COVID-19 Strategic Action Framework: Supporting Long-Term Care Facilities

Page updated on Aug 20, 2020 at 10:51 PM

This document is congruent with Alexandria Health Department’s (AHD) Strategic Action Framework and is one of a series of frameworks outlining AHD’s COVID-19 Pandemic Response

Mission

Save lives and improve quality of life for residents, their families, and staff of Long-Term Care Facilities

Objectives

  • Reduce and eliminate deaths, hospitalizations, and infections due to COVID-19 in facilities’ residents and staff
  • Support Alexandria’s long-term care facilities (LTCFs) in infection control and outbreak prevention and response
  • Improve quality of workplace support for facilities’ workers

Key Context

This is a living document and changes will be made based on updates in public health’s understanding of COVID-19, updated CDC and VDH guidance, and AHD resources and prioritizations.

The owners for each task are AHD staff with multiple responsibilities. Target dates for each task are subject to change based on COVID-19 circumstances and priorities.

Strategy/Tactics

1. Guidance, training, and coaching on day-to-day infection prevention and control practices

TASK

OWNER(S)

STATUS/ UPDATES

Conduct Infection Control Assessment and Response (ICAR) Program surveys

CBC

8 of 9 Alexandria LTCFs completed by 4/29
(1 refused)

As of 8/4 all participating LTCF have had at least 1 subsequent ICAR, most have had 2.  LTCF showing measurable improvement.

Advocate to Virginia COVID-19 LTCF Task Force that VDSS allow ALFs leniency pertaining to staff orientation and training, direct care staff training NOT be advanced as proposed

SH

4/16/2020

Identify MRC volunteers with appropriate KSAs and interest to draft training and coaching plans with LTCFs

CBC
JJ

5/1/2020

4 MRC assumed train the trainer roles

Conduct fit-testing and provide PPE

JJ

Fit-testing 3/23/2020
PPE provision: ongoing

As of 8/4 all interested LTCF been trained to do fit testing for their own staff

Engage LTCFs and determine those interested in pursuing training and coaching of staff

CBC
JJ
SN

5/1/2020

Iterative weekly as of 6/8

Implement HCW infection prevention and control practices training and coaching on-site – LTCFs

MRC Lead
CBC oversight
SN 6/1

Completed

Iterative, ongoing

12 MRC engaged in doing infection prevention visits

   

Moved to Congregate Care Framework

Provide advice based on PPS and community results

CBC
SN

Iterative, ongoing

Ensure LTCF have a plan in place for distribution of COVID-19 vaccine when it becomes available JJ As of 8/4  8 out of 9 LTCF have signed closed POD agreements with AHD
Ensure LTCF have plan for achieving high vaccination coverage for influenza among staff and residents SN  
2. PPE Management

TASK

OWNER(S)

STATUS/ UPDATES

Conduct surveys of facilities to determine PPE status

KXL
JJ

Started 3/16/2020
Iterative, weekly, will assess as needed--working in coordination with the Regional Health Care Coalition which is also distributing PPE.

Analyze and report AHD’s inventory

KXL
JJ

Started 3/16/2020
Iterative, weekly

Order PPE from VDH

JJ

Started 5/1/2020
Iterative, weekly

Provide fit-testing kits and training

JJ

Completed 5/8/2020

Training on donning and doffing

JJ
IL

Completed 5/8/2020
Iterative, as needed

Deliver PPE to LTCFs

JJ

Started 3/30
Iterative, weekly, gowns, tyvek suits, gloves, face shields, goggles, surgical mask, and shoe covers. 

Coalesce into singular document interim guidance for LTCFs to obtain PPE

SH

Completed 5/8/2020

Support LTCF in creating and implementing a Respiratory Protection Program according to OSHA guidelines CBC
JJ
SN
Offer and give support by start of flu season to interested facilities
3. Contact Tracing

TASK

OWNER(S)

STATUS/ UPDATES

Interviewing exposed HCWs to determine risk level and positive HCWs to identify close contacts

CBC

Jan-April
Resumed July-current due to increased AHD staffing

Supporting facilities to conduct contact tracing

CBC
SN

April – July

Develop 3 teams of Public Health Nurses dedicated to specific LTCFs

DB
DD

Completed May

In July reorganized into one strike team covering all LTCF

Assure initiation of contact tracing within 24 hours of notification of positive case in facilities

CBC
SN
KXL

Ongoing

Re-evaluate current contact tracing strategy (of facilities conducting)

SN
CBC

6/22 or Phase 2

Re-evaluated and implemented in July as noted above

4. Serial point prevalence survey (PPS) testing (see Appendix A)
TASK

OWNER(S)

STATUS/ UPDATES

Preparations prior to serial testing planning

 

 

Complete ICARs

CBC

See Strategy/Tactic 1
All 8 engaged LTCFs completed

Complete Facility Wide Testing

CBC

See Appendix A
All 8 engaged LTCFs to complete by 6/3

Serial Testing Plan

 

 

Develop Prioritization Criteria for Serial Testing

KXL
CBC
SN

Reference Appendix A
Completed 6/3

Assure LTCF Contingency Plan is established

CBC

Completed by 8 of 9
5/15/2020

Plan for specimen collection and data management – for initial PPS

CBC
SN
JJ
MR

6/3/2020

Coordinate ordering of tests kits – for initial PPS

CBC

Completed 6/3/2020

Coordinate reporting of test results

CBC

Completed 6/3/2020

Discuss possible collaboration with Neighborhood Health in collection of HCW specimens

SH

5/30/2020

Deferred--NH efforts currently directed at mobile community testing

Provide guidance and technical assistance and analyze test results – for serial testing

SN
CBC
SH
KXL

Iterative

Explore methods of, and avenues of funding for, serial testing (resident and HCW)

SH
SN
CBC

6/3/2020
6/8-10 – SH requested support from  VDH; NVHA  (via regional planner); VA Secretary HHR

Develop Appendix B into recommendation/ guidelines for facilities

SN
CBC
SH

6/3/2020

8/5 All facilities are now competent in specimen collection

5. Continuous quality improvement plans

TASK

OWNER(S)

STATUS/ UPDATES

Identify MRC volunteers with appropriate KSAs and interest to initiate CQI plans with LTCFs

CBC
IL

Completed 5/15/2020

Engage LTCFs and determine those interested in pursuing CQI planning

SN

Target date: 7/15/2020

Deferred until facilities are ready for reopening phase 3

Initiate CQI planning with engaged facilities

MRC Lead
(SN and KXL oversight)

Target date: 7/31/2020

Deferred until facilities are ready for reopening phase 3

6. Business practices to support a healthy workforce and living environment (see Appendix B)

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

TASK

OWNER(S)

STATUS/ UPDATES

Advocate to LTCFs that they adopt business models supportive of this strategy (components A, B, C)

SH

Emailed LTCF administrators:
3/31/20
4/9/20

Advocate to Virginia COVID-19 LTCF Task Force that additional proposed Medicaid funding stipulate increase wages for HCWs

SH

4/16/2020

Develop comprehensive plan to advocate for adoption of strategy 6 among LTCFs

NT
SH

Target date: 7/15/2020

7. Maintain communications with partners

TASK

OWNER(S)

STATUS/ UPDATES

Email notification to LTCFs of COVID-19 in other facilities
(Authorized by Commissioner of Health and in collaboration with NoVA region epidemiologist)

CBC

5/6/2020
5/12/2020
5/19/2020
8/4 this list has been emailed out weekly since May

Update Mayor and City Council on AHD activities supporting LTCFs

SH

Multiple dates via emails and phone discussions
March 2020
April 2020

City Council Meetings:
4/14; 4/28; 5/12; 5/26

Phone discussion with Mayor Wilson 5/28

Provide “Advice Line” to facility staff to obtain rapid advice and technical assistance

CBC
NT

Target date: 6/5/2020

Conduct periodic conference calls to determine facilities’ challenges, problem-solve and provide updated information and guidance

SN
CBC
KXL
SH

6/10
7/28

Develop comprehensive communications strategy

NT
SH

7/15/2020

Launched a periodic newsletter for LTCF staff and administrators SN 7/14

SWOT Analysis

Strengths:

Motivated AHD workforce

MRC volunteers

LTCF teams well established and trained

Strongly established relationships between LTCF and AHD COVID-19 LTCF team

Weaknesses:

LTCFs may not want our assistance (e.g. REDACTED traditionally refuses help)

Currently only two epidemiology positions filled;both with familiarity with Alexandria LTCFs

If increase in LTCF staffing shortages, exposed staff members would still allowed to work even when they should be on a 14-day quarantine

Opportunities:

Training LTCF & Assisted staff

Training additional MRC and AHD staff

VDH support from regional epidemiologist and laboratory for point prevalence surveys

Threats:

No vaccine

Lack of affordable testing options; lack of point of care testing

Lack of PPE and training

Asymptomatic and pre-symptomatic transmission

Information dissemination: Difficult to ensure that information from AHD is  shared with the employees that need the information

Appendix A: Serial COVID-19 Testing Plan

(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:
  • 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
  • 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.
Appendix B: Procedural Recommendations for Conducting Swabbing

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

General Considerations

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

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