Coronavirus Latest Update

 

January 27, 2023

MODIFICATION OF COVID PROTECTIVE MEASURES (CHANGE #6)

**Subject to Change**

 

Go directly to information on:  Off-Campus Activities, Travel, Visitors and Volunteers, Tours for Prospective Residents, or New Admissions

SUMMARY

Updates quarantine and isolation protocols; adapts Centers for Disease Control and Prevention (CDC) strategies for managing healthcare staff and updates in alignment with Safer Federal Workforce Task Force guidance; includes developing clinical information.

Previous versions dated May 17, 2021; September 29, 2021; January 12, 2022; March 3, 2022; and May 17, 2022 are obsolete.

OVERVIEW

This memorandum provides updated guidance to both AFRH campuses for measures implemented during the COVID pandemic.

It is important to remember that Centers for Disease Control and Prevention (CDC) guidance for the general public does not apply at AFRH.  This is because of our close living environment, shared facilities and amenities, on-site healthcare services including higher levels of care, and the greater risk of infection and severe illness among the residents we serve.  Therefore, our approach incorporates some features of CDC guidance for the general public, congregate living settings, healthcare settings, and healthcare personnel, and for long-term care, assisted living, and healthcare settings.  CDC guidelines change frequently and differently in each of these areas.

AFRH incorporates elements of the CDC recommended layered strategy to reduce exposures to SARS-CoV-2, the virus that causes COVID-19.  The AFRH layered strategy combines multiple components including but not limited to the use of masks and respirators, ventilation, physical distancing, cleaning, and disinfecting.

DEFINITIONS

Booster dose:  Additional vaccine doses after the initial series (one or two doses depending on manufacturer).  There have been several boosters issued and additional ones may be released to counter new variants of the virus.

Community levels:  CDC calculation of levels of COVID by county is available at https://www.cdc.gov/coronavirus/2019-ncov/your-health/covid-by-county.html. These levels do not apply in healthcare settings, such as clinics and nursing homes, per the CDC.

Exposure: Close contact (within 6 feet of someone for a cumulative total of 15 minutes or more over a 24-hour period) with someone who has COVID or after discharge from an inpatient stay at any healthcare facility.

Fully vaccinated: Two weeks have passed since the final dose of an initial vaccine series (one or two doses depending on manufacturer).  There is waning immunity and the first series no longer provides as much protection several months after administration.  Many individuals who have been fully vaccinated are still at risk for infection.  All booster doses are strongly encouraged.

Healthcare personnel (HCP):  All persons working in healthcare settings who have the potential for direct or indirect exposure to patients or infections materials.  The full CDC definition can be found at the footnote1.  All AFRH staff are HCP per AFRH determination.

Post-COVID conditions:  A CDC umbrella term for the wide range of health consequences that can be present for four (4) or more weeks after acute COVID infection.  CDC uses the four-week timeframe in describing post-COVID conditions to emphasize the importance of initial clinical evaluation and supportive care during the initial 4 to 12 weeks after acute COVID-19.  Symptoms may persist, evolve, or take longer to resolve than 12 weeks.  Commonly reported symptoms include: increased respiratory effort, fatigue, post-exertional malaise or poor endurance, cognitive impairment or "brain fog," cough, chest pain, headache, irregular or high heartbeat, joint stiffness, muscle ache, burning or prickling sensations, abdominal pain, diarrhea, insomnia and other sleeping difficulties, fever, lightheadedness, impaired daily function and mobility, pain, rash, mood changes, loss of smell or taste, and other symptoms.

Quarantine vs isolation: Quarantine keeps someone who was exposed to the virus and might have become infected away from others. Isolation keeps someone who is sick or tested positive without  symptoms away from others.

Source control:  Use of respirators such as N95s or well-fitting facemasks such as KN95s or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing.

Staff: Includes Federal employees, contractor employees, and volunteers.

Transmission-based precautions:  A set of practices specific for patients with known or suspected infectious agents that require additional control measures to prevent transmission.

ADJUSTING PROTECTIVE MEASURES

AFRH's highest priority is to keep the two communities safe, and some limits will remain in place while others will be adjusted in response to conditions at either campus or their surrounding communities. Key conditions are:

  1. Positive cases on campus.
  2. Community level, as reported by CDC at https://www.cdc.gov/coronavirus/2019-ncov/your-health/covid-by-county.html.
  3. Local data, as reported by CDC at https://covid.cdc.gov/covid-data-tracker/#county-view.

REQUIRED CORE INFECTION PREVENTION PROTOCOLS

All residents, staff, volunteers, and visitors must maintain core infection prevention protocols:

  • Properly wear face masks when and where required per current guidelines (see details below).
  • Maintain at least 6 feet of physical distancing.
  • Wash or sanitize hands frequently.
  • Complete sanitizing and screening steps when arriving on campus.
  • Self-monitor at all times for any symptoms associated with COVID (i.e., sore throat, cough, nasal drainage, dizziness, fever or chills, shortness of breath, new loss of taste or smell, headache, fatigue) and if they occur, immediately self-isolate and notify the Wellness Center staff who will provide further instructions.

DETAILED PROTOCOLS

Masks

The CDC has advised that mask wearing is not required when out in the community in counties with low and medium community levels. See the definition for community levels for online county information.

It is important to recognize that healthcare settings have separate CDC guidelines and masking continues to be mandatory in healthcare settings at AFRH. 

  • Residents and visitors must wear masks in the Wellness Centers, Assisted Living, Long Term Care, and Memory Support units, and are encouraged to wear KN95 masks specifically. KN95s are more protective than standard cloth masks and do not require fit testing, training, medical questionnaires, or approval before use.
  • Staff must wear N95s or KN95s in the Wellness Centers and the Assisted Living, Long Term Care, and Memory Support units.
  • Signage requiring masking for all, regardless of vaccination status or CDC community level, will be posted at entrances to healthcare units.
  • Staff must wear personal protective equipment (PPE) including but not limited to gloves, eye protection, and N95s when caring for residents with diagnosed COVID.

Masks are required by everyone in all areas at AFRH whenever CDC community COVID levels are high.  The campus Administrators will monitor community levels in their respective counties for changes.

The most common source for new COVID infection has been from those returning from inpatient stays and travel.  Residents in all levels of care who leave the facility for 24 hours or longer are strongly encouraged to wear masks in common areas and when close to others whenever possible for the 10 days following their return.

Outside of healthcare settings, campus Administrators set masking requirements for their respective campus in consultation with the Headquarters Chief Medical Officer when CDC community levels are low or medium.  In general, at the low and medium levels, masks are strongly encouraged, but not required, in all other indoor areas where others are present, particularly for indoor group events.  There may be times when the community levels are low or medium when the campus Administrator may require masking.

Vaccination

The AFRH community has high rates of COVID vaccination and boosters. Residents, staff, and visitors are advised to speak with their healthcare provider about COVID primary vaccination series and boosters.

Vaccination status documentation is not currently required for staff, visitors, volunteers, or on-site contractors as per updated Safer Federal Workforce Task Force guidance.

Vaccines are one of the tools available, but are not guaranteed to prevent illness or even death from COVID.  Since COVID can result in illness, hospitalization, and death, every available defense should be employed.

Testing

Symptomatic individuals will immediately receive both rapid and PCR tests. Asymptomatic individuals identified through contact tracing will receive a rapid test on days 1, 3, and 5 after potential exposure.

A single new case of COVID in any HCP or resident should be evaluated to determine if others in the facility could have been exposed.  The approach to an outbreak investigation could involve either contact tracing or a broad-based approach.  A broad-based (i.e., by unit, floor, etc.) approach is preferred if all potential contacts cannot be identified with certainty or managed with contact tracing.  As part of the broad-based approach, testing should continue on affected units or facility-wide every 3-7 days until there are no new facility cases in either residents or staff for 14 days. 

Management and Treatment

There is now widely available effective treatment for COVID.  Don’t delay—treatment must be started within 5 days after you first develop symptoms to be effective. See your healthcare provider within 5 days of a positive test result or the onset of COVID-like symptoms, even if your symptoms are mild or non-existent. The FDA has issued emergency use authorizations for certain antiviral medications and monoclonal antibodies to treat mild to moderate COVID in people who are more likely to get very sick. Treatment may reduce your chances of being hospitalized or dying from the disease. For mild to moderate cases, some people may be able to take a short course of pills as an outpatient.

AFRH physicians and nurse practitioners have more information and may be able to prescribe COVID treatments for residents. Or, visit https://covid-19-test-to-treat-locator-dhhs.hub.arcgis.com/ or call 1-800-232-0233 (TTY 1-888-720-7489) to find a testing location that can provide treatment if you test positive. 

When any resident, including those accommodated in Independent Living, is in COVID isolation or quarantine at AFRH, staff will ensure they receive food, hydration, and medication.

Each shift, healthcare staff will assess and document vitals, oxygen saturation, hydration status, and general health status of any resident in isolation or quarantine, including those in Independent Living.  Physician/nurse practitioner notification parameters will be set including but not limited to:  oxygen saturation <94% on room air at sea level; a respiratory rate >30 breaths/minute; a heart rate >95 beats/minute; systolic blood pressure < 90 mmHG.  Notify provider of weight gain or loss of more than 2 pounds in 24 hours, chest pain, shortness of breath, lethargy, inadequate oral intake, dehydration, change in mental status, inability to awaken or stay awake, intractable nausea, vomiting or diarrhea, generalized severe weakness, or other condition for which the healthcare staff determines the physician/nurse practitioner should be notified.

Additionally, the physician/nurse practitioner will be notified if the resident refuses assessment or any prescribed treatments or medications or food or water while in isolation or quarantine on any shift during that same shift.

This notification will be documented along with any further orders from the physician/nurse practitioner.  In certain cases of COVID, emergency or specialty care may be required at an emergency department, hospital, or specialty setting.  Residents who have post-COVID symptoms may be evaluated and treated at AFRH and in some cases will need specialty care.

Transmission-Based Precautions (Quarantine and Isolation)

For determing the duration of transmission-based quarantine or isolation, the first day of symptoms is counted as day zero.  The first day with a positive COVID test is counted as day one.

Residents

Quarantine after exposure:

All AFRH residents, regardless of vaccination or asymptomatic status, who have a qualifying exposure to COVID (see definition, which includes returning from an inpatient stay) will receive rapid antigen tests for COVID.  Testing is advised on days 1, 3, and 5.  Testing is generally not recommended for asymptomatic exposed residents that have recovered from COVID infection in the prior 30 days.

Exposed residents identified through contact tracing are strongly encouraged to wear a mask for 10 days.

The following residents must quarantine in their apartments following known exposure:

  • Residents of Assisted Living, Long-Term Care, and Memory Support units.
  • Independent Living residents who are unable to test.
  • Independent Living residents who are unable or decline to wear a mask as recommended for 10 days following exposure.
  • Independent Living residents who are severely immunocompromised.

The time period for quaratine is as follows:

  • Residents who complete the tests described above with all negative tests and no development of symptoms may exit quarantine on day 7 and continue to wear a mask until day 10.
  • Residents who do not complete testing may exit quarantine after 10 days if they develop no symptoms.

Residents should limit interactions with others and their movements around the facility as much as possible.  To that end, staff will monitor and assist residents in quarantine as described in the Management and Treatment section above.  Residents who have been exposed to COVID should NOT be cohorted with residents with confirmed COVID.  Campus Administrators are responsible for managing cohorting decisions based on staffing availability and other factors.

A resident who tests positive or develops any symptoms during this period will move to the isolation protocol below.

Isolation with COVID symptoms or positive test:

All AFRH residents, regardless of vaccination status, with a positive COVID test or mild to moderate symptoms of COVID infection will isolate for 10 days in a location determined by the campus Administrator.

  • Staff will monitor and assist residents in isolation as described in the Management and Treatment section above.
  • They will be rapid tested after 10 days.  If the test is negative and the resident is asymptomatic, including no fever for 24 hours prior without the use of fever reducing medications, they may end isolation.
  • In general, residents should continue to wear source control when not alone and when possible until symptoms resolve or, for those who never developed symptoms, until they meet the criteria to end isolation.
  • Immunocompromised residents or those who have severe symptoms may have specialized transmission-based precautions tailored by their healthcare providers in support of their needs, which may include precautions for a longer duration than 10 days.
  • If COVID symptoms rebound, these residents should be placed back into isolation until they again meet the healthcare criteria to discontinue isolation precautions.

Staff

Work restrictions and precautions after exposure:

All AFRH staff are defined as HCP. Exposures can occur both while at work and in the community.  In general, most asymptomatic staff who have had a COVID exposure do not require work restriction, regardless of vaccination status, if they do not develop symptoms or test positive for COVID.

Higher-risk exposures generally involve exposure of the staff member's eyes, nose, or mouth to material potentially containing the SARS-CoV-2 virus, particularly if the staff member was present in the room for an aerosol generating procedure such as a nebulized treatment.

Following a higher-risk exposure, staff should have a series of three (3) rapid antigen tests for COVID.  Test on days 1, 3, and 5 following exposure.  Testing is generally not recommended for asymptomatic exposed staff that have recovered from COVID infection in the prior 30 days.

Exposed staff will wear a KN95 or N95 mask while performing their job as recommended for the 10 days following exposure.

Work restriction is not necessary for most asymptomatic staff following even higher-risk exposure, regardless of vaccination status.  Examples of when work restriction may be considered include:

  • The staff member is unable to test.
  • The staff member is unable medically to wear a KN95 or N95 while performing their job as recommended for the 10 days following exposure.
  • The staff member is moderately to severely immunocompromised and their provider places work restrictions.
  • The staff member directly cares for or works on a unit with patients who are moderately to severely immunocompromised.

If work restriction quarantine is recommended, staff could return to work after the following time periods:

  • After day 7, if they do not develop symptoms, and if all tests are negative, these staff must wear an N95 or KN95 mask for at least 10 days after exposure or infection and must be physically able to wear the mask while performing their duties.
  • If viral testing is not performed, staff can return to work after day 10 following exposure if they do no develop symptoms.

Staff who test positive at any point will then follow the rubric below for infection isolation.

Work restrictions and precautions with positive COVID:

Staff with positive COVID tests who remain asymptomatic will isolate and could return to work after:

  • Seven (7) days if a negative test is obtained within 48 hours prior to returning to work.
  • Ten (10) days if testing is not performed or if a positive test during days 5-7.

These staff must wear an N95 of KN95 mask at least 10 days after infection and must be physically able to wear the mask while performing their duties.

Staff with mild to moderate COVID illness will isolate and could return to work after:

  • Seven (7) days have passed since symptoms first appeared if a negative test is taken within 48 hours prior to returning to work.
  • Ten (10) days if testing is not performed or if a positive test during days 5-7.

Staff may not return to work until at least 24 hours have passed since last fever without the use of fever-reducing medications and symptoms have improved.

Staff with severe to critical illness or who are moderately to severely immunocompromised should consult thier physician for individualized guidance prior to returning to work.

CDC guidelines for conventional staffing were updated to advise that, in most circumstances, asymptomatic healthcare personnel with higher-risk exposures do not require work restriction, regardless of their vaccingation status; therefore, the contingency and crisis strategies in previous editions of this memo have been removed.  In certain critical staffing cases, negative test and return to work options less than those described above may be authorized by campus Administrators in consultation with the campus Chief of Healthcare Services or Headquarters Chief Medical Officer considering individual circumstances and staffing needs in alignment with CDC guidance.  Staff authorized to return to work under thses circumstances must wear an N95 or KN95 mask at least 10 days after infection and must be physically able to wear the meask while performing their duties.

Aerosol-Generating Procedures

Procedures that could generate aerosols should be performed cautiously and avoided if appropriate alternatives exist.  The number of HCP present during the procedure should be limited to only those essential for patient care and procedure support. N95s must be worn by staff.  Visitors should not be present for the procedure.

Dental Care

Residents with suspected or confirmed COVID should postpone all non-urgent dental treatment until they meet criteria to discontinue transmission-based quarantine and isolation precautions.  Because dental patients cannot wear a mask, in general, those who have had qualifying exposure to COVID should also postpone all non-urgent dental treatment until they meet the healthcare criteria to end quarantine.

Gatherings and Social Distancing

Large crowds should be avoided when possible. Social distancing of 6 feet between all people whenever possible regardless of group size, including in the dining hall, and masking is strongly recommended at indoor group events. Ventilation should be maximized with fresh outdoor air when possible in any area where groups of people are located. Independent Living residents should limit the number of visitors in their apartment to ensure 6 feet of social distancing can be maintained. Virtual meetings are strongly encouraged, particularly for staff.

Off-Campus Activities

Residents intending to participate in activities off campus are strongly recommended to obtain the latest booster vaccine, in consultation with their healthcare provider, before doing so.

All residents and staff should try to avoid off-campus areas with known high community levels, as reported by CDC at https://www.cdc.gov/coronavirus/2019-ncov/your-health/covid-by-county.html. Large groups and crowds should be avoided if possible. AFRH encourages residents and staff to continue wearing masks when interacting off-campus with the general public.

All occupants in shuttle buses or shared vehicles should wear masks, distance as much as possible, and maximize ventilation.  Staff must wear masks when in AFRH vehicles with other persons.  Residents are encouraged to wear masks.

Travel

Travel increases your chance of spreading and getting COVID. If you do travel, AFRH strongly recommends you take these actions to protect yourself and others from COVID:

  • Contact the Wellness Center prior to your trip if you will travel via common carrier (such as an airplane). Consider asking for a COVID test within 2 days prior to departure.
  • Check https://covid.cdc.gov/covid-data-tracker/#county-view prior to making any travel plans to avoid areas with high local community levels. If the destination has high community levels, it is advised to wear a mask while there.
  • During travel by common carrier, consider wearing a mask, avoid crowds, and stay 6 feet or more away from others if possible, and wash or sanitize your hands often.
  • After travel via common carrier, self-monitor for symptoms and contact the Wellness Center immediately if you develop any symptoms. Request rapid tests on days 1, 3, and 5 after returning.

Visitors and Volunteers

AFRH will continue to assume that visitors represent COVID exposure risks.

Consistent with Safer Federal Workforce Task Force guidance, AFRH will not collect vaccination information from visitors or volunteers or on-site contractors.

Campus Administrators may permit visitors outside the buildings and in designated areas inside the buildings, subject to the following:

  • Visitors must follow core infection prevention protocols and screening procedures per current campus guidance at all times while on AFRH grounds.
  • Visitors must adhere to campus requirements for wearing masks and are encouraged to wear them in AFRH buildings even when not required. Visitors must wear masks in healthcare units and whenever the CDC community level is high.
  • Visitors will not be permitted if they have had a fever or other COVID symptoms within 24 hours, or have had any COVID diagnosis, or have been in isolation or quarantine within the past 10 days.
  • Campuses will explain the risks associated with visitation to residents and visitors so they can make an informed decision about participation.
  • Visitors must remain in designated areas to minimize contact with other residents and staff.
  • Indoor visits may need to be scheduled in advance due to space and staffing limitations and to aid contact tracing if needed.
  • Indoor visitation for residents in quarantine or isolation will be limited to compassionate care situations as permitted by the campus Administrator, in consultation with the Chief of Healthcare Services or Headquarters Chief Medical Officer.

Tours for Prospective Residents

AFRH will remain closed to the general public for indoor tours without prior approval by campus Administrators.  Prospective residents may tour the facilities by appointment only.  Tour participants must follow core infection prevention protocols and guidance for visitors, particularly regarding symptoms or COVID diagnosis, at all times during their visit. They will not be permitted in Assisted Living, Long Term Care, and Memory Support at this time.

New Admissions

Incoming residents will follow protocols including testing for COVID within 48 hours prior to arrival, having a health screening upon arrival, and submitting information on their COVID vaccination status including any boosters to the Wellness Clinic. 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.  Residents who are not up to date on their COVID vaccinations will be offered the opportunity to receive the vaccines.  Incoming residents will also follow all outlined rules if a companion is needed to assist them with their move-in, or if a moving company is needed.  Residents are encouraged to ask companions to be fully vaccinated and up to date on boosters. Companions must follow the above guidance for visitors and volunteers.  Newly admitted residents must wear masks for the 10 days following admission.  Residents in Assisted Living, Long-Term Care, and Memory Support levels of care who leave the facility for 24 hours or longer should wear masks for source control for the 10 days following their return.

CONDUCT

Failure to observe core infection prevention protocols may result in disciplinary measures or exclusion from certain areas. Only managers and healthcare providers have a need to query any individual regarding COVID related issues.

CONCLUSION

AFRH will continue to assess current conditions and adjust protective measures as necessary, utilizing resources including but not limited to the Department of Defense, CDC, Executive Orders, and other applicable Federal guidance. Our ultimate goal has been, and continues to be, to maintain a safe and healthy environment for our residents, staff, and visitors.

 

JOHN S. RISCASSI

JOHN S. RISCASSI
Chief Operating Officer

1https://www.cdc.gov/infectioncontrol/guidelines/healthcare-personnel/appendix/terminology.html (10/2/2019 rev.)

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