COVID-19: Facility Solutions

COVID-19 Testing Guidance for Assisted Living Facilities

Requirements in assisted living facilities

Assisted living facilities are required to develop an infection prevention and control program that complies with long-term care infection prevention guidance from the Centers for Disease Control and Prevention (CDC) and accepted health care, medical, and nursing standards. As a component of infection prevention and control, this document summarizes the minimum testing requirements that assisted living facilities must meet as a standard of licensure and are based upon CDC recommendations for testing in nursing homes.

Definitions

Prolonged close contact is defined as being within 6 feet of someone with COVID-19 for a cumulative total of 15 or more minutes during a 24-hour period. High-risk exposure is experienced by staff members who have had prolonged close contact with a social or household contact who has COVID-19 or staff members who have had an occupational interaction (e.g., infectious patient, coworker) while not using all appropriate personal protective equipment (PPE), according to risk assessment criteria. Information about exposure risk assessment is provided by the Minnesota Department of Health (MDH). Responding to and Monitoring COVID-19 Exposures in Health Care Settings  SARS-CoV-2 viral testing includes two types of viral tests: nucleic acid amplification tests (NAATs) and antigen tests. Fully vaccinated people are two weeks past their final COVID-19 vaccine dose (two doses in a two-dose series or one dose in a one-dose series).

Summary of required testing

This section summarizes COVID-19 testing approaches that meet minimum assisted living facility infection prevention standards. Testing described below must be conducted with SARS-CoV-2 viral tests and regardless of vaccination status. Information about required testing is described in more detail in the sections that follow. Testing of people with symptoms of COVID-19. All people with any signs or symptoms of COVID-19, no matter how mild, must be tested as soon as possible. Outbreak testing in response to a new case of COVID-19 in a resident or staff member. Asymptomatic staff with a high-risk exposure and residents who have had prolonged close contact with someone with SARS-CoV-2 infection. These people must be tested immediately upon identification of the case (but not earlier than two days after exposure) and, if negative, five to seven days after the exposure. This testing is relevant whether the exposure happened within or outside the facility.

Outbreak testing approaches

Upon identification of a single new case of COVID-19 in any staff or residents, outbreak testing must be conducted. Facilities must choose to perform outbreak testing through one of two approaches:

  • Targeted testing after contact tracing to identify residents or staff who had prolonged close contact or high-risk exposure, respectively, to the test-positive person.
  • Broad (e.g., facility wide or group wide) testing approach. Facilities should attempt to identify close contacts of the person with COVID-19 within 24 hours of learning of the positive test. Facilities can choose to conduct targeted testing based on this contact tracing. When using this targeted approach, the following people must be tested:
  • Residents who have had prolonged close contact with the test-positive person, regardless of whether a mask or PPE was used by either person during the interaction.
  • Staff who experienced a high-risk exposure to the positive person. If a facility does not have the expertise, resources, or ability to identify all close contacts, the facility must take a broad approach and conduct outbreak testing facility wide or at a group level (e.g., unit, floor, or other specific area(s) of the facility).A broad testing approach is also required if the facility is directed to do so by the jurisdiction’s public health authority, or in situations where all potential contacts cannot be identified.

Targeted outbreak testing after contact tracing

Targeted outbreak testing involves contact tracing to identify any staff who have had a high-risk exposure or residents who may have had prolonged close contact with the test-positive person.

Facilities may choose this approach if contact tracing allows the facility to successfully identify all potential exposures.

  • Test these identified residents and staff immediately upon identification of the case (but not earlier than two days after exposure).
  • Retest residents and staff who test negative again five to seven days after the most recent exposure to the test-positive person.
  • If testing reveals additional positive staff or residents, contact tracing must be continued to identify additional residents with prolonged close contact or staff with high-risk exposures to the newly identified person or people with SARS-CoV-2 infection.
  • Action must be taken to isolate test-positive residents and exclude test-positive staff from work. Discontinuation of isolation precautions and return to work should be based on existing guidance.
    • CDC: Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic
    • COVID-19 Recommendations for Health Care Workers
  • Facilities must move from a targeted contact tracing approach to a broad approach, described below, if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission.

Broad approach to outbreak testing

If a facility does not have the expertise, resources, or ability to conduct contact tracing, or in situations where all potential contacts are unable to be identified or are too numerous to manage, or when contact tracing fails to halt transmission, facilities must instead investigate the outbreak at a facility level or group level (e.g., unit, floor, or other specific area(s) of the facility). A broad approach is also required if the facility is directed to do so by the jurisdiction’s public health authority.

  • Perform testing for all residents and staff on the affected unit(s), regardless of vaccination status, immediately upon identification of the case (but not earlier than two days after exposure) and, if negative, again five to seven days after the exposure.
  • If no additional cases are identified during testing, room restriction and full PPE use by staff caring for unvaccinated residents can be discontinued after 14 days. Additional information on room restriction and PPE use by staff are discussed below. No further testing is necessary unless further cases are identified.
  • If additional cases are identified on the initial testing round, testing must continue on the affected unit(s) or facility-wide every three to seven days. The facility should continue room restriction and full PPE use for care of unvaccinated residents until there are no new cases for 14 days. Additional information on room restriction and PPE use by staff are discussed below.
  • If antigen testing is used as part of an outbreak response, more frequent testing is recommended (e.g., every three days).

Other outbreak testing considerations

Unvaccinated people

Unvaccinated residents identified as prolonged close contacts of a case or those included in broad outbreak testing should generally be restricted to their rooms until outbreak testing is over (even when a test result is negative) and cared for by staff using an N95 or higher-level respirator, eye protection (goggles or a face shield that covers the front and sides of the face), gloves, and gown. They should not participate in group activities. Work restriction for unvaccinated staff with high-risk exposures should be based on existing MDH recommendations

COVID-19 Recommendations for Health Care Workers

Fully vaccinated people

Fully vaccinated residents do not need to be restricted to their rooms or cared for by staff using the full PPE recommended for the care of a resident with SARS-CoV-2 infection unless the residents develop symptoms of COVID-19, test positive, or the facility is directed to do so by the jurisdiction’s public health authority.

Fully vaccinated staff who remain asymptomatic do not need to quarantine from work or the community following a high-risk exposure. Information about fully vaccinated staff should be based on existing MDH recommendations.

In the event of ongoing transmission within a facility that is not controlled with initial interventions, strong consideration should be given to use of quarantine for fully vaccinated residents and work restriction of fully vaccinated staff with high-risk exposures. In addition, there may be other circumstances for which the jurisdiction’s public authority recommends these and additional precautions.

Testing of people who previously tested positive

Because people can test positive, persistently, or intermittently, following COVID-19 infection, CDC recommends that asymptomatic people be excluded from routine screening (e.g., weekly staff testing, point prevalence survey testing) for 90-days after initially testing positive by PCR. However, given the potential for false-positive antigen test results, people should continue to be included in routine screening if they tested positive by antigen test without confirmatory PCR testing and were asymptomatic during the initial infection. Any asymptomatic person who tests positive on a screening antigen test should have confirmatory PCR conducted.

Exclude person from routine screening for three months following initial positive test if:

  • Person was positive by RT-PCR testing, regardless of symptoms during the initial infection.
  • Person was positive by antigen test (with or without RT-PCR confirmation) AND was symptomatic at time of testing or developed symptoms during the initial infection.

Continue to include person in routine screening after initial positive test if:

  • Person was positive by antigen test (without confirmatory PCR test) AND person had no symptoms during the initial infection.
  • Person was positive by antigen test, but determined to be a false positive after obtaining a negative confirmatory RT-PCR test (within 48 hours of antigen specimen collection) and a second negative RT-PCR test at least 24 hours after the first.

Although these people will not be excluded from testing after their infection, a person who tests positive by antigen test (without a confirmatory test) and does not have symptoms should be treated as positive. Staff should be isolated, including exclusion from work for a minimum of 10 days, including at least 24 hours fever-free and with improving symptoms. Residents should be placed into Transmission-based Precautions.

Refusal of testing

  • Facilities must have procedures in place to address staff and residents who refuse testing.
  • Ensure that staff who have signs or symptoms of COVID-19 and refuse testing are prohibited from entering the building until the return-to-work criteria are met.
  • Residents (or resident representatives) may exercise their right to decline COVID-19 testing under Minnesota Statutes, section 144G.91, subdivision 5.
  • In discussing testing with residents, staff should use person-centered approaches when explaining the importance of testing for COVID-19.
  • Residents who have signs or symptoms of COVID-19 and refuse testing must be placed on Transmission-based Precautions until criteria for discontinuation are met.
  • If outbreak testing has been triggered and an asymptomatic resident refuses testing, the facility should be extremely vigilant, such as through additional monitoring, to ensure the resident maintains appropriate distance from other residents, wears a face covering, and practices effective hand hygiene until the procedures for outbreak testing have been completed.