Testing Guidance for Nursing Homes

Interim Testing Guidance in Response to Suspected or Confirmed COVID-19 in Nursing Home Residents and Healthcare Personnel

Updated May 19, 2020

Summary of Changes to the Guidance:

Nursing home residents are at high risk for infection, serious illness, and death from COVID-19. Testing for SARS-CoV-2, the virus that causes COVID-19, in respiratory specimens can detect current infections (referred to here as viral testing or test) among residents and healthcare personnel (HCP) in nursing homes. Viral testing in nursing homes is an important addition to other infection prevention and control (IPC) recommendations aimed at:

  • Keeping COVID-19 out
  • Detecting cases quickly
  • Stopping transmission

Testing should not supersede existing IPC interventions.

Testing conducted at nursing homes should be implemented in addition to recommended IPC measures.

Testing should be used when results will lead to specific IPC actions.

Viral testing can be used to inform additional IPC actions necessary to keep SARS-CoV-2 out of facilities, detect COVID-19 cases quickly, and stop transmission. Testing practices should aim for rapid turn-around-times (e.g., less than 48 hours) in order to facilitate effective IPC action. At the current time, antibody test results should not be used to diagnose someone with an active SARS-CoV-2 infection and should not be used to inform IPC action.

While this guidance focuses on testing in nursing homes, it can also be applied to other long-term care facilities (e.g., assisted living facilities).  Nursing homes should adhere to any state or federal testing requirements.

Keeping COVID-19 out

  • Actively screen all HCP for fever and COVID-19 symptoms at the start of their shift; test any who screen positive.
    • HCP who have fever or symptoms should be excluded from work pending results of the test.
    • HCP who test positive for COVID-19 should be excluded from work until they meet return to work criteria.
  • Facility leadership and local and state health departments should have a plan for meeting staffing needs to provide safe care to residents when HCP who test positive are excluded from work. CDC has created strategies to assist facilities with mitigating HCP shortages.
  • Baseline testing of all residents and HCP along with weekly testing of all HCP are recommended for nursing homes as part of the reopening processpdf iconexternal icon. State and local officials may adjust the requirement for weekly testing of HCP based on the prevalence of the virus in their community, for example performing weekly testing in areas with moderate to substantial community transmission. Facilities performing such surveillance should have a plan for testing (including access to testing with a rapid-turnaround-time) and responding to results. Decisions should be based on guidance from state and local officials.

Detecting cases quickly

  • Actively screen all residents for fever and COVID-19 symptoms each day and test any resident who exhibits fever or symptoms consistent with COVID-19.
  • Test all residents and HCP in the nursing home if there is a new confirmed case of COVID-19; this refers to new SARS-CoV-2 infection in any HCP or any nursing home-onset SARS-CoV-2 infection in a resident. During the reopening processpdf iconexternal icon, nursing homes should test all residents and staff when there is a suspected or confirmed case in any resident or a confirmed case in any HCP.
    • When one case is detected in a nursing home, there are often other residents and HCP who are infected with SARS-CoV-2 and can continue to spread the infection, even if they are asymptomatic. Testing all residents and HCP as soon as there is a new confirmed case in the facility will identify infected individuals quickly to allow rapid implementation of IPC interventions (e.g., isolation, cohorting, use of personal protective equipment). When undertaking facility-wide testing, facility leadership should expect to identify multiple asymptomatic residents and HCP with SARS-CoV-2 infection and be prepared to cohort residents and mitigate potential staffing shortages. See Public Health Response to COVID-19 in Nursing Homes and Strategies to Mitigate Healthcare Personnel Staffing Shortages for more detail.
    • If testing capacity is limited, CDC suggests directing testing to residents and HCP on the same unit or floor of a new confirmed case.
    • If testing all residents on the same unit or floor is also not possible, CDC suggests directing testing to symptomatic residents and HCP and residents who have known exposure to a case (e.g., roommates of cases or those cared for by a known positive HCP).
    • See Considerations for Performing Facility-wide SARS-CoV-2 Testing Nursing Homes for additional details.

Stopping transmission

  • After testing all residents and HCP in response to a new case, CDC recommends follow-up testing to ensure transmission has been terminated as follows:
    • Immediately test any resident or HCP who subsequently develops fever or symptoms consistent with COVID-19
    • Continue repeat testing of all previously negative residents (e.g., once a week) until the testing identifies no new cases of COVID-19 among residents or HCP over at least 14 days since the most recent positive result.
      • If test capacity is limited, CDC suggests directing repeat rounds of testing to residents who leave and return to the facility (e.g., for outpatient dialysis) or have known exposure to a case (e.g., roommates of cases or those cared for by a known positive HCP). For large facilities with limited test capacity, testing all residents on affected units could be considered, especially if facility-wide serial testing demonstrates no transmission beyond a limited number of units.
    • Continue repeat testing of all previously negative HCP (e.g., at least once a week, consider more frequent testing in settings where community incidence is high) until the testing identifies no new cases of COVID-19 among residents or HCP over at least 14 days since the most recent positive result.
      • If testing capacity is limited, CDC suggests directing repeat HCP testing to HCP who work at other facilities where there are known COVID-19 cases. 

Definitions

  • Healthcare Personnel (HCP): HCP include, but are not limited to, emergency medical service personnel, nurses, nursing assistants, physicians, technicians, therapists, phlebotomists, pharmacists, students and trainees, contractual HCP not employed by the healthcare facility, and persons not directly involved in patient care, but who could be exposed to infectious agents that can be transmitted in the healthcare setting (e.g., clerical, dietary, environmental services, laundry, security, engineering and facilities management, administrative, billing, and volunteer personnel).
  • Nursing home onset SARS-CoV-2 infections refers to SARS-CoV-2 infections that originated in the nursing home. It does not refer to the following:
    • Residents who were known to have COVID-19 on admission to the facility and were placed into appropriate Transmission-Based Precautions to prevent transmission to others in the facility.
    • Residents who were not known to have COVID-19 on admission but who became positive within 14 days after admission, as long as these individuals had been placed into Transmission-Based Precautions upon admission to prevent transmission to others in the facility.