Georgia DPH Provides Guidance to LTCFs on Admitting Residents from a Hospital

As coronavirus infections continue to spike nationwide prompting an increase in hospitalizations, the Georgia Department of Public Health (DPH) recently issued interim guidance for long-term care facilities (LTCFs), including nursing homes and assisted living communities, regarding how such facilities should care for residents being admitted from the hospital.

The guidance states that LTCFs “ideally” should not admit residents when such facilities are experiencing a COVID-19 outbreak and are conducting weekly follow up testing; however, DPH recognizes that flexibility should be maintained to admit residents if hospital capacity is limited and the particular circumstances within the facility are such that resident safety can be maintained.  As a result, the following factors should be considered:

• Availability of leadership and resident care staff to direct and implement proper infection prevention practices;
• Sufficient PPE to properly provide quarantine and transmission-based precautions;
• An established observation unit with sufficient capacity for new residents;
  • Any observation unit should be separate from the facility’s COVID-19 unit and can be a floor, a wing, or even just a group of rooms at the end of a hallway. Residents coming from the hospital whose COVID-19 status is not known should be housed in the observation unit and monitored at least three (3) times per day for symptoms for a period of 14 days.
• An established COVID-19 unit with the ability to provide designated staff; and
• No evidence of ongoing transmission of COVID-19 among residents.

DPH makes clear, however, that any LTCF that accepts admissions during an outbreak must disclose the presence of COVID-19 cases to the resident, the resident’s family or other representatives, and the transferring facility prior to admission.  This may have a chilling effect on the willingness of the resident and/or family to accept placement in the facility.  Much depends on the case rate in the broader community and, more importantly, in other LTCFs in the same general service area.

The guidance also makes recommendations for newly admitted residents regarding transmission-based precautions.  Residents should be placed in a non-airborne isolation room unless aerosol-producing procedures will be performed, in which event the resident should be placed in an airborne isolation room. If a separate isolation room is not available, the resident can be cohorted with other residents with confirmed COVID-19, though it is unclear whether this cohorting recommendation applies to newly admitted residents who are merely suspected of having COVID-19.  If this is the case, it would seemingly conflict with Centers for Disease Control (CDC) recommendations that call for separate cohorting of residents suspected of having COVID-19.

Facilities should employ a symptom-based or time-based strategy for discontinuation of transmission-based precautions.  A test-based strategy should be implemented only in a very narrow set of circumstances.

Facilities may consider discontinuing transmission-based precautions for residents with symptomatic COVID-19 infection as follows:

• For residents with mild to moderate illness, who are not severely immunocompromised, when at least ten (10) days have passed since symptoms first appeared; at least 24 hours have passed since the last sign of a fever (without the use of fever-reducing medications); and symptoms have improved.
• For residents with severe to critical illness or those who are severely immunocompromised, when at least twenty (20) days have passed since symptoms first appeared; at least 24 hours have passed since the last sign of a fever (without the use of fever-reducing medications); and symptoms have improved.

DPH includes in the guidance definitions for the severity of illness and degree of immunocompromization within the guidance.

LTCFs may consider discontinuing transmission-based protocols for residents with asymptomatic COVID-19 infection who are not severely immunocompromised at least ten (10) days after the date of their first positive viral test.  For residents who are severely immunocompromised, transmission-based protocols may be discontinued at least twenty (20) days after the date of their first viral test.

With respect to residents suspected of having COVID-19, transmission-based precautions can be discontinued after the resident has received a negative result from a molecular assay for detection of the SARS-CoV-2 virus; however, if there is a higher level of clinical suspicion for COVID-19, then precautions should be maintained and a second test should be performed.  If a resident suspected of having COVID-19 never receives a test, then the symptom-based strategy should be employed to determine whether transmission-based precautions may be discontinued.

LTCFs in Georgia will need to ensure that their policies and procedures adequately address the circumstances outlined in the guidance.  To date, the Centers for Medicare and Medicaid Services have not released similar guidance directed to LTCFs within the agency’s regulatory purview.