August 18, 2023
MODIFICATION OF COVID PROTECTIVE MEASURES (CHANGE #7)
**Subject to Change**
Updates related to termination of the national emergency and federal public health emergency related to the COVID-19 pandemic.
Previous versions dated May 17, 2021; September 29, 2021; January 12, 2022; March 3, 2022; May 17, 2022; and January 27, 2023 are obsolete.
This memorandum provides updated guidance to both AFRH campuses for measures related to COVID-19 following expiration of the national emergency.
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.
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.
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.
Healthcare settings/units: AFRH healthcare settings/units include the Wellness Centers and the Assisted Living, Long-Term Care, and Memory Support levels of care.
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: Refers to 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:
- Positive cases on campus.
- 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).
- Six (6) feet of physical distancing is encouraged, if possible.
- 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.
Residents, staff, and visitors who do not have COVID or COVID-like symptoms and who are not at high risk for severe COVID illness are not required to wear masks except as specified below, and unless the Campus Administrator requires it due to a local surge in cases as indicated by local data posted by the CDC and cases at the facility.
The Campus Administrators will monitor cases at the facility and CDC data tracking local hospitalization rates from COVID-19 in their respective counties for changes and post notifications if masks become required in non-healthcare areas.
It is important to recognize that healthcare settings have separate CDC guidelines and masking continues to be mandatory in certain healthcare settings at AFRH.
- Visitors to assisted living, long term care, and memory support units, are required to wear masks according to current conditions, and are encouraged to wear masks in these units at other times. KN95 or surgical masks are specifically recommended since these medical-grade masks are more protective than standard cloth masks and do not require fit testing, training, medical questionnaires, or approval before use..
- Staff must wear N95, KN95, or surgical masks according to current conditions in Assisted Living, Long Term Care, and Memory Support 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.
- Any resident, staff, or visitor presenting to the Wellness Center with COVID-like symptoms will be required to mask and any HCP caring for them in the Wellness Center will be required to wear PPE including N95 masks..
Common sources for new COVID infection have been from those returning from inpatient hospital stays and travel. Residents in assisted living, long-term care, and memory support levels of care who are hospitalized or otherwise leave AFRH for 24 hours or longer will be rapid tested at the Wellness Center and are encouraged to wear masks for the 10 days following their return to campus.
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.
COVID vaccinations are not mandatory for residents. Voluntary COVID vaccination is encouraged but not required. Vaccination status documentation is not required for staff, visitors, volunteers, or on-site contractors.
For residents, staff, and visitors who have had their primary series of the vaccine, the recommendation is to have at least one updated booster per year if eligible. If it has been 2 months or more since the last vaccine dose, check with your healthcare provider to see if you are eligible to receive a booster.
People aged 65 years and older may get one additional dose of bivalent COVID-19 vaccine 4 or more months after the first updated bivalent COVID-19 vaccine.
People who are moderately or severely immunocompromised may get one additional dose of updated bivalent COVID-19 vaccine 2 or more months after the first updated bivalent COVID-19 vaccine.
Talk to your healthcare provider about additional updated doses. The CDC recommends everyone age 6 months or older gets one updated vaccine dose. Additionally, getting a vaccine booster dose after you have recovered from a COVID infection provides added protection from getting COVID again.
Symptomatic individuals will immediately receive rapid testing. Residents will receive follow-up PCR tests. Asymptomatic individuals identified through contact tracing will receive a rapid test on days 1 and 5 after potential exposure and be asked to self monitor for the onset of symptoms.
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, weekly testing should continue for those in the identified group 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.
AFRH physicians and nurse practitioners have more information and may be able to prescribe COVID treatments for residents.
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.
On 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.
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 determining the duration of transmission-based quarantine or isolation precautions, the first day of known exposure, symptoms, or positive COVID test is counted as day zero. The first day after a positive COVID test is counted as day one.
Quarantine after exposure:
All AFRH residents, regardless of vaccination or asymptomatic status, who have a known qualifying exposure to COVID (see definition, which includes returning from an inpatient stay) will receive rapid tests for COVID. Testing is advised on days 1 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 advised to monitor or be monitored for symptoms and to wear a mask for 10 days. Exposed residents should limit interactions with others and their movements around the facility as much as possible during this 10-day period. To that end, staff will monitor and assist residents in quarantine as described in the management and treatment section above. In general, residents who wear a mask, participate in monitoring for symptoms, and socially distance as much as possible, and limit their movements around the facility as much as possible will not have to quarantine after exposure.
However, the following residents must quarantine in their apartments following known exposure:
- Residents of Assisted Living, Long-Term Care, and Memory Support units who are unable or decline to wear a mask as recommended for 10 days following exposure.
- Residents who are severely immunocompromised.
- Residents who are unable to test.
The time period for quaratine, if required, is as follows:
- Residents who complete the tests described above with all negative tests and no development of symptoms may exit quarantine on day 5 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 and cannot wear a mask.
Residents who have been exposed to COVID should NOT be cohorted with residents with confirmed COVID. Campus Administrators, in collaboration with chiefs of healthcare services and resident services, 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:
AFRH observes CDC recommendations for healthcare in the community setting2 . In general:
- Residents who test positive but are asymptomatic or have mild COVID symptoms will isolate through at least day 5 if they are able to wear a mask through day 10.
- Residents with moderate or severe COVID symptoms or those who cannot wear a mask will isolate through at least day 10. Those with severe Covid may remain infectious beyond 10 days and may need to extend isolation for up to 20 days.
- 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.
Residents will isolate in a location determined by the Campus Administrator, and staff will monitor and assist residents in isolation as described in the management and treatment section above. In general, isolation may end once fever has resolved for at least 24 hours (without taking fever-reducing medications) and other symptoms are improving. Loss of taste and smell may persist for weeks or months after recovery and need not delay the end of isolation. Campus healthcare providers will determine when isolation may end based on the resident’s individual circumstances. If symptoms recur or worsen, the isolation period will restart.
Work restrictions and precautions after exposure:
In general, most asymptomatic staff who have had a COVID exposure, including higher-risk 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 tests for COVID. Test on days 1 and 5 following exposure. Testing is generally not recommended for asymptomatic exposed staff that have recovered from COVID infection in the prior 30 days. Following higher-risk exposure, staff will wear a KN95 or N95 mask while performing their job as recommended for the 10 days following exposure.
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.
In those cases where work restriction 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 will isolate and could return to work after:
- For those who remain asymptomatic, 5 days if a negative test is obtained within 48 hours prior to returning to work. These staff must wear an N95 or KN95 mask at least 10 days after infection and must be physically able to wear the mask while performing their duties.
- For those with mild to moderate COVID illness, 5 days since symptoms first appeared if a negative test is taken within 48 hours prior to returning to work. 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. These staff must wear an N95 or KN95 mask at least 10 days after infection and must be physically able to wear the mask while performing their duties.
- Ten (10) days if testing is not performed, if the staff member is unable to wear an N95 or KN95 mask, or if a positive test during days 5-7.
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.
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.
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 but not required at indoor group events.
Ventilation should be maximized with fresh outdoor air when possible in any area where groups of people are located.
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:
- During travel by common carrier, consider wearing a mask, avoid crowds and stay 6 feet or more away from others when possible, and wash or sanitize hands often.
- 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.
- Upon return, consider wearing a mask for 10 days and get rapid tested.
- All occupants in shuttle buses or shared vehicles are encouraged but not required to wear masks. Good ventilation is strongly encouraged.
Visitors and Volunteers
Campus Administrators may permit visitors 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 will not be permitted if they have had a fever or other COVID symptoms, have had any positive 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.
- Indoor visitation for residents in quarantine or isolation for positive COVID will be limited to compassionate care situations as permitted by the Campus Administrator, in consultation with the Chief of Healthcare Services or Chief Medical Officer.
Tours for Prospective Residents
Prospective residents may tour the facilities by appointment only. Tour participants must follow core infection prevention protocols and guidance for visitors at all times during their visit, particularly regarding symptoms or COVID diagnosis. They may be asked to wear masks if they tour Assisted Living, Long Term Care, and Memory Support as determined by the Campus Administrator.
New residents to the home will be asked to follow the core infection prevention protocols, self-monitorfor 10 days after arrival and notify the Wellness Center if they develop symptoms.
Failure to observe core infection prevention protocols may result in re-education requirements, disciplinary measures, and/or exclusion from certain areas. Only managers and healthcare providers have a need to query any individual regarding COVID related issues.
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
Chief Operating Officer
2 https://www.cdc.gov/coronavirus/2019-ncov/hcp/duration-isolation.html (8/31/2022 rev.)
ARCHIVE OF COVID RELATED MATERIALS:
- 27 January 2023, COO Memo Modification of COVID Protective Measures (Change 6)
- 17 May 2022, COO Memo Modification of COVID Protective Measures (Change 5)
- 3 Mar 2022, COO Memo Modification of COVID Protective Measures (Change 4)
- 12 Jan 2022, COO Memo Modification of COVID Protective Measures (Change 3)
- 29 Sep 2021, COO Memo Modification of COVID-19 Protective Measures (Change 2)
- 17 May 2021, COO Memo Post Vaccine Pilot Modification of Protective Measures (Change 1)
- 25 August 2021, COO Memo Campus Operations and Quarantines (with Process Map and Operational Services Table)