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​Interim Guidance for Personal Care Homes and Assisted Living Residences and Private Intermediate Care Facilities During COVID-19

 The Department of Human Services (Department) is providing the below guidance as an update to the guidance issued on March 12, 2020 To protect the residents and staff of Personal Care Homes (PCHs), Assisted Living Residences (ALRs) and private Intermediate Care Facilities (ICFs) during the COVID-19 pandemic, restrictions were put in place. To continue to protect the safety of residents of those facilities, the restrictions will be lifted in a three-step process as detailed in Section 6 of this updated guidance. 

1. Cohorting Residents 

If a PCH, ALR or ICF wishes to expand the number of beds or convert closed wings or entire facilities to support COVID-19 patients or residents, first review PA-HAN 496, Universal Message Regarding Cohorting of Residents in Skilled Nursing Facilities. If the facility believes its planned strategy conforms to PA-HAN 496, submit a request to the Department's appropriate regional office for approval. Each request will be considered on a case-by-case basis, and dialogue with the facility will occur to acquire all details needed for the Department to render a decision. To ensure the Department has the necessary information to enter into that dialogue, include at a minimum the following information for the new or expanded space (if applicable) with the request: 
• Number of beds and/or residents impacted, including whether residents will be moved initially. 
• Location and square footage (with floor plan and pictures, if appropriate). 
• Available equipment in the residents room. 
• Staffing levels and plan for having adequate staffing for the duration of the cohorting. 
• Plan for locating displaced residents including care of vulnerable residents (such as dementia residents) either in the same facility or sister facility. 
• Description of how residents with COVID-19 will be handled (e.g., moving within the facility, admitted from other facilities, admitted from the hospital). 
• Plan for discontinuing use of any new, altered or renovated space upon the expiration of the Governor's Proclamation of Disaster Emergency issued on March 6, 2020. 
• Contact information for person responsible for the request.

Upon submission of the request, a representative from the Department will reach out to the facility's contact person to discuss next steps. Questions regarding this process can be directed to the appropriate regional office. 

2. Mandatory Reporting 

All ALRs and PCHs are required to use the COVID-19 Tracker to report all cases of COVID-19 in their facility. Negative and positive results are to be included. Instructions and the Tracker can be located on the Licensing page. All facilities must update all data fields each day, including cumulative case counts (total counts identified in the facility since the beginning of the outbreak) where indicated. 

All ICFs should follow reporting instructions issued by the Office of Developmental Programs (ODP) for residents and staff. 

3. Infection Control and Personal Protective Equipment (PPE) 

a. Review PPE guidelines with all staff. 

b. Screen residents and staff for fever and respiratory symptoms (using a checklist for employees such as the one developed by the American Health Care Association and the National Center for Assisted Living or as described by the CDC. Staff should be screened at the beginning of every shift, and residents should be screened daily. All other personnel who enter the facility should be screened. 

c. Staff with even mild symptoms of COVID-19 should consult with their supervisor before reporting to work. If symptoms develop while working, staff must cease resident care activities and leave the work site immediately after notifying their supervisor, in accordance with facility policy. 

d. Minimize resident interactions with other personnel and contractors performing essential services (e.g., plumbers, electricians, etc.) 

e. Arrange for deliveries to areas where there is limited person-to-person interaction. 

f. Ensure cleaning practices comport with CDC guidance. 

g. Refer to the following for guidance on infection control and PPE use, including universal masking for all persons entering the facility:

Facilities and residents of facilities that are not reopening as explained in Section 6 must follow the guidance in this section for visitors. 
a. To limit exposure to residents, restrict visitation as follows: o Restrict all visitors, except those listed in Section 4b below. 
o Restrict all volunteers, non-essential health care personnel and other non-essential personnel and contractors (e.g., barbers). 
o Restrict cross-over visitation from Skilled Nursing Facility, Independent Living Facility and Continuing Care Community residents to the PCH, ALR or ICF. Ensure cross-over staff adhere to the facility's Infection Control Plan. 


b. The following personnel are permitted to access PCHs, ALRs and ICFs and must adhere to universal masking protocols in accordance with HAN 492 and HAN 497 :
o Physicians, nurse practitioners, physician assistants, and other clinicians; 
o Home health and dialysis services; 
o The Department of Aging/Area Agency on Aging, including the Ombudsman, where there is concern for serious bodily injury, sexual abuse, or serious physical injury; 
o Hospice services, clergy and bereavement counselors, who are offered by licensed providers within the PCH, ALR and ICF; and 
o Department of Human Services or designees working on behalf of the Department. 

5. Dining Services 

Facilities and residents of facilities that are not reopening as defined in Section 6 must follow the guidance in this section for dining. 
a. Provide in-room meal service for residents who are assessed to be capable of feeding themselves without supervision or assistance. 

b. Identify residents at-risk for choking or aspiration who may cough, creating droplets. Meals for these residents should be provided in their rooms with assistance. If meals cannot be provided in their rooms, the precautions outlined below must be taken for eating in a common area in addition to ensuring the residents remain at least six feet or more from each other.

c. Residents who need assistance with feeding and eat in a common area should be spaced apart as much as possible, ideally six feet or more. Where it is not possible to have these residents six feet apart, no more than one resident who needs assistance with feeding may be seated at a table.

Precautions When Meals Are Served in a Common Area

  • Stagger arrival times and maintain social distancing;
  • Increase the number of meal services or offer meals in shifts to allow fewer residents in common areas at one time;
  • Take appropriate precautions with eye protection and gowns for staff feeding the resident population at high-risk for choking, given the risk to cough while eating; and
  • Staff members who are assisting more than one resident at the same time must perform hand hygiene with at least hand sanitizer each time when switching assistance between residents.

6. Reopening of PCHs, ALRs and ICFs

To safely lift restrictions, the reopening has two primary components:

  • Reopening prerequisites, requirements, and criteria (sections 6b-d); and
  • Reopening "steps" (section 6e).

These components were developed based on the Centers for Medicare and Medicaid Services guidance on reopening nursing homes.  The prerequisites and requirements define the capability and capacity the facility must have to enter the reopening process. The criteria for moving forward and backward among the steps are defined, and the requirements associated with visitation are specified.  

The word "Step" was intentionally chosen to differentiate it from the White House's "Opening Up America Again" Phases to reopening, as well as Governor Wolf's Phased Reopening Plan.  If a county is in Governor Wolf's Yellow or Green phase, it is considered part of the White House's Phase 3.  The "Steps" were developed to carefully allow PCHs, ALRs and ICFs to resume communal dining and activities, entry of volunteers, non-essential personnel and  visitors, and outings in a measured approach.  The Steps strike a balance between protecting residents' physical health (through incrementally reopening when it is safe) with their mental and emotional health (that necessitates visitation and communal activities). 

Terms used in explaining reopening are defined in section 6a. Given the interrelated nature of these sections, it is recommended that each be read in coordination with the others.   

a. Terms Used in this Section

Terms used in section 6 are defined below:

  • • "Cross-over visitation" refers to visits from an individual residing in a PCH, ALR, ICF, independent living facility, skilled nursing facility or continuing care retirement community.
  • • "Exposed residents" refers to those residents with a known recent exposure to COVID-19 or who have had a positive test result for COVID-19 in the past 14 days.
  • • "Neutral zone" means a pass-through area (such as a lobby or hallway not in a red, yellow, or green zone per HAN 509) and/or an area of the facility or facility grounds not typically occupied or frequented by residents with COVID-19 or exposed to COVID-19 (such as an outside patio area or a dining or activity room).
  • • "New facility onset of COVID-19 cases" refers to COVID-19 cases that originated in the facility, and not cases where the nursing home admitted individuals from a hospital with a known COVID-19 positive status, or unknown COVID-19 status but became COVID-19 positive within 14 days after admission. In other words, if the number of COVID-19 cases increases because a facility is admitting residents from the hospital AND they are practicing effective Transmission-Based Precautions to prevent the transmission of COVID-19 to other residents, that facility may still advance through the steps of reopening. However, if a resident contracts COVID-19 within the facilty without a prior hospitalization within the last 14 days, the facility will be deemed to have new facility onset of COVID-19.
  • • "Non-essential personnel" includes contractors and other non-essential personnel such as barbers and hair stylists.
  • • "Screening" includes checking for fever and symptoms of COVID-19 and asking questions about possible exposure.
  • • "Social distancing" is the practice of increasing the physical space between individuals and decreasing the frequency of contact to reduce the risk of spreading COVID-19 (ideally to maintain at least 6 feet between all individuals, even those who are asymptomatic).
  • • "Unexposed to COVID-19" refers to an individual who has no known recent exposure to COVID-19 or has not had a positive test result for COVID-19 in the past 14 days.
  • • "Universal masking" means the protocols set forth in PA-HANs 492 and 497, with homemade cloth masks being acceptable for visitors.
  • • "Visitors" includes individuals from outside of the facility as well as cross-over visitors.
  • • "Volunteer" is an individual who is a part of the facility's  established volunteer program.

b. Reopening Prerequisites and Requirements

Consistent with CMS guidelines, the Department will inpsect those PCHs, ALRs and ICFs that experienced a COVID-19 outbreak prior to reopening to ensure the facility is adequately preventing transmission of COVID-19. In order to enter the reopening process, the facility must meet the following prerequisites and the requirements for entering either Step 1 or Step 2. Once those prerequisites and requirements are met, the facility must notify the Department's program office Regional Director via email that they are entering the reopening process, providing the date and step at which the facility is entering. ICFs must notify ODP through RA-PWODPEMRGNCYSPRQ@pa.gov

1)Prerequisites:

All the following prerequisites must be met:
  • •Develop a Reopening Implementation Plan. The Plan must be posted on thefacility's website, if they have an existing website, or otherwise available to allresidents, families, advocates such as the Ombudsman and the Department uponrequest. The Implementation Plan shall include, at a minimum, the following components: A testing plan that, at minimum:
  • Complies with the Order of the Secretary of the PennsylvaniaDepartment of Health Directing Testing at Long-Term CareFacilities, issued June 26, 2020, and has already been implementedto conduct baseline Universal testing;
  • Describes the capacity to administer COVID-19 diagnostic tests toall residents showing symptoms of COVID-19 within 24 hours;
  • Describes the capacity to administer COVID-19 diagnostic test toall residents and staff if the facility experiences an outbreak;
  • Describes the capacity to administer COVID-19 diagnostic tests toall staff, including asymptomatic staff;
  • Describes a procedure for addressing needed testing of non-essential staff and volunteers; and
  • Describes a procedure for addressing residents or staff that decline orare unable to be tested.
  • A plan to cohort or isolate residents diagnosed with COVID-19 inaccordance with PA-HAN 509 pursuant to Section 1 of this guidance.
  • A written screening protocol for all staff during each shift, each residenton a daily basis, and all persons (visitors, volunteers, non-essentialpersonnel, and essential personnel) entering the facility or facilitygrounds.A plan to ensure and a current cache of an adequate supply ofpersonal protective equipment for staff (based on the type of care expectedto be provided).
  •  A plan to ensure and the current status of adequate staffing to avoid staffing shortages, and confirmation that the facility is not under a contingency staffing plan. 
  •  A plan to allow for communal dining and activities to resume pursuant to the guidance provided in Section 6e "Step to Reopen." 
  • A plan to allow visitationto begin, pursuant to the guidance provided in Section 6d "Visitation Requirements," no later than 28 days after the date the county in which the facility is located moved into the green phase and all other prerequisite criteria are met. An additional 10 days is allowable, if needed to address the risks and complications of the facilitiy's current situation. 
  •  A plan to halt all reopening facilities if the county in which the facility is located is reverted to the Red Phase of the Governor's Reopening Plan.  
  • To begin reopening, a facility must be in a Yellow or Green county per the Governor's Reopening Plan. 

2) Requirements for Initial Reopening: 


• To enter the reopening process at Step 1, the facility must meet all the prerequisites. 


• To enter the reopening process at Step 2 (that is, the PCH, ALR and ICF skips Step 1 and moves immediately into Step 2), the facility must meet all the prerequisites AND have the absence of any new facility onset of COVID-19 cases (resident or staff) for 14 consecutive days since baseline COVID-19 testing. 


c. Criteria for Advancing to and Regressing from Next Step 
The following criteria will be applied to determine movement among steps of the reopening process. Each time a facility moves from one step to another, the PCH or ALR must notify the Department's program office Regional Director. ICFs must notify ODP through RA-PWODPEMRGNCYSPRQ@pa.gov 
1) From the date the facility enters Step 1, if there is no new facility onset of COVID-19 cases for 14 consecutive days the facility may move to Step 2. 

If at any point during Step 1 (14 consecutive days) there is a new facility onset of COVID-19 cases the facility must cease Step 1 reopening and return to the guidance described in Sections 4 and 5 relating to visitors and dining, respectively. Moving back to the guidance described in Sections 4 and 5 restarts the 14-day period. After the new 14-day period, if there is no new facility onset of COVID-19 cases the facility may reinitiate Step 1. 

2) From the date the facility enters Step 1, if there is no new facility onset of COVID-19 cases for 14 consecutive days the facility may move to Step 2. 

If at any point during Step 2 (14 consecutive days) there is a new facility onset of COVID-19 cases the facility must cease Step 1 and Step 2 reopening and return to the guidance described in Section 4 and 5 relating to visitors and dining, respectively. Moving back to the guidance described in Sections 4 and 5 restarts the 14-day period . After the new 14-day period, if there is no new facility onset of COVID-19 cases the facility may reinitiate Step 1. 

3) From the date the facility enters Step 2, if there is no new facility onset of COVID-19 cases for 14 consecutive days the facility may move to Step 3. 

If at any point during Step 3 there is a new facility onset of COVID-19 cases, the facility must cease Step 1, 2, and 3 reopening and return to the guidance described in Section 4 and 5 relating to visitors and dining, respectively. Moving back to the guidance described in Sections 4 and 5 restarts the 14-day period count. After the new 14-day period, if there is no new facility onset of COVID-19 cases the facility may reinitiate Step 1. 

4) If a county in which a facility is located returns to the Red Phase, the PCH, ALR and ICF must return to the guidance described in Section 4 and 5 relating to visitors and dining, respectively. When the county moves back to the Yellow Phase, the facility may enter reopening again only when the prerequisites and requirements in Section 6b are also met. 


d. Visitation Requirements 
For visitation to be permitted under Steps 2 and 3 (as described in Section 6e), a facility must establish and enforce a visitation plan that meets the following requirements while ensuring that visitation and the facility's operations remain safe: 

1) Establish a schedule of visitation hours. 

2) Designate a specific visitation space in a neutral zone, ensuring that visitors can access that area passing only through other neutral zones. Where possible, use a specified entrance and route for visitors.

a) Outdoor visitation is strongly preferred when weather and resident appropriate. The facility should have a plan for how visitation will safely occur in neutral zones in the event of severe weather (e.g. rain, excessive heat or humidity, etc.). 


3) For the outdoor visitation area, ensure coverage from inclement or excessive weather, such as a tent, canopy, or other shade or coverage. 


4) Ensure adequate staff or volunteers to schedule and screen visitors, assist with transportation and transition of residents, monitor visitation, and wipe down visitation areas after each visit. The facility may leverage technology to use volunteers to perform scheduling activities remotely. 


5) Establish and maintain visitation spaces that provide a clearly defined six-foot distance between the resident and the visitor(s). 


6) Determine the allowable number of visitors per resident based on the facility's capability to maintain social distancing and infection control protocols. 


7) Use an EPA-registered disinfectant to wipe down visitation area between visits. 


8) Determine those residents who can safely accept visitors at Steps 2 and 3. 


9) Prioritize scheduled visitation for residents with diseases that cause progressive cognitive decline (e.g., Alzheimer's disease) and residents expressing feelings of loneliness. 


10) Provide facemask to resident (if they are able to comply) to wear during visit. 


11) Children are permitted to visit when accompanied by an adult visitor, within the number of allowable visitors as determined by the facility. Adult visitors must be able to manage children, and children older than 2 years of age must wear a facemask during the entire visit. Children must also maintain strict social distancing. 


12) Ensure compliance with the following requirements for visitors: 

a) Establish and implement protocols for screening visitors for signs and symptoms of COVID-19. Do not permit visitors to access facility or facility grounds if they do not pass screening. 
b) Provide alcohol-based sanitizer to each visitor and demonstrate how to use it appropriately, if necessary. 
c) Visitors must: 
• Wear a face covering or facemask during the entire visit;
• Use alcohol-based sanitizer before and after visit; 
• Stay in designated facility locations; 
• Sign in and provide contact information; 
• Sign out upon departure; and 
• Adhere to screening protocols. 

e. Steps to Reopen 
The following steps provide an incremental lifting of restrictions. The prerequisites and requirements to enter reopening are detailed in Section 6b, and the criteria for advancing (or retreating) a Step are detailed in Section 6c. Further detail on visitation requirements is provided in section 6d.

​
​Step 1
​Step 2
​Step 3
​Dining
​Communal dining is limited to residents unexposed to COVID-19. Those residents may eat in the same room with social distancing (limited number of people at tables and spaced by at least six feet). Adhere to the Precautions When Meals Are Served in a Common Area in Section 5 of this guidance. All other residents must adhere to the restrictions in Section 5, Dining Services when not in the reopening process.
​
​
​Activites
​Limited activities may be conducted with no more than five residents unexposed to COVID-19. Social distancing, hand hygiene, and universal masking are required.
​Limited activities may be conducted with no more than ten residents unexposed to COVID-19. Social distancing, hand hygiene, and universal masking are required. 
​Activities may be conducted with residents unexposed to COVID-19. Social distancing, hand hygiene, and universal masking are required. 
​Non-Essential Personnel
​Adhere to restrictions in Section 4, Visitor Policies when Not in the Reopening Process. 
​Non-essential personnel are allowed as determined necessary by the facility, with screening and additional precautions including social distancing, hand hygiene, and universal masking. Services for exposed residents adhere to the restrictions in Section 4, Visitor Policies When Not In the Reopening Process. 
​Non-essential personnel are allowed with screening and additional precautions including social distancing, hand hygiene, and universal masking. Barber and hair stylist services are permitted for residents unexposed to COVID-19, at the facility's discretion. Facility must establish protocols in the Implementation Plan for barber or hair stylists including PPE and ensuring six feet between residents receiving services. Services for all other residents adhere to the restrictions in Section 4, Visitor Policies when not in the Reopening Process. 
​Volunteers
​Adhere to restrictions in Section 4, Visitor Policies when not in the Reopening Process. 
​Volunteers are allowed only for the purpose of assisting with outdoor visitation protocols2 and may only conduct volunteer duties with residents unexposed to COVID-19. Screening, social distancing, and additional precautions including hand hygiene and universal masking are required. 

2 Outdoor visitation protocols could include scheduling of visits, transporting (but not lifting) residents and monitoring visitation
​Volunteers are allowed but may only conduct volunteer activities with residents unexposed to COVID-19. Screening, social distancing, and additional precautions including hand hygiene and universal masking are required. 
​Visitors
​Adhere to restrictions in Section 4, Visitor Policies when not in the Reopening Process. 
​Outdoor visitation (weather permitting) is allowed in neutral zones to be designated by the facility. If weather does not permit outdoor visitation, indoor visitation is allowed in neutral zones to be designated by the facility and defined in the Implementation Plan. Visitation is limited to residents unexposed to COVID-19. Review Section 6e for additional requirements. Visitation for exposed residents adhere to the restrictions in Section 4, Visitor Policies Not Impacted by the Reopening Process. 
​Indoor visitation is allowed in neutral zones to be designated by the facility. Visitation is limited to residents unexposed to COVID-19. Visiting in a resident's room (within facility's established protocols) is permitted only if the resident is unable to be transported to designated area. Screening and additional precautions including hand hygiene and universal masking are required. Space between visitor(s) and resident (and other groups of visitors/resident) must be at least six feet. Visitation time is scheduled, and facility determines appropriate number of visitors to meet visitation requirements. Visitation is not permitted during mealtimes. Cross-over visitation is only permitted if there is no new facility onset of COIVD-19 in the facility in which the cross-over visitor resides. Visitation for all other residents adhere to the restrictions in Section 4, Visitor Policies Not Impacted by the Reopening Process.
​Outings
​Adhere to restrictions in Section 4, Visitor Policies Not Impacted by the Reopening. 
​Adhere to restrictions in Section 4, Visitor Policies Not Impacted by the Reopening. 
​Outings are allowed only for residents unexposed to COVID-19. Outings limited to no more than the number of people where social distancing between residents can be maintained. Appropriate hand hygiene, and universal masking are required. Outings for all other residents adhere to the restrictions in Section 4, Visitor Policies Not Impacted by the Reopening Process. 


With the Governor's authorization as conferred in the disaster proclamation issued on March 6, 2020, all statutory and regulatory provisions that would impose an impediment to implementing this guidance are suspended. Those suspensions will remain in place while the proclamation of disaster emergency remains in effect. 

This updated guidance will be in effect immediately and through the duration of the Governor's COVID-19 Disaster Declaration. The Department may update or supplement this guidance as needed. 

RESOURCES 
Department's Guidance, FAQs, and Orders for Skilled nursing Facilities
Department of Health's Health Alerts, Advisories, and Updates
CDC Reopening FAQ 
CDC Reopening Memo