Interim Guidance for Protecting Workers at Skilled Nursing and Long-term Care Facilities from Exposure to Coronavirus Disease (COVID-19)
April 5, 2020
NOTE: This document refers to requirements for respirators, respiratory protection programs and airborne infection isolation rooms. See Cal/OSHA Interim Guidance on COVID-19 for Health Care Facilities: Severe Respirator Supply Shortages, for information on making good faith efforts to comply with Cal/OSHA respiratory protection standards during the current respirator shortage.
Cal/OSHA’s regulations require protection for workers exposed to airborne infectious diseases such as COVID-19, first identified in December 2019. This interim guidance provides employers and workers in skilled nursing and long-term care facilities with vital information for preventing exposure to the virus. Employers and employees should review their own health and safety procedures as well as the recommendations and standards detailed below, to ensure workers are protected from COVID-19.
Virus Signs, Symptoms and Transmission
Common signs and symptoms of COVID-19 include fever, cough and difficulty breathing. In reported cases, the severity of the illness ranges from mild symptoms to death. The time from exposure to symptom onset ranges from two to 14 days. The virus is spread from person-to-person, likely through close contact, and small and large respiratory droplets and possibly particles that may strike the mucous membranes of the eyes, nose or mouth, or may be breathed into the nose or mouth.
Skilled Nursing/Long-Term Care Facilities and COVID-19
Residents of skilled nursing and long-term care facilities are at very high risk of serious illness or death from COVID-19 due to the congregate nature of the facilities and the characteristics of their resident population, which often includes older adults or others with underlying chronic medical conditions. The vulnerability of these facilities also puts their employees at risk. COVID-19 can spread rapidly in long-term residential care facilities, as illustrated in a recent outbreak in the State of Washington, detailed in a report by the Centers for Disease Control and Prevention (CDC) and another published in the New England Journal of Medicine.1
The outbreak occurred in King County, Washington, where thirty long-term skilled nursing and assisted living facilities reported one or more confirmed COVID-19 cases from February 27 to March 18, 2020. As of March 18, 101 residents, 50 health care workers, and 16 visitors were confirmed to have COVID-19; 34 residents died.
The CDC identified the following factors as likely contributing to the outbreak:
- Staff members worked while experiencing symptoms of the disease
- Staff members worked in more than one facility
- Inadequate familiarity and adherence to standard, droplet and contact precautions and eye protection recommendations 2
- Delayed recognition of cases because of low index of suspicion, limited testing availability, and difficulty identifying persons with COVID-19 based on signs and symptoms alone.
After the outbreak, local and state authorities in Washington instituted prevention measures for long-term care facilities that include:
- Implementation of symptom screening and restriction policies for visitors and nonessential personnel.
- Active screening of health care workers, including measurement and documentation of body temperature and ascertainment of respiratory symptoms to identify and exclude symptomatic workers.
- Symptom monitoring of residents.
- Social distancing, including restricting resident movement and group activities.
- Staff training on infection control and PPE use.
- Establishment of plans to address local PPE shortages, including county and state coordination of supply chains and stockpile releases to meet needs.
The Aerosol Transmissible Diseases (ATD) standard (California Code of Regulations, title 8, section 5199), contains requirements for protecting employees from diseases and pathogens transmitted by aerosols. COVID-19 is an airborne infectious disease covered by the ATD standard. ]
The ATD Standard applies to skilled nursing and long-term health care facilities. It also applies to many other facilities and services not listed here where there is increased risk of aerosol transmitted infection. For further information and more details on how to comply with the ATD Standard, see the Cal/OSHA COVID-19 website.
Skilled Nursing and Long-Term Care Facilities that Refer or Transfer Suspect and Confirmed COVID-19 Patients to Other Facilities
Under most circumstances, skilled nursing and long-term health care facilities transfer patients to hospitals when they are in need of airborne infection isolation. Employers that transfer such patients are “referring employers” under the ATD Standard and have less stringent requirements than acute care facilities. However, medical facilities are experiencing surge conditions due to COVID-19, and it is anticipated that some referring employers will maintain COVID-19 patients rather than transfer them. This is anticipated in the ATD Standard, and additional requirements apply in those circumstances as discussed below.
General Requirements for Referring Employers
If the skilled nursing or long-term care facility does not care for, diagnose, treat, house or transport patients with suspected or confirmed airborne infectious diseases such as COVID-19 they may be a referring employer. Referring employers must take certain precautions to protect their employees from aerosol-transmitted diseases under the ATD Standard, including the following:
- Implement written infection control procedures, as follows, for transmission of aerosol-transmissible diseases, including COVID-19.
- Designate a person to administer the infection control procedures.
- Include procedures for cleaning and disinfecting work areas, vehicles and equipment that may pose an infection risk to employees.
- Include procedures recommended by CDC for COVID-19 prevention in long-term care facilities such as:
- Restrict visits except for certain compassionate care situations, such as end of life situations.
- Restrict entry of volunteers, non-essential healthcare personnel and other services (e.g., barbers).
- Cancel all group activities and communal dining.
- Implement active screening of residents and health care workers for fever and respiratory symptoms.
- Make the infection control procedures available at the worksite to employees and their representatives
- Implement written procedures to quickly screen, refer and transfer persons, if possible, with a suspected or confirmed airborne infectious disease to a qualified facility.
- Implement written source control procedures including masking patients when medically possible.
- Provide and ensure employees use appropriate personal protective equipment and respiratory protection when entering a room or area where a suspect or confirmed patient is located, if the patient is not wearing a mask. Respirators must also be used if the facility is going to house a COVID-19 patient, rather than transfer them to a hospital or other facility with airborne infection isolation rooms. Respirators must be certified by NIOSH and must have filters that remove at least 95 percent of airborne particles (N95) or more.
ATTENTION: In non-emergency conditions, covered employers must provide and ensure use of NIOSH certified respirators to all employees occupationally exposed to novel pathogens such as SARS-CoV-2. However, for the current COVID-19 crisis, covered employers must provide surgical masks when the respirator supply is insufficient for anticipated surges or when efforts to optimize the efficient use of respirators does not resolve the respirator shortage. Surgical masks can only be used for lower hazard tasks involving patient contact. Employees must be protected by NIOSH certified powered air-purifying respirators (PAPRs) when performing aerosol generating procedures. N95 respirators may only be used for those procedures when PAPRs are unavailable due to a surge. Further information is available at Cal/OSHA Interim Guidance on COVID-19 for Health Care Facilities: Severe Respirator Supply Shortages. Please note that when respirators are again available in sufficient supply, both Cal/OSHA requirements and CDC recommendations call for skilled nursing facilities to develop a respiratory protection plan.
- Provide medical services to employees
- Offer employees vaccinations for seasonal flu and other diseases listed in title 8 section 5199 Appendix E
- Investigate and take preventative measures when an exposure incident occurs:
- Report any suspected or confirmed COVID-19 case to the local health officer.
- Notify any other employer of employees that may have had contact with a suspected or confirmed COVID-19 case, such as paramedics, emergency medical technicians, emergency responders or health care facilities or agencies receiving referred patients.
- Investigate and determine which employees had significant exposures to COVID-19 and conduct an exposure analysis. Make the exposure analysis available to the local health officer.
- Notify employees who had significant exposures of the date, time, and nature of the exposure.
- Have a licensed health care provider provide medical evaluations to all employees who had a significant exposure, which includes any appropriate vaccination, prophylaxis and treatment.
- Remove employees from their regular assignment when necessary to prevent spread of COVID-19 if recommended by the licensed health care professional or local health officer.
When removal is necessary, the employer must maintain the employee's earnings, seniority and all other employee rights and benefits, including the employee's right to his or her former job status, as if the employee had not been removed from his or her job or otherwise medically limited.
- Provide the following training to employees with the opportunity for interactive questions:
- Signs, symptoms, modes of transmission and when a medical evaluation is needed for aerosol transmissible diseases including COVID-19
- Methods and criteria for screening patients that may require a referral to another facility
- The employer's source control measures and how these measures will be communicated to patients and visitors
- The employer's procedures for referring patients to another facility
- The employer's procedures to protect employees from aerosol transmissible diseases prior to transfer, and how to use all PPE
- Respirator training when respiratory protection is used
- The employer’s procedures for reporting incidents, providing vaccines, medical services and evaluations
- How employees can access the employer's written procedures and how employees can participate in reviewing the effectiveness of the employer's procedures
Skilled Nursing and Long-Term Care Facilities that Do Not Transfer Suspect and Confirmed COVID-19 Patients
If a skilled nursing or long-term care facility is not able to refer or transfer a suspect or confirmed COVID-19 patient, in addition to the requirements explained above, the employer must:
As noted above, this guidance provides information on the requirements of Cal/OSHA’s ATD Standard, 8 CCR Section 5199. During the current respirator shortage, employers should review and adhere to Cal/OSHA Interim Guidance on COVID-19 for Health Care Facilities: Severe Respirator Supply Shortages.
Move the patient in a timely manner to an airborne infection isolation room (AIIR) if the facility has one available. If no AIIR is available, the facility should consult with the California Department of Public Health and provide the maximum level of separation available and appropriate. This may include a private room with the door normally kept closed with portable systems to create negative pressure.
- Provide employees with a fit-tested, NIOSH-approved respirator whenever the employee is in the area where COVID-19 patients are located. The employer should implement a respiratory protection program to ensure that employees are medically evaluated for respirator use, trained and fit-tested. Cal/OSHA has published instruction on how to set-up a respiratory protection program online.
- Provide any medical screening or surveillance recommended by CDPH or the Local Health Department to employees to support the early detection of COVID-19 infection.
For additional information, please see the Cal/OSHA Coronavirus website.
Skilled Nursing and Long-Term Care
- California Association of Health Facilities. CAHF Disaster Preparedness Program.
- California Department of Public Health. All Facilities Letter AFL 20-25. Preparing for Coronavirus Disease 2019 (COVID-19) in California Skilled Nursing Facilities
- U.S. Centers for Disease Control and Prevention. Preparing for COVID-19: Long-term Care Facilities, Nursing Homes.
- U.S. Centers for Disease Control and Prevention. COVID-19 in a Long-Term Care Facility — King County, Washington, February 27–March 9, 2020
- U.S. Centers for Medicare & Medicaid Services. Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes (REVISED)
Cal/OSHA Guides and Fact Sheets for the ATD Standard and Respiratory Protection Program:
- General Industry Guidance for Protecting Workers from Coronavirus (COVID-19)
- Cal/OSHA Interim Guidance on COVID-19 for Health Care Facilities: Severe Respirator Supply Shortages
- Safety & Health Fact Sheet | Aerosol Transmissible Diseases
- The California Workplace Guide to Aerosol Transmissible Diseases
- Respiratory Protection in the Workplace
- Respiratory Protection Fact Sheet
Cal/OSHA Model Written Plans and Programs
- Aerosol Transmissible Diseases Model Exposure Control Plan
- Aerosol Transmissible Diseases Model Laboratory Biosafety Plan
- Aerosol Transmissible Diseases Referring Employer Model Written Program
1 Centers for Disease Control and Prevention. COVID-19 in a Long-Term Care Facility — King County, Washington, February 27–March 9, 2020. MMWR. March 18, 2020. Available at: https://www.cdc.gov/mmwr/volumes/69/wr/mm6912e1.htm; Temet M. McMichael et al. Epidemiology of Covid-19 in a Long-Term Care Facility in King County, Washington. The New England Journal of Medicine. Mar 27, 2020
2 In California, airborne infection isolation is required to protect workers from COVID-19 in addition to standard, droplet and contact precautions under Cal/OSHA’s Aerosol Transmissible Diseases (ATD) Standard (title 8 section 5199).