Healthcare Workers

CDC’s COVID-19 Community Levels recommendations do not apply in healthcare settings, such as hospitals and nursing homes. Instead, healthcare settings should continue to use community transmission rates and continue to follow CDC’s infection prevention and control recommendations for healthcare settings.

Infection Prevention and Control Program

Assign One or More Individuals with Training in Infection Prevention and Control to Provide On-Site Management of the IPC Program

• This should be a full-time role for at least one person in facilities that have more than 100 residents or that provide on-site ventilator or hemodialysis services. Smaller facilities should consider staffing the IPC program based on the resident population and facility service needs identified in the IPC risk assessment.
• CDC has created an online training courseexternal icon that can orient individuals to this role in nursing homes.

Provide Supplies Necessary to Adhere to Recommended IPC Practices

• Ensure HCP have access to all necessary supplies including alcohol-based hand sanitizer with 60-95% alcohol, personal protective equipment (PPE), and supplies for cleaning and disinfection.
  • Put FDA-approved alcohol-based hand sanitizer with 60-95% alcohol in every resident room (ideally both inside and outside of the room) and other resident care and common areas (e.g., outside dining hall, in therapy gym).

Educate Residents, HCP, and Visitors about SARS-CoV-2, Current Precautions Being Taken in the Facility, and Actions They Should Take to Protect Themselves

• Regularly review CDC’s Interim Infection Control Recommendations for Healthcare Personnel During the COVID-19 Pandemic for current information and ensure staff and residents are updated when this guidance changes.
• Educate and train HCP about recommended practices to prevent spread of SARS-CoV-2, including reminding them not to report to work when ill.
  • Training should include facility-based and consultant personnel (e.g., rehabilitation therapy, wound care, podiatry, barber), ombudsmen, and volunteers who provide care or services in the facility. Including consultants is important since they commonly provide care in multiple facilities where they can be exposed to and serve as a source of SARS-CoV-2.
  • CDC has created training resources for front-line staff that can be used to reinforce recommended practices for preventing transmission of SARS-CoV-2 and other pathogens.
• Educate residents and families through educational sessions and written materials on topics, including information about SARS-CoV-2, actions the facility is taking to protect them and their loved ones from SARS-CoV-2, and actions they should take to protect themselves and others in the facility, emphasizing when they should wear source control, physically distance, and perform hand hygiene.

Notify HCP, Residents, and Families about Outbreaks, and Report SARS-CoV-2 Infections, Facility Staffing, Testing, and Supply Information to Public Health Authorities   

Vaccinations

Vaccinate Residents and HCP against SARS-CoV-2

Source Control and Physical Distancing Measures

Refer to Interim Infection Control Recommendations for Healthcare Personnel During the COVID-19 Pandemic for details regarding source control and physical distancing measures recommended for HCP, residents, and visitors.

Visitation

Have a Plan for Visitation

Additional information about visitation for nursing homesexternal icon and intermediate care facilities for individuals with intellectual disabilities and psychiatric residential treatment facilitiespdf iconexternal icon is available from CMS.

Guidance addressing visitation during an outbreak is described in Section: Respond to a Newly Identified SARS-CoV-2-infected Healthcare Personnel or Resident.

Personal Protective Equipment

Ensure Proper Use, Handling, and Implementation of Personal Protective Equipment

• Information on personal protective equipment (PPE), including the implementation of universal use of PPE, is available in:

Testing

Create a Plan for Testing Residents and HCP for SARS-CoV-2

• FDAexternal icon evaluates test characteristics and facilities should be aware of how tests perform for circulating variants.
• Anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test as soon as possible.
• Newly-admitted residents and residents who have left the facility for >24 hours, regardless of vaccination status, should have a series of two viral tests for SARS-COV-2 infection; immediately and, if negative, again 5-7 days after their admission.
• Asymptomatic residents with close contact with someone with SARS-CoV-2 infection, regardless of vaccination status, should have a series of two viral tests for SARS-CoV-2 infection. In these situations, testing is recommended immediately (but generally not earlier than 24 hours after the exposure) and, if negative, again 5–7 days after the exposure.
• In general, testing is not necessary for asymptomatic people who have recovered from SARS-CoV-2 infection in the prior 90 days; however, if testing is performed on these people, an antigen test instead of a nucleic acid amplification test (NAAT) is recommended. This is because some people may remain NAAT positive but not be infectious during this period.
• Guidance for HCP with higher-risk exposures, including exposures in the community is available in the Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2 | CDC
• Expanded screening testing of asymptomatic HCP should be as follows:
  • HCP who are up to date with all recommended COVID-19 vaccine doses may be exempt from expanded screening testing.
  • In nursing homes, HCP who are not up to date with all recommended COVID-19 vaccine doses should continue expanded screening testing based on the level of community transmission as follows:
    • In nursing homes located in counties with substantial to high community transmission, these HCP should have a viral test twice a week.
      • If these HCP work infrequently at these facilities, they should ideally be tested within the 3 days before their shift (including the day of the shift).
    • In nursing homes located in counties with moderate community transmission, these HCP should have a viral test once a week.
    • In nursing homes located in counties with low community transmission, expanded screening testing for asymptomatic HCP, regardless of vaccination status, is not recommended. Per recommendations above, these facilities should prioritize resources to test symptomatic people and all close contacts, as well as be prepared to initiate outbreak response immediately if a nursing home-onset infection is identified among residents or HCP.

Detailed information on outbreak testing is described in Section: New Infection In Healthcare Personnel or Resident.

Evaluating and Managing Personnel and Residents

Refer to CDC’s Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic for more information.

Identify Space in the Facility that Could be Dedicated to Monitor and Care for Residents with Confirmed SARS-CoV-2 Infection

• Determine the location of the COVID-19 care unit and create a staffing plan.
• The location of the COVID-19 care unit should ideally be physically separated from other rooms or units housing residents without confirmed SARS-CoV-2 infection. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with SARS-CoV-2 infection.
• Identify HCP who will be assigned to work only on the COVID-19 care unit when it is in use. At a minimum this should include the primary nursing assistants (NAs) and nurses assigned to care for these residents. If possible, HCP should avoid working on both the COVID-19 care unit and other units during the same shift.
  • To the extent possible, restrict access of ancillary personnel (e.g., dietary) to the unit.
  • Ideally, environmental services (EVS) staff should be dedicated to this unit, but to the extent possible, EVS staff should avoid working on both the COVID-19 care unit and other units during the same shift.
  • To the extent possible, HCP dedicated to the COVID-19 care unit (e.g., NAs and nurses) will also be performing cleaning and disinfection of high-touch surfaces and shared equipment when in the room for resident care activities. HCP should bring an Environmental Protection Agency (EPA)-registered disinfectant (e.g., wipe) from List Nexternal icon into the room and wipe down high-touch surfaces (e.g., light switch, doorknob, bedside table) before leaving the room.

Guidance addressing placement, duration, and recommended PPE when caring for residents with SARS-CoV-2 infection is described in Section: Manage Residents with Suspected or Confirmed SARS-CoV-2 infection.

Evaluate Residents at least Daily

• Ask residents to report if they feel feverish or have symptoms consistent with COVID-19 or an acute respiratory infection.
• Actively monitor all residents upon admission and at least daily for fever (temperature ≥100.0^°F) and symptoms consistent with COVID-19. Ideally, include an assessment of oxygen saturation via pulse oximetry. If residents have fever or symptoms consistent with COVID-19, implement precautions described in Section: Manage Residents with Suspected or Confirmed SARS-CoV-2 Infection.
  • Older adults with SARS-CoV-2 infection may not show common symptoms such as fever or respiratory symptoms. Other COVID-19 symptoms can include fatigue, muscle or body aches, headache, sore throat, loss of taste and/or smell, or new dizziness, nausea, vomiting, or diarrhea. Additionally, more than two temperatures >99.0^°F might also be a sign of fever in this population. Identification of these symptoms should prompt isolation and further evaluation for SARS-CoV-2 infection.
  • Because some of the symptoms are similar, it may be difficult to tell the difference between influenza, COVID-19, and other acute respiratory infections, based on symptoms alone. Consider testing for pathogens other than SARS-CoV-2 and initiating appropriate infection prevention precautions for symptomatic older adults.
  • Refer to CDC resourcespdf icon for performing respiratory infection surveillance in long-term care facilities during an outbreak.
• Information about the clinical presentation and course of patients with SARS-CoV-2 infection is described in the Management of Patients with Confirmed 2019-nCoV | CDC.

Manage Residents with Suspected or Confirmed SARS-CoV-2 Infection

• HCP caring for residents with suspected or confirmed SARS-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator).
• Ideally, a resident with suspected SARS-CoV-2 infection should be moved to a single-person room with a private bathroom while test results are pending.
  • In general, it is recommended that the door to the room remain closed to reduce transmission of SARS-CoV-2. This is especially important for residents with suspected or confirmed SARS-CoV-2 infection being cared for outside of the COVID-19 care unit. However, in some circumstances (e.g., memory care units), keeping the door closed may pose resident safety risks and the door might need to remain open. If doors must remain open, work with facility engineers to implement strategies to minimize airflow into the hallway.
• If limited single rooms are available, or if numerous residents are simultaneously identified to have known SARS-CoV-2 exposures or symptoms concerning for COVID-19, residents should remain in their current location pending return of test results.
• Residents should only be placed in a COVID-19 care unit if they have confirmed SARS-CoV-2 infection.
• Roommates of residents with SARS-CoV-2 infection should be managed as described in Section: Manage Residents who have had Close Contact with Someone with SARS-CoV-2 Infection.
• Increase monitoring of residents with suspected or confirmed SARS-CoV-2 infection, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to identify and quickly manage serious infection.
• For decisions on removing residents who have had SARS-CoV-2 infection from Transmission-Based Precautions, refer to the Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic.
• If a resident requires a higher level of care or the facility cannot fully implement all recommended infection control precautions, the resident should be transferred to another facility that is capable of implementation. Transport personnel and the receiving facility should be notified about the suspected diagnosis prior to transfer.

Manage Residents with Close Contact

Manage Residents who had Close Contact with Someone with SARS-CoV-2 Infection

• Residents who are not up to date with all recommended COVID-19 vaccine doses and who have had close contact with someone with SARS-CoV-2 infection should be placed in quarantine after their exposure, even if viral testing is negative. HCP caring for them should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator).
  • Residents can be removed from Transmission-Based Precautions after day 10 following the exposure (day 0) if they do not develop symptoms. Although the residual risk of infection is low, healthcare providers could consider testing for SARS-CoV-2 within 48 hours before the time of planned discontinuation of Transmission-Based Precautions.
  • Residents can be removed from Transmission-Based Precautions after day 7 following the exposure (day 0) if a viral test is negative for SARS-CoV-2 and they do not develop symptoms. The specimen should be collected and tested within 48 hours before the time of planned discontinuation of Transmission-Based Precautions.
• Residents who are up to date with all recommended COVID-19 vaccine doses and residents who have recovered from SARS-CoV-2 infection in the prior 90 days who have had close contact with someone with SARS-CoV-2 infection should wear source control and be tested as described in the testing section. In general, these residents do not need to be quarantined, restricted to their room, or cared for by HCP using the full PPE recommended for the care of a resident with SARS-CoV-2 infection unless they develop symptoms of COVID-19, are diagnosed with SARS-CoV-2 infection, or the facility is directed to do so by the jurisdiction’s public health authority. Quarantine might also be considered if the resident is moderately to severely immunocompromised.
• Guidance addressing quarantine and testing during an outbreak is described in Section: Respond to a Newly Identified SARS-CoV-2-infected Healthcare Personnel or Resident.

New Admissions and Residents who Leave the Facility

Create a Plan for Managing New Admissions and Readmissions

• Residents with confirmed SARS-CoV-2 infection who have not met New Infection in Healthcare Personnel or Residents

  When performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction’s public health authority.

  Respond to a Newly Identified SARS-CoV-2-infected HCP or Resident

  • Because of the risk of unrecognized infection among residents, a single new case of SARS-CoV-2 infection in any HCP or a nursing home-onset SARS-CoV-2 infection in a resident should be evaluated as a potential outbreak.
    • The approach to an outbreak investigation should take into consideration whether the facility has the experience and resources to perform individual contact tracing, the vaccination acceptance rates of staff and residents, whether the index case is a healthcare worker or resident, whether there are other individuals with suspected or confirmed SARS-CoV-2 infection identified at the same time as the index resident, and the extent of potential exposures identified during the evaluation of the index resident.
    • Consider increasing monitoring of all residents from daily to every shift, to more rapidly detect those with new symptoms.
  • HCP and residents with symptoms of COVID-19:
    • Symptomatic HCP, regardless of vaccination status, should be restricted from work pending evaluation for SARS-CoV-2 infection.
    • Symptomatic residents, regardless of vaccination status, should be restricted to their rooms and cared for by HCP using a NIOSH-approved N95 or equivalent or higher-level respirator, eye protection (goggles or a face shield that covers the front and sides of the face) gloves, and a gown pending evaluation for SARS-CoV-2 infection.
  • Perform contact tracing to identify any HCP who have had a higher-risk exposure or residents who may have had close contact with the individual with SARS-CoV-2 infection:
    • All HCP who have had a higher-risk exposure and residents who have had close contacts, regardless of vaccination status, should be tested as described in the testing section.
    • Residents who are close contacts should be managed as described in Section: Manage Residents who had Close Contact with Someone with SARS-CoV-2 Infection. Management decisions will depend on if they are up to date with all recommended COVID-19 vaccines.
    • HCP with higher-risk exposures should be managed as described in the Interim U.S. Guidance for Managing Healthcare Personnel with SARS-CoV-2 infection or Exposure to SARS-CoV-2. Decisions about work restriction will depend on if they are up to date with all recommended COVID-19 vaccine doses.
    • If testing of close contacts reveals additional HCP or residents with SARS-CoV-2 infection, contact tracing should be continued to identify residents with close contact or HCP with higher-risk exposures to the newly identified individual(s) with SARS-CoV-2 infection.
      • A facility-wide or group-level (e.g., unit, floor, or other specific area(s) of the facility) approach should be considered if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission.
      • If the outbreak investigation is broadened to either a facility-wide or unit-based approach, follow recommendations below for alternative approaches to individual contact tracing.
    • Alternative, broad-based approach:
      • If a facility does not have the expertise, resources, or ability to identify all close contacts, they should instead investigate the outbreak at a facility-level or group-level (e.g., unit, floor, or other specific area(s) of the facility).
        • Broader approaches might also be required if the facility is directed to do so by the jurisdiction’s public health authority, or in situations where all potential contacts are unable to be identified, are too numerous to manage, or when contact tracing fails to halt transmission.
      • Perform testing for all residents and HCP on the affected unit(s), regardless of vaccination status, immediately (but generally not earlier than 24 hours after the exposure, if known) and, if negative, again 5-7 days later.
      • Residents and HCP who are not up to date with all recommended COVID-19 vaccine doses:
        • These residents should generally be restricted to their rooms, even if testing is negative, and cared for by HCP using an N95 or higher-level respirator, eye protection (goggles or a face shield that covers the front and sides of the face), gloves and gown. They should not participate in group activities.
        • Close contacts, if known, should be managed as described in Section: Manage Residents who had Close Contact with Someone with SARS-CoV-2 Infection.
        • For guidance about work restriction for these HCP who are identified to have had higher-risk exposures, refer to Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2.
      • Residents and HCP who are up to date with all recommended COVID-19 vaccine doses:
        • These residents should wear source control and be tested as described in the testing section; they do not need to be restricted to their rooms or cared for by HCP using the full PPE recommended for the care of a resident with SARS-CoV-2 infection unless they develop symptoms of COVID-19, are diagnosed with SARS-CoV-2 infection, or the facility is directed to do so by the jurisdiction’s public health authority.
        • For guidance about work restriction for these HCP who have higher-risk exposures, refer to Interim U.S. Guidance for Managing Healthcare Personnel with SARS-CoV-2 infection or Exposure to SARS-CoV-2.
        • In the event of ongoing transmission within a facility that is not controlled with initial interventions, strong consideration should be given to use of quarantine for residents and work restriction of HCP with higher-risk exposures, even if they are up to date with all recommended COVID-19 vaccine doses. In addition, there might be other circumstances for which the jurisdiction’s public authority recommends these and additional precautions.
      • If no additional cases are identified during the broad-based testing, room restriction and full PPE use by HCP caring for residents who are not up to date with all recommended COVID-19 vaccine doses can be discontinued after 14 days and no further testing is indicated.
      • If additional cases are identified, testing should continue on affected unit(s) or facility-wide every 3-7 days in addition to room restriction and full PPE use for care of residents who are not up to date with all recommended COVID-19 vaccine doses, until there are no new cases for 14 days.
        • If antigen testing is used, more frequent testing (every 3 days), should be considered.
      • Indoor visitation during an outbreak response:
        • Facilities should follow guidance from CMSexternal icon about visitation.
        • Visitors should be counseled about their potential to be exposed to SARS-CoV-2 in the facility.
        • Whether residents who are up to date with all recommended COVID-19 vaccine doses are known to be close contacts or are identified as a part of a broad-based outbreak response but not known to be close contacts, indoor visitation should ideally occur only in the resident’s room, the resident and their visitors should wear well-fitting source control (if tolerated) and physically distance (if possible).
        • Source control and physical distancing recommendations should also be followed for residents who are up to date with all recommended COVID-19 vaccine doses.
        • Outdoor visitation could be allowed, but residents should wear well-fitting source control (if tolerated), maintain physical distancing from others, and not linger in common spaces when moving from their rooms to the outdoors.

Cloth mask: Textile (cloth) covers that are intended primarily for source control. They are not personal protective equipment (PPE) appropriate for use by healthcare personnel. Guidance on design, use, and maintenance of cloth masks is available.