Over the past week, CMS and CDC issued updated guidance related to COVID-19. On September 23, 2022, CMS updated the QSO memos 20-38-NH related to nursing home testing requirements and 20-39-NH related to nursing home visitation.
Key changes/additions to the CMS guidance include:
- Routine testing of asymptomatic staff is no longer recommended but may be performed at the discretion of the facility.
- For testing information regarding residents who are newly admitted or readmitted to the facility and those who leave the facility for 24 hours or longer, see the Managing admissions and residents who leave the facility section of the CDC’s Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic webpage.
- Testing for staff and residents with COVID-19 signs or symptoms of COVID-19 must be completed as soon as possible.
- An outbreak investigation is initiated when a single new case of COVID-19 occurs among residents or staff to determine if others have been exposed. An outbreak investigation would not be triggered when a resident with known COVID-19 is admitted directly into Transmission Based Precautions (TBP), or when a resident known to have close contact with someone with COVID-19 is admitted directly into TBP and develops COVID-19 before TBP are discontinued.
- Updated recommendations for testing individuals who have recovered from COVID-19, which indicates that in general, testing is not necessary for asymptomatic people who have recovered from SARSCoV-2 infection in the prior 30 days; testing should be considered for those who have recovered in the prior 31-90 days
- Instruct facility staff, regardless of their vaccination status, to report any of the following criteria to occupational health or another point of contact designated by the facility, so that they can be properly managed:
- a positive viral test for SARS-CoV-2,
- symptoms of COVID-19, or
- a higher-risk exposure to someone with SARS-CoV-2 infection
- Updated guidance for face coverings and masks during visits and removed vaccination status from the guidance
- Facilities should provide guidance (e.g., posted signs at entrances) about recommended actions for visitors who have a positive viral test for COVID-19, symptoms of COVID-19, or have had close contact with someone with COVID-19. Visitors with confirmed COVID-19 infection or compatible symptoms should defer non-urgent in-person visitation until they meet CDC criteria for healthcare settings to end isolation. For visitors who have had close contact with someone with COVID-19 infection, it is safest to defer non-urgent in-person visitation until 10 days after their close contact if they meet criteria described in CDC healthcare guidance (e.g., cannot wear source control)
- During peak times of visitation and large gatherings (e.g., parties, events) facilities should encourage physical distancing
- If your county COVID-19 community transmission is high, everyone in the healthcare setting should wear face coverings or masks.
- If your county COVID-19 community transmission is not high, the safest practice is for residents and visitors to wear face coverings or masks, however, the facility could choose not to require visitors wear face coverings or masks while in the facility, except during an outbreak.
- The facility’s policies regarding face coverings and masks should be based on recommendations from the CDC, state and local health departments, and individual facility circumstances.
- Regardless of the community transmission level, residents and their visitors when alone in the resident’s room or in a designated visitation area, may choose not to wear face coverings or masks and may choose to have close contact (including touch). If a roommate is present during the visit, it is safest for the visitor to wear a face covering or mask.
- Nursing homes should use the Community Transmission Level metric not the Community Level metric
- In most circumstances, quarantine is not recommended for residents who leave the facility for less than 24 hours (e.g., for medical appointments, community outings with family or friends) except in certain situations, described in the CDC’s empiric transmission-based precautions guidance
On September 23, 2022 the CDC also updated Infection Control Guidance , Strategies to Mitigate Healthcare Staff Shortages, and the Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2.
Updates to the CDC guidance include:
- Guidance was updated to note that vaccination status is no longer used to inform source control, screening testing, or post-exposure recommendations
- Updated circumstances when use of source control is recommended, which includes:
- When SARS-CoV-2 Community Transmission levels are high source control is recommended for everyone in a healthcare setting
- When Community Transmission levels are not high, facilities could choose not to require universal source control, however, it remains recommended for individuals in healthcare setting who:
- Have suspected or confirmed SARS-CoV-2 infection or other respiratory infection (e.g., those with runny nose, cough, sneeze); or
- Had close contact (patients and visitors) or a higher-risk exposure (HCP) with someone with SARS-CoV-2 infection, for 10 days after their exposure; or
- Reside or work on a unit or area of the facility experiencing a SARS-CoV-2 outbreak; universal use of source control could be discontinued as a mitigation measure once no new cases have been identified for 14 days; or
- Have otherwise had source control recommended by public health authorities
- Updated circumstances when universal use of personal protective equipment should be considered
- As community transmission levels increase, facilities should consider implementing broader use of respirators and eye protection by staff during patient care encounters.
- Updated recommendations for testing frequency to detect potential for variants with shorter incubation periods and to address the risk for false negative antigen tests in people without symptoms, which includes:
- Anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test as soon as possible
- Asymptomatic patients with close contact with someone with SARS-CoV-2 infection should have a series of 3 viral tests (24 hours after exposure, again 48 hrs after first negative test, and 48 hours after the second negative test). This will typically be at day 1, day 3, and day 5.
- Testing is generally not recommended for asymptomatic people who have recovered from COVID-19 in the prior 30 days, but should be considered for those who have recovered in the prior 31-90 days.
- Clarified that screening testing of asymptomatic healthcare personnel, including those in nursing homes, is at the discretion of the healthcare facility
- Updated to note that, in general, asymptomatic patients no longer require empiric use of Transmission-Based Precautions following close contact with someone with SARS-CoV-2 infection.
- Archived the Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes and special considerations for nursing homes not otherwise covered in Sections 1 and 2 were added to Section 3: Setting-specific considerations
- Updated screening testing recommendations for nursing home admissions
- In general, admissions in counties where Community Transmission levels are high should be tested upon admission; admission testing at lower levels of Community Transmission is at the discretion of the facility.
- Testing is recommended at admission and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test.
- They should also be advised to wear source control for the 10 days following their admission. Residents who leave the facility for 24 hours or longer should generally be managed as an admission
- Clarified the types of long-term care settings for whom the healthcare infection prevention and control recommendations apply
- In general, long-term care settings (excluding nursing homes) whose staff provide non-skilled personal care* similar to that provided by family members in the home (e.g., many assisted livings, group homes), should follow community prevention strategies based on COVID-19 Community Levels, similar to independent living, retirement communities or other non-healthcare congregate settings.
- In general, admissions in counties where Community Transmission levels are high should be tested upon admission; admission testing at lower levels of Community Transmission is at the discretion of the facility.
*Non-skilled personal care consists of any non-medical care that can reasonably and safely be provided by non-licensed caregivers, such as help with daily activities like bathing and dressing; it may also include the kind of health-related care that most people do themselves, like taking oral medications. In some cases where care is received at home or a residential setting, care can also include help with household duties such as cooking and laundry.
- Conventional strategies were updated to advise that, in most circumstances, asymptomatic healthcare personnel (HCP) with higher-risk exposures do not require work restriction, regardless of their vaccination status; therefore, the contingency and crisis strategies about earlier return to work for these HCP was removed.
- In most circumstances, asymptomatic HCP with higher-risk exposures do not require work restriction, regardless of vaccination status, if they do not develop symptoms or test positive for SARS-CoV-2.
- Updated recommendations for testing frequency to detect potential for variants with shorter incubation periods and to address the risk for false negative antigen tests in people without symptoms, which mirrors the updated CMS guidance provided.
