COVID-19 Guidelines for Assisted Living, and other Higher Risk Community Congregate Living Settings

The Illinois Department of Public Health (IDPH) has adopted the updated Centers for Disease Control and Prevention (CDC) COVID-19 Guidance for Assisted Living Facilities and other Higher Risk Community Congregate Living Settings, which is summarized in this document. Clarifications have been added to aid facilities with assessing risk and responding to COVID-19 cases and outbreaks. In addition to Assisted Living Facilities, this guidance applies to other Illinois non-skilled facilities such as Supportive Living, Shared Housing Establishments, Sheltered Care, and Specialized Mental Health Rehabilitation Facilities (SMHRF), whose staff provide non-skilled personal care, similar to that provided by family members in the home. The CDC definition of non-skilled personal care is provided below.

Health care personnel (HCP) providing health care to one or more residents in non-skilled facilities (e.g., hospice care, memory support, physical therapy, wound care, intravenous injections, or catheter care) should follow the CDC Infection Prevention and Control Recommendations for Healthcare Personnel and the IDPH Updated Interim Guidance for Nursing Homes and Other Licensed Long-Term Care Facilities.

Please note, the Illinois Department of Human Services has separately issued Suggested COVID-19 Guidance for Small Congregate Settings, that is intended for small congregate settings, including Community Integrated Living Arrangements (CILAs), of eight or less, unrelated individuals

Non-skilled facilities should use both COVID-19 Community Levels, and facility-specific risks to guide decisions about when to apply specific COVID-19 prevention actions. Assessing the following factors can help decide if additional layers of protection are needed because of facility-specific risks:

Assess whether facility characteristics or operations contribute to COVID-19 spread. For example, facilities may have a higher risk of transmission if they have frequent resident or staff turnover, a high volume of outside visitors, poor ventilation, or areas where many people sleep close together.

Assess what portion of people in the facility are more likely to get very sick from COVID-19, for example, due to underlying health conditions, lack of COVID-19 vaccination, older age, pregnancy, or poor access to medical care.

Assess the extent to which transmission is occurring within the facility, through diagnostic testing of people with COVID-19 symptoms and their close contacts, as described below, under “Post-Exposure Guidance”.

The actions facilities can take to help keep their populations safe from COVID-19 can be categorized as prevention strategies for everyday operations and enhanced prevention strategies when COVID-19 Community Levels are high.

• Prevention strategies for everyday operations should be in place at all times, even if COVID-19 Community Levels are low or medium. These include all of the strategies listed below except those marked enhanced strategy.
• Enhanced prevention strategies should be added to supplement the prevention strategies for everyday operations when COVID-19 Community Levels are high, and when there has been transmission within the facility (i.e., when in outbreak), or based on the assessment of facility-specific factors that increase risk. This is not an exhaustive list, please contact your local health department to discuss additional measures based on the situation.
  

When adding enhanced prevention strategies, facility operators should balance the need for COVID-19 prevention with the impact of reducing access to services and programming. Facilities may not be able to apply all enhanced COVID-19 prevention strategies due to local resource constraints, facility and population characteristics, or other factors (such as impact on lifestyle). However, they should use as a multi-layered approach to increase the level of protection against COVID-19 by adding as many prevention strategies as feasible.

Depending on the risk in different areas of the facility, enhanced prevention strategies can be applied across an entire facility, or can be targeted to a single housing area, wing, or building. Facilities with higher risk profile can apply enhanced prevention strategies at any time, including when the COVID-19 Community Level is low or medium.

Encourage and enable staff, volunteers, and residents to stay up to date on COVID-19 vaccination. Where possible, offer vaccine onsite and support peer promotion of vaccination.

• Resources are available for onsite COVID-19 vaccinations, through long-term care pharmacies and mobile response teams. Please contact the local health department for additional information.
• In accordance with emergency rules, non-CMS-certified/licensed-only facilities must report aggregate COVID-19 vaccinations, cases and deaths weekly for staff and residents here: COVID-19 Smartsheet Reporting Form (Illinois Register Vol. 46, Issue 52, Dec. 27, 2022)
  

Ensure HVAC systems operate properly and provide acceptable indoor air quality.

Where possible, consider holding group activities outdoors.

Increase and improve ventilation as much as possible. Identify, obtain, and test enhanced ventilation options in advance of higher risk periods to be ready to deploy when needed. Short-term and long-term tools to improve ventilation in buildings can be found on the CDC website, and in the IDPH Updated Interim Guidance for Nursing Homes and Other Licensed Long-Term Care Facilities.

• Maintain a stock of personal protective equipment (PPE) for staff.
• Offer high-quality masks/respirators to all residents and staff, and provide other PPE for staff and residents based on risk (see below for more information on PPE).
  

Require universal indoor masking, regardless of vaccination status.

• Residents or staff may choose to wear well-fitted masks or respirators, based on their personal preference, when in the common areas of the facility, especially if attending a large gathering and to and from the dining room or activities.
• Residents who have been exposed to someone with SARS-CoV-2 infection, should wear a well-fitted mask for 10 days after their exposure, when around others.
  
• Residents who have COVID-19 or are suspected of having COVID-19, should wear a well-fitted mask or respirator for 10 days, whenever they are around others.
  
• Staff who will have close contact with residents who are in isolation precautions, including during transport, should wear a NIOSH-approved respirator, eye protection (goggles/face shield), gowns/coveralls, and gloves.
  

If not already in place, employers should establish a respiratory protection program, to ensure that staff members are fit-tested, medically cleared, and trained for any respiratory protection they will need within the scope of their responsibilities. For more details, see the OSHA Respiratory Protection Standard.

• Institute standard infection prevention and control measures, cleaning, and disinfection at least daily in common areas.
• Maintain supplies for hand hygiene, cleaning, and disinfection.
  
• Maintain signage regarding respiratory hygiene and etiquette for staff and visitors.
  
• Monitor hand hygiene, cleaning, and disinfection and train staff at least annually.
  

Apply enhanced cleaning and disinfection recommendations.

Routine physical distancing is no longer emphasized in the updated CDC recommendations, unless the facility is experiencing an outbreak or when community levels are high. However, when respiratory illnesses are circulating in the community it is best practice for higher risk facilities to

1. take measures to limit crowding in communal spaces
2. encourage physical distancing at large gatherings, such as parties or events
   

Create physical distance of 6 feet or more in common areas when COVID-19 community levels are high, or the facility is experiencing an outbreak.

Reduce movement and contact between different parts of the facility when the facility is experiencing an outbreak.

Test residents and staff who either have symptoms of COVID-19 or have had a moderate-risk or higher-risk exposure (see Table 1)

Facilities that perform point-of-care (POC) antigen testing must comply with state and federal regulations and must report all positive tests to IDPH. Instructions are located at Guidance on Antigen Testing for COVID-19 in Long-Term Care

Consult with your local health department about implementing routine screening testing of residents and/or staff if there are concerns about the population being at especially high risk for severe illness from COVID-19. Routine testing can help identify infections early, which is important for people who are eligible for treatment.

A person with COVID-19 can spread the virus beginning two days prior to the onset of any symptoms (or two days prior to a positive test if they do not have symptoms). Persons with COVID-19 are considered infectious for 10 days although that time period may be shortened to 7 days with a negative test (see below under “Isolation Guidance for Residents and Non-Healthcare Staff”). People who have been exposed (close contacts) to someone when they are infectious with COVID-19 can be identified through contact tracing as described here:

• See CDC recommendations for Investigating a COVID-19 Case.
• Case investigations should prioritize identification of close contacts who are more likely to get very sick from COVID-19, so that they can be referred to a healthcare provider to determine eligibility for treatment if they test positive for COVID-19.
  

• Location-based contact tracing is preferable when identifying close contacts is difficult due to residents’ and staff movements in and out of the facility.
• Location-based contact tracing identifies potential exposures based on where a person with COVID-19 spent time while infectious. For residents, this could include their housing unit, transport bus, dining area, and any programmatic activities; for staff and volunteers, this could include their duty station/unit, break room, carpool, and areas where they interacted with residents.
  
• For areas of a facility identified in location-based contact tracing, consider conducting testing of those who were present based on their exposure risk (see Table 1).
  
• If any additional cases are identified, facilities should consider adding enhanced prevention strategies.
  
• All cases of COVID-19 must be reported to the local health department.
  

Residents and non-healthcare staff who have had a moderate – or higher-risk exposure should test at least five full days after exposure (or sooner, if they develop symptoms) and should wear a well-fitted mask while indoors for 10 full days after exposure, regardless of vaccination status.

If all 6 criteria are evaluated as lower-risk--no further action is required by the facility, resident, or staff

If 1 or more criteria are evaluated as a moderate-risk or higher-risk follow the guidance below

Residents do not need to be restricted to their apartments or rooms following a COVID-19 exposure, regardless of vaccination status, unless they develop symptoms or test positive for SARS-CoV-2. Residents who have been exposed should be monitored for the development of symptoms, to ensure prompt treatment to prevent severe illness or hospitalization.

• Testing following exposure
  • Test residents 5 full days after exposure, even if they do not develop symptoms. Count day of exposure as day 0.
  • If residents develop symptoms, test immediately.
    
  • No testing is required if residents have had COVID-19 within the last 30 days, as the risk of reinfection is low.
    
• Residents should wear a mask for 10 days post-exposure.
  

Work restriction is not required for staff following a moderate-risk or higher-risk exposure, regardless of vaccination status, unless they develop symptoms or test positive for SARS-CoV-2.

Healthcare Personnel should follow the recommendations from the IDPH Updated Interim Guidance for Nursing Homes and Other Licensed Long-Term Care Facilities.

• Testing following exposure
  • Test staff 5 full days after exposure, even if they do not develop symptoms. Count day of exposure as day 0.
    
  • If staff develop symptoms, test immediately.
    
  • No testing is required if staff have had COVID-19 in last 30 days, as the risk of reinfection is low.
    
• Staff should wear a well-fitted mask for 10 days post-exposure.
  

Isolate staff, volunteers, and residents who test positive for COVID-19 away from other residents or away from the facility, as applicable, for 10 days since symptoms first appeared or from the date of sample collection for the positive test (if asymptomatic).

If the individual has a negative viral test (Either a NAAT test, such as a PCR test, typically performed in a laboratory, or an onsite antigen test may be used to determine if isolation can be shortened to 7 days. If using a NAAT, a single test is acceptable and must be obtained no sooner than day 5 of isolation. If using an antigen test, two negative tests must be obtained, one no sooner than day 5 and the second 48 hours later. Because NAAT tests can remain positive for some time, antigen testing may be preferred.), isolation can be shortened to 7 days, as long as symptoms are improving and the individual has been fever-free for 24 hours (without the use of fever-reducing medications), the individual was not hospitalized, and the individual does not have a weakened immune system.

Note that the isolation period for higher risk community congregate living settings is longer than the duration recommended for the general public, because of the risk of widespread transmission and the high prevalence of underlying medical conditions associated with severe COVID-19.

• If multiple residents have tested positive, they can isolate together in the same area.
• Ensure continuation of support services, including behavioral health and medical care, for residents while they are in isolation.
  
• During crisis-level operations, such as severe shortages of staffing or space, facilities should consult with their local health department for additional guidance and support.
  

Healthcare personnel should follow the IDPH Updated Interim Guidance for Nursing Homes and Other Licensed Long-Term Care Facilities for work exclusions while ill, testing requirements, and return to work criteria.

Effective treatments are now widely available and must be started within a few days after symptoms develop. Treatment has been shown to reduce the risk of severe COVID-19 disease and hospitalization, especially in the elderly, and those with underlying health conditions. As soon as a resident is diagnosed with COVID-19, contact the resident’s medical provider to assess whether treatment is indicated.

• National Institutes of Health (NIH) COVID-19 treatment guidelines.
• A clinical decision tree is also available to help clinicians determine if a resident is eligible for COVID-19 treatment and the right choice of treatment.
  
• Resources are available for onsite COVID-19 treatment, through long-term care pharmacies and mobile response teams. Contact the local health department right away if you have trouble securing treatment for residents with COVID-19.
  

Assisted Living facilities and other high risk congregate settings shall notify the Office of Health Care Regulation of reportable communicable disease, including COVID-19 affected residents and/or staff.

1. Being within 6 feet of a person with confirmed SARS-CoV-2 infection for a period of 15 minutes or longer within a 24-hour period.
2. Having unprotected direct contact with infectious secretions or excretions of the person with confirmed SARS-CoV-2 infection.
   
3. Distances of more than 6 feet might also be of concern, particularly when exposures occur over long periods of time in indoor areas with poor ventilation.
   

CDC defines non-skilled personal care as consisting of any non-medical care that can reasonably and safely be provided by non-licensed caregivers, such as help with daily activities like bathing and dressing; it may also include reminders for the kind of health-related care that most people do themselves, like taking oral medications. In some cases where care is received at home or a residential setting, care can also include help with household duties such as cooking and laundry.

An individual has received the primary series of COVID-19 vaccine (either two doses or one dose, depending on the vaccine), and has received all additional and booster doses for which they are eligible as recommended by the CDC. (CDC up to date recommendations for COVID-19 vaccines)