Business practices that promote a healthy workforce and living environment include:

1. Livable wage
2. Sick leave benefits
3. Full-time positions / Require healthcare facility employment at only one site
4. Telework
5. Modification of duties
6. Redundant and expanded workforce

(Adapted from CDC’s Testing Guidance for Nursing Homes www.cdc.gov/coronavirus/2019-ncov/hcw/nursing-homes-testing.html)

Preparations prior to serial testing planning

Serial testing is recommended after performing infection control assessments and facility-wide testing to facilitate cohorting and identify new transmission events early.

Completing Infection Control Assessments

AHD has conducted ICAR’s in:

• 8 of 9 of Alexandria Long-Term Care Facilities.
  • One has declined/refused multiple outreach attempts

Completing Facility-Wide Testing

AHD has facilitated or conducted Point Prevalence Surveys in:

• 8 of 9 of Alexandria Long-Term Care Facilities
  • REDACTED (5/6)
  • REDACTED (5/19)
  • REDACTED (5/21)
  • REDACTED (5/28)
  • REDACTED (6/1)
  • REDACTED (conducted their own 5/20-24)
  • REDACTED – (conducted their own 5/20-24)
  • REDACTED (6/3)
  • REDACTED (declined assistance despite multiple attempts)

  • Facility Bed and Staff Status

    Census (full capacity)

    Facility Type & Name	Number of Beds	Number of Staff (Est)	Notes
    Skilled Nursing Facilities
    REDACTED	REDACTED	REDACTED
    REDACTED	REDACTED	REDACTED
    REDACTED	REDACTED	REDACTED
    REDACTED	REDACTED	REDACTED
    REDACTED	REDACTED	REDACTED
    Assisted Living Facilities
    REDACTED	REDACTED	REDACTED	REDACTED
    REDACTED	REDACTED	REDACTED	REDACTED
    REDACTED	REDACTED	REDACTED	REDACTED
    REDACTED	REDACTED	REDACTED	REDACTED

    Serial Testing Planning

    Prioritizing Facilities for Serial Testing

  • AHD can schedule public health testing for facilities that are unable to conduct their own testing. Serial testing prioritizations shall be based on:
    • Skilled Nursing Facilities over Assisted Living Facilities
    • Memory Care over other Assisted Living Facilities
    • Other: number of cases in the facility, community prevalence, size of facility (including potential burden for hospitalization), number of residents with recent exposures, residential areas with resident with greater co-morbidities and/or other risk factors, ability of facility to cohort
    • Serial testing will begin with weekly testing of LTCF staff and residents, with subsequent periodicity adjusted according to community and facility infection status
    • If testing is limited, serial testing will be done for only LTCF staff and testing residents who were in close contact with the new case.

  • Contingency Planning

  • Facilities shall submit plans to respond to results of serial testing prior to initiating series, including:
    • Cohorting plan for COVID-19 cases
    • Overflow plan when unable to cohort (e.g. using alternative facilities)
    • Excluding positive HCW from work
      • Establish policies to mitigate possible HCW staff shortages as a result of testing
    • Determine how testing might be used to inform discontinuation of Transmission-Based Precautions for residents and when positive HCW will be allowed to return to work
  • AHD shall ensure the above and provide consultation
  • AHD shall ensure the facility has adequate personal protective equipment (PPE) supplies needed for serial facility-wide specimen collection.

  • Planning for specimen collection and data management

  • Facility shall identify staff responsible for performing specimen collection from residents & HCW
    • AHD shall provide training support to staff collecting specimens to ensure proper PPE use, specimen collection, handling, and packaging
  • AHD and facility shall establish a process for specimen collection and transport.
    • Ensure all staff (among all shifts and PRN) can be tested, considering
      • Number of testing opportunities (e.g. weekday and weekend)
      • Testing locations (e.g. onsite and/or offsite)
      • Testing method (e.g. drive-through, supervised self-swab)
      • Process for capturing which staff were tested or unable to be tested (e.g. SARA Alert, punch card, etc…)
    • Identify a clinician who will order testing
    • Identify funding source for testing of:
      • Staff
      • Residents
  • AHD capture test results by VEDSS (Outbreak Number) and using line list

  • Coordinating ordering of tests kits and reporting of test results

  • AHD shall advise to select a laboratory that can quickly process large numbers of tests with rapid reporting of results (e.g. within 48 hours)
    • Only Emergency Use Authorization (EUA) or Food and Drug Administration (FDA) approved viral tests shall be ordered to collect the approved specimen (e.g., nasopharyngeal, anterior nares)
    • For facilities that require public health resources for testing, AHD shall ensure availability of the required number of specimen collection kits from designated laboratory
  • If the designated laboratory sends results directly to the facility, facilities shall ensure that all lab reports are provided to AHD within 24 hours of receiving the report
    • If the facility is notified by AHD that their laboratory of choice does not report directly to the Virginia Department of Health (VDH), the facility shall transmit the lab reports to AHD within 24 hours of receipt by a secure method (fax or encrypted email).
    • Facility will ensure authorizations for exchange of information are obtained from staff and residents as applicable and in accordance with the Americans with Disabilities Act (ADA) and the Health Insurance Portability and Accountability Act (HIPAA).
    • AHD will ensure results are shared with facilities, even if multiple laboratories perform testing (e.g., state lab performs testing for residents and commercial laboratory performs testing for HCW).
  • AHD shall use the Virginia Electronic Surveillance System (VEDSS) to receive testing results from laboratories, LTCFs, and assisted living facilities, ensuring the results include date of testing, facility name, and the role of the individual tested (i.e., resident, HCW).
  • Facilities shall maintain records of HCW and residents who have positive tests
    • For nursing homes, those records can facilitate reporting aggregate data into the National Healthcare Safety Network (NHSN) COVID-19 Module for LTCF.
  • Data collection tools, which may include baseline epidemiologic information, provided by AHD, should continue to be maintained by the LTCF. The facility point of contact have been advised on how to collect and submit such data to ensure consistency across LTCFs.
    • AHD has provided line list templates with facilities and are working in conjunction with all facilities to track COVID-19 among staff and residents.
  • Federal regulations require informing patients, staff, and families of the number of cases in the facility; facilities must have plans for meeting these regulations.

(Adapted from CDC’s Testing Guidance for Nursing Homes www.cdc.gov/coronavirus/2019-ncov/hcw/nursing-homes-testing.html)

General Considerations

• Follow CDC’s Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Persons for Coronavirus Disease 2019 (COVID-19)
• The number of people present during specimen collection should be limited to only those essential for care and procedure support.
  • Visitors or other bystanders should not be present for specimen collection.
• Swabbing of multiple individuals should not be performed in the same room at the same time, unless appropriate separation between swabbing stations can be maintained (see below).

Consider if self-collection is appropriate

• PPE use can be minimized through self-collection while HCW remain at least 6 feet away of the individual being swabbed.
• The individual must be able to correctly self-swab and place the swab in transport media or sterile transport device and seal.
  • If the individual needs assistance, assistance can be provided by placing the swab into transport media or a sterile transport device and sealing it for them.
• If bulk-packaged swabs are used for sample collection, care must be exercised to avoid contamination of any of the swabs in the bulk-packaged container.

Location of specimen collection for nursing home residents

• Specimen collection should be performed one at a time in each resident’s room with the door closed. An airborne infection isolation room is not required. Ideally for rooms with multiple residents, specimen collection should be performed with only one individual at a time in a room, when possible, with the door closed.

Location of specimen collection for HCW

• Ideally, specimen collection should be performed one individual at a time in a room with the door closed and no other individuals present. If individual rooms are not available, other options include:
  • Large spaces (e.g., gymnasiums) where sufficient space can be maintained between swabbing stations (e.g., greater than 6 feet apart).
  • An outdoor location, weather permitting, where other individuals will not come near the specimen collection activity.
• Considerations for multiple HCW being swabbed in succession in a single room:
  • Consider the use of portable HEPA filters to increase air exchanges and to expedite removing infectious particles.
  • Minimize the amount of time the HCW will spend in the room. HCW awaiting swabbing should not wait in the room where swabbing is being done. Those swabbed should have a facemask or cloth cover in place for source control throughout the process, only removing it during swabbing.
• Minimize the equipment kept in the specimen collection area. Consider having each person bring their own prefilled specimen bag containing a swab and labeled sterile viral transport media container into the testing area from the check-in area.

PPE for swabbing

• HCW in the room or specimen collection area should wear an N95 or higher-level respirator (or facemask if a respirator is not available) and eye protection. A single pair of gloves and a gown should also be worn for specimen collection or if contact with contaminated surfaces is anticipated.
  • If respirators are not readily available, they should be prioritized for other procedures at higher risk for producing infectious aerosols (e.g., intubation), instead of for collecting nasopharyngeal specimens.
• Extended use of respirators (or facemasks) and eye protection is permitted. However, care must be taken to avoid touching the necessary face and eye protection. If extended use equipment becomes damaged, soiled, or hard to breathe or see through, it should be replaced. Hand hygiene should be performed before and after manipulating PPE.
• Gloves should be changed and hand hygiene performed between each person being swabbed.
• Gowns should be changed when there is more than minimal contact with the person or their environment. The same gown may be worn for swabbing more than one person provided the HCW collecting the test minimizes contact with the person being swabbed. Gowns should be changed if they become soiled.
• Consider having an observer who does not engage in specimen collection but monitors for breaches in PPE use throughout the specimen collection process.
• HCW who are handling specimens, but are not directly involved in collection (e.g., self-collection) and not working within 6 feet of the individual being tested, should follow Standard Precautions; gloves are recommended, as well as a facemask for source control.

Cleaning and disinfection between individuals

• Surfaces within 6 feet of where specimen collection was performed should be cleaned and disinfected using an Environmental Protection Agency-registered disinfectant from List N
• If visibly soiled and at least hourly.
• Terminal cleaning and disinfection of all surfaces and equipment in the specimen collection area should take place at the end of each day. Resident rooms should be cleaned and disinfected in accordance with Implementing Environmental Infection Control in the Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings.