Considerations When Preparing for COVID-19 in Assisted Living Facilities

Key Actions
  • Assisted living facility (ALF) owners and administrators are urged to implement these recommendations to protect their residents and staff.
    • They should ensure staff know how to contact the health department for any of the following:
      • If COVID-19 is suspected or confirmed among residents or facility personnel
      • If a resident develops severe respiratory infection
      • If more than 2 residents or facility personnel develop fever or respiratory symptoms within 72 hours of each other.
    • CDC has resourcespdf icon that can assist with tracking infections.
  • State licensing authorities, which have oversight of ALFs, are encouraged to share this guidance with all ALFs in their jurisdiction and work with state healthcare-associated infections programs to assist ALFs with implementation.

Given their congregate nature and population served, assisted living facilities (ALFs) are at high risk of COVID-19 spreading and affecting their residents. If infected with SARS-CoV-2, the virus that causes COVID-19, assisted living residents—often older adults with underlying chronic medical conditions—are at increased risk of serious illness. CDC is aware of suspected and confirmed cases of COVID-19 among residents of ALFs in multiple states. Recent experience with outbreaks in nursing homes has also reinforced that residents with COVID-19 may not report typical symptoms such as fever or respiratory symptoms; some may not report any symptoms. Unrecognized asymptomatic and pre-symptomatic infections likely contribute to transmission in these settings. Because of this, CDC is recommending that the general public wear a cloth face covering for source control whenever they leave their home. Updates were also made to CDC’s Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings to address universal source control for everyone in a healthcare facility. Refer to that guidance for more detailed recommendations, including when facemasks versus cloth face coverings could be used.

CDC has released Interim Additional Guidance for Infection Prevention and Control for Patients with Suspected or Confirmed COVID-19 in Nursing Homes. Many of the recommended actions to prepare for COVID-19 described in that guidance also apply to ALFs.

CDC has also released guidance Interim Guidance for Preventing the Spread of COVID-19 in Retirement Communities and Independent Living Facilities.

However, as states are responsible for licensing and regulating ALFs, the structure and care provided within ALFs can be distinctly different from that of nursing homes. As such, implementing that guidance might present some unique challenges or additional considerations state by state.

For example, the care provided in ALFs can vary greatly by the extent and type of supervision and provision of skilled nursing services. Full- or part-time nursing staff are typically not required in ALFs, and residents may receive care from contract healthcare personnel (HCP) or use outpatient providers. Because staff at many of these facilities are generally not trained to provide medical care, their access to and training to use recommended personal protective equipment (PPE) and their ability to care for residents with COVID-19 is limited. Many ALFs will not have access to an Infection Preventionist or professional nursing staff that can assist with COVID-19 preparation, prevention, and control efforts. Further, because the care and documentation of resident conditions may not be centralized within the facility, identification of a cluster or residents with fever or respiratory symptoms might be delayed.

Definitions:

Cloth face covering: Textile (cloth) covers that are intended to keep the person wearing one from spreading respiratory secretions when talking, sneezing, or coughing. They are not PPE and it is uncertain whether cloth face coverings protect the wearer. Guidance on design, use, and maintenance of cloth face coverings is available.

Facemask: Facemasks are PPE and are often referred to as surgical masks or procedure masks. Use facemasks according to product labeling and local, state, and federal requirements. FDA-cleared surgical masks are designed to protect against splashes and sprays and are prioritized for use when such exposures are anticipated, including surgical procedures. Facemasks that are not regulated by FDA, such as some procedure masks, which are typically used for isolation purposes, may not provide protection against splashes and sprays.

Respirator: A respirator is a personal protective device that is worn on the face, covers at least the nose and mouth, and is used to reduce the wearer’s risk of inhaling hazardous airborne particles (including dust particles and infectious agents), gases, or vapors. Respirators are certified by the CDC/NIOSH, including those intended for use in healthcare. Refer to the Appendix for a summary of different types of respirators.

To prepare for COVID-19 in their facilities, ALFs should take the following actions:

Educate residents, family members, and personnel about COVID-19:

  • Have a plan and mechanism to regularly communicate with personnel, residents, and any family members specified by the resident.
  • Provide information about COVID-19 (including information about signs and symptoms) and strategies for managing stress and anxiety.
  • Describe actions the facility is taking to protect residents and personnel.
  • Describe actions residents and personnel can take to protect themselves in the facility, emphasizing the importance of social (physical) distancing, hand hygiene, respiratory hygiene and cough etiquette, and source control.
    • Remind residents and visitors that public health authorities have urged older adults to remain home and limit their interactions with others. Encourage residents to remain in their rooms as much as possible, practice social (physical) distancing, and not allow outside visitors to the facility. If residents leave their room or are around others, they should wear a cloth face covering (if tolerated), regardless of symptoms. If the resident does not have a cloth face cover, a facemask may be used for source control if supplies allow.
  • Encourage residents, personnel, and visitors to remain vigilant for and immediately report fever or symptoms consistent with COVID-19 (e.g., sore throat, new or worsening cough, shortness of breath, muscle aches).
    • Ask visitors to inform the facility if they develop fever or symptoms consistent with COVID-19 within 14 days of visiting the facility.

Keep COVID-19 from entering the facility:

  • Ask residents to not allow outside visitors until further notice. Visitor restrictions are to protect them and others in the facility who might have conditions making them more vulnerable to COVID-19. Facilitate alternative methods of communication (e.g., video conferencing).
  • Create or review an inventory of all volunteers and personnel who provide care in the facility. Use that inventory to determine which personnel are non-essential and whose services can be delayed. This inventory can also be used to notify personnel if COVID-19 is identified in the facility.
  • Restrict all volunteers and non-essential personnel including consultant services (e.g., barber, nail care).
  • Post signage at all entrances and leave notices for contract service providers at all residences that discourage visitors. Signs should remind visitors and personnel to not to enter the building if they have fever or symptoms of COVID-19.
  • Consider designating one central point of entry to the facility and establishing visitation hours if visitation must occur.
  • As part of source control efforts, personnel should wear a facemask (or cloth face covering if facemask not available) at all times while they are in the facility. When available, facemasks are generally preferred over cloth face coverings for healthcare personnel as facemasks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others. If there are shortages of facemasks, facemasks should be prioritized for healthcare personnel and then for residents with symptoms of COVID-19 (as supply allows).  Guidance on extended use and reuse of facemasks is available. Cloth face coverings should NOT be worn instead of a respirator or facemask if more than source control is required.
    • All personnel should be reminded to practice social distancing (e.g., remain at least 6 feet apart while in break rooms and common areas, cancel non-essential meetings).
  • Designate one or more facility employees to actively screen all visitors and personnel, including essential consultant personnel, for the presence of fever and symptoms of COVID-19 before starting each shift/when they enter the building. Send visitors and personnel home if they are ill or have a fever of 100.0°F or greater. Ill personnel should be prioritized for testing.
  • Implement sick leave policies that are flexible and non-punitive.
    • Personnel who work in multiple locations may pose higher risk and should be encouraged to tell facilities if they have had exposure to other facilities with recognized COVID-19 cases.
  • Ask residents not to leave the facility except for medically necessary purposes. Cancel all group field trips.
  • Ensure residents who must leave the facility (e.g., residents receiving hemodialysis) wear their cloth face covering whenever leaving the facility.

Implement recommended infection prevention and control practices:

  • Provide access to alcohol-based hand sanitizer with 60-95% alcohol throughout the facility and keep sinks stocked with soap and paper towels.
  • Ensure adequate cleaning and disinfection supplies are available. Provide EPA-registered disposable disinfectant wipes so that commonly used surfaces can be wiped down. Routinely (at least once per day, if possible) clean and disinfect surfaces and objects that are frequently touched in common areas. This may include cleaning surfaces and objects not ordinarily cleaned daily (e.g., door handles, faucets, toilet handles, light switches, elevator buttons, handrails, countertops, chairs, tables, remote controls, shared electronic equipment, and shared exercise equipment). Use regular cleaners, according to the directions on the label. For disinfection, most common EPA-registered household disinfectants should be effective. A list of products that are EPA-approved for use against the virus that causes COVID-19 is available hereexternal icon. Follow the manufacturer’s instructions for all cleaning and disinfection products (e.g., concentration, application method and contact time).
  • Cancel all group activities. Instead of communal dining, consider delivering meals to rooms, creating a “grab n’ go” option for residents, or staggering meal times to accommodate social distancing while dining (e.g., a single person per table).
  • Work to implement social distancing among residents. Social distancing means people remain at least 6 feet apart to limit potential for transmission.

Rapidly identify and properly respond to residents with suspected or confirmed COVID-19:

  • Designate one or more facility employees to ensure all residents have been asked at least daily about fever and symptoms of COVID-19 (e.g., sore throat, new or worsening cough, shortness of breath, muscle aches).
    • Implement a process or facility point of contact that residents can notify (e.g., call by phone) if they develop symptoms.
  • If COVID-19 is identified or suspected in a resident (i.e., resident reports fever or symptoms of COVID-19), immediately isolate the resident in their room and notify the health department.

    Older people with COVID-19 may not show typical symptoms such as fever or respiratory symptoms. Atypical symptoms may include: new or worsening malaise, new dizziness, or diarrhea. Identification of these symptoms should prompt isolation and further evaluation for COVID-19. Additional information about clinical presentation of patients with COVID-19 is available.

    • Encourage all residents to self-isolate, if not already doing so.
    • Implement processes to maintain social distancing (remaining at least 6 feet apart) between all residents and personnel while still providing necessary services.
    • For situations where close contact between any (symptomatic or asymptomatic) resident cannot be avoided, personnel should at a minimum, wear eye protection (goggles or face shield) and an N95 or higher-level respirator (or a facemask if respirators are not available or personnel are not fit tested). Cloth face coverings are not PPE and should not be used when a respirator or facemask is indicated. If personnel have direct contact with the resident, they should also wear gloves. If available, gowns are also recommended but should be prioritized for activities where splashes or sprays are anticipated or high-contact resident-care activities that provide opportunities for transfer to pathogens to hands and clothing of personnel (e.g., dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, wound care).
    • Personnel who do not interact with residents (e.g., not within 6 feet) and do not clean patient environments or equipment do not need to wear PPE. Consistent with the guidance for the general public, however, they should wear a cloth face covering for source control.
    • Personnel who are expected to use PPE should receive training on selection and use of PPE, including demonstrating competency with putting on and removing PPE in a manner to prevent self-contamination.
    • CDC has provided strategies for optimizing personal protective equipment (PPE) supply that describe actions facilities can take to extend their supply if, despite efforts to obtain additional PPE, there are shortages. These include strategies such as extended use or reuse of respirators, facemasks, and disposable eye protection.
  • An ill resident might be able to remain in the facility if the resident:
    • Is able to perform their own activities of daily living
    • Can isolate in their room for the duration of their illness
    • Can have meals delivered
    • There is a mechanism for staff to regularly check on the resident (e.g., checking in by phone during each shift; visits by home health agency personnel who wear all recommended PPE)
    • Is able to request assistance
  • It might also be possible for ill residents who require more assistance to remain in the facility if they can remain isolated in their room, and on-site or consultant personnel can provide the level of care needed with access to all recommended PPE and training on proper selection and use.
  • If the ill resident requires more assistance than can be safely provided by on-site or consultant personnel (e.g., home health agency), they should be transferred (in consultation with public health) to another location (e.g., alternate care site, hospital) that is equipped to adhere to recommended infection prevention and control practices. Transport personnel and the receiving facility should be notified about the suspected diagnosis prior to transfer.
    • While awaiting transfer, symptomatic residents should wear a cloth face covering (if tolerated) and be separated from others (e.g., kept in their room with the door closed). Appropriate PPE (as described above) should be used by healthcare personnel when coming in contact with the resident.
  • If residents are transferred to the hospital or another care setting, actively follow up with that facility and resident family members to determine if the resident was known or suspected to have COVID-19. This information will inform need for contact tracing or implementation of additional IPC recommendations.

Resources:

Interim Additional Guidance for Infection Prevention and Control for Patients with Suspected or Confirmed COVID-19 in Nursing Homes

Strategies to Optimize the Supply of PPE and Equipment

Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease (COVID-19)

Discontinuation of Transmission-Based Precautions and Disposition of Patients with COVID-19 in Healthcare Settings (Interim Guidance)

Criteria for Return to Work for Healthcare Personnel with Confirmed or Suspected COVID-19 (Interim Guidance)