. The spread of COVID-19 in a nursing home can amplify or seed further spread to other facilities when patients are transferred and when staff and visitors come and go. According to CDC, visitors and health care personnel who are ill are the most likely source of introduction of COVID-19 into nursing homes, necessitating today’s change in guidance to restrict visitors and personnel.

CMS understands the vital importance of keeping nursing home residents connected with their loved ones. However, the rapid spread of COVID-19 and its transmission through visitors and health care workers – as well as nursing home residents’ high risk – has made it necessary to restrict nonessential visitation in order to protect the health and safety of residents. In lieu of visits, CMS encourages nursing homes to facilitate increased virtual communication between residents and families. CMS also encourages nursing homes to keep residents’ loved ones informed about their care. This could include assigning a staff member as a primary contact for families to facilitate inbound communications, as well as regular outbound communications. Nursing homes are expected to notify potential visitors to defer visitation until further notice through signage and other outreach, such as emails and phone calls.

CDC has made several additional recommendations for nursing homes as they work to keep their residents safe. Nursing homes should put alcohol-based hand sanitizer with 60-95 percent alcohol in every resident room – both inside and outside the room if possible – and in every common area. Additionally, nursing homes should ensure sinks are well-stocked with soap and paper towels for hand washing. They should make tissues and facemasks available for people who are coughing, and make necessary PPE available in areas where resident care is provided. Finally, they should ensure hospital grade disinfectants are available to allow for frequent cleaning of high-touch surfaces and shared resident equipment.

COVID-19 Preparedness Checklist for Nursing Homes and other Long-Term Care Settings

Nursing homes and other long-term care facilities can take steps to assess and improve their preparedness for responding to coronavirus disease 2019 (COVID-19). This checklist should be used as one tool to develop a comprehensive COVID-19 response plan, including plans for:

• Rapid identification and management of ill residents
• Considerations for visitors
• Supplies and resources
• Sick leave policies and other occupational health considerations
• Education and training
• Surge capacity for staffing, equipment and supplies, and postmortem care

The checklist identifies key areas that long-term care facilities should consider in their COVID-19 planning. Long-term care facilities can use this tool to self-assess the strengths and weaknesses of current preparedness efforts. This checklist does not describe mandatory requirements or standards; rather, it highlights important areas to review to prepare for the possibility of residents with COVID-19.

Interim Additional Guidance for Infection Prevention and Control for Patients with Suspected or Confirmed COVID-19 in Nursing Homes

Summary of Changes to the Guidance:

Updated guidance to recommend that nursing homes:

• Restrict all visitation except for end of life situations.
• Restrict all volunteers and non-essential healthcare personnel (HCP), including non-essential healthcare personnel (e.g., barbers)
• Cancel all group activities and communal dining
• Implement active screening of residents and HCP for fever and respiratory symptoms

COVID-19 is being increasingly reported in communities across the United States. It is likely that SARS-CoV-2 is circulating in all communities even if cases have not yet reported. As such, nursing homes should assume it is now in their community and move to restrict all visitors and unnecessary HCP from the facility. Cancel group activities and communal dining and implement active screening of residents and HCP for fever and respiratory symptoms.

Data Note: How might Coronavirus Affect Residents in Nursing Facilities?

Introduction

While knowledge about COVID-19 continues to evolve daily, experts agree that certain populations are particularly vulnerable to severe cases of the infection – those with chronic conditions, compromised immune systems, and of old age. Nursing facilities provide care to populations with those characteristics, and residents in these facilities are particularly at risk of developing serious illness or dying if infected. In 2017, there were approximately 1.3 million residents receiving care across 15,483 nursing facilities in the US (Table 1). This data note provides key data points to highlight the potential implications of COVID-19 on nursing facility residents and overall operations.

During this COCA Call, presenters will focus on current information about COVID-19 and provide clinicians with updated information on implementing infection prevention and control measures, assessing risks for exposures, and optimizing the use of personal protective equipment supplies.

Special Request: Due to the high demand we anticipate for this COCA Call, we kindly ask participants to access it in a group format, if possible, to allow for the maximum number of people to participate.

Watch on Facebook: You may also participate in this COCA Call by joining COCA's Facebook Live.  

Advanced registration is not required.

Continuing Education will not be offered for this COCA Call. 

There will only be a few slides for this COCA Call. Slides will not advance during the presentation portion of this webinar. You can find the slides under the "Call Materials" tab on the call page.         

Date: Friday, March 13, 2020

Time: 2:00pm–3:00pm (ET)