This guidance is intended for small congregate settings, including Community Integrated Living Arrangements (CILA), of eight or less, unrelated individuals.
These settings are different than long-term care facilities as they:
- Have limited nursing and medical personnel by rule and/or regulation (no 24-hour on-site presence usually).
- Utilize Direct Support Professionals (not certified nursing assistants, licensed practical nurses, or registered nurses) to complete caregiver tasks, including the administration of medicine.
Introduction/Background:
This guidance outlines layered infection prevention strategies that service providers can use to lower the risk of COVID-19 transmission to help maintain healthy environments and operations. The guidance also includes measures for controlling outbreaks that should be implemented in collaboration with public health officials to prevent the spread of COVID-19.
COVID-19 Vaccination:
Vaccination is an important tool to control the COVID-19 pandemic. The goal is for every eligible person to be able to easily get a COVID-19 vaccine and complete the series, including booster doses, as soon as possible. Recommendations for administrators of shared or congregate housing to improve vaccine accessibility and to build vaccine confidence among residents and staff include:
- Building relationships and providing clear, consistent, transparent information to ensure that individuals feel comfortable receiving the COVID-19 vaccine.
- Making vaccines available on-site through partnership with the local health department (LHD) or other healthcare provider. If on-site vaccinations are not available, helping residents identify locations where they can receive the COVID-19 vaccine and providing transportation or other resources to facilitate acquisition of the vaccine.
- Consider holding vaccination events to provide access to residents and staff to receive the vaccine.
- Integrating reminders into the process for vaccinating residents and staff to ensure that they receive all required vaccine doses including boosters.
Screening for Signs & Symptoms of COVID-19:
When COVID-19 Community Levels are high:
Screening and other Procedures for Newly Admitted Residents:
- Screen residents upon admission for signs or symptoms of COVID-19.
- Testing of new admissions is recommended because of the risk of unrecognized COVID-19 infection, regardless of vaccination status. If negative, test again 5-7 days after admission.
- PCR testing is the preferred testing method. If unable to perform PCR testing, rapid Antigen point-of-care (POC) or At-Home testing is acceptable.
- Educate newly admitted residents on the core principles of infection prevention and control and instruct them to comply with masking, physical distancing, hand hygiene, and environmental cleaning, particularly when in shared spaces.
- Strongly encourage and facilitate vaccination for unvaccinated new admissions and booster vaccines for eligible individuals.
Screening for Residents and Staff:
- Screen residents and staff for signs or symptoms of COVID-19 and perform temperature checks regularly; ideally daily or every time they enter the facility or home.
- Staff should perform self-screening regularly and should not work when sick. Staff who develop symptoms at home should not report to work. Staff who develop symptoms at work should immediately notify their supervisor and go home.
- Screen/assess residents with COVID-19 at least daily for signs and symptoms of severe illness. Minimize the number of staff interacting with COVID-positive residents.
- Consider virtual check-ins for residents who have high independence; consider use of tablet/smart phone for assessments.
Screening for Visitors:
- Visitors should be screened upon arrival.
- Everyone must be screened upon entry, and individuals excluded with:
- A positive COVID-19 test in the past 5 days.
- Signs or symptoms of COVID-19.
- Exposure to someone with COVID-19 in the past 5 days if the visitor is unvaccinated OR not boosted.
- Individuals can be screened on arrival or with an electronic system prior to arrival.
- All visitors should wear a well-fitting face mask and perform hand hygiene.
Core Infection Prevention Measures:
Masking:
- Staff should consider wearing a well fitted mask or face covering when indoors with residents, when there is high COVID-19 Community Levels.
- Residents may consider wearing a well fitted mask or face covering when indoors (outside of their rooms) and when staff or other visitors enter their rooms.
Physical Distancing:
Physical distancing, also called social distancing, is the practice of staying at least 6 feet away from others to prevent the spread of a contagious disease such as COVID-19. Recommendations when COVID-19 Community Levels are high for administrators include:
For Residents:
- Unvaccinated residents should be encouraged to stay at least 6 feet apart (e.g., during dining, group activities, outings and or socializing).
- Vaccinated residents do not need to adhere to physical distancing (6 feet) requirements (e.g., during dining, group activities, outings and or socializing).
- Group gatherings or activities in common spaces may be restricted or suspended if the home has a COVID-19 positive individual present.
- Consider altering schedules to reduce mixing and close contact by staggering meals and other social and group activities.
- Evaluate the utility of "cohorting" residents by forming small groups that perform activities together to avoid mixing larger groups of people.
For Staff:
- Unvaccinated staff should physically distance from unvaccinated individuals, unless providing direct care.
- Vaccinated staff do not need to adhere to physical distancing requirements (e.g., during dining, group activities, outings and or socializing).
- If staff need to be within 6 feet of a resident who is ill, appropriate PPE per OSHA standards should be worn for contact and droplet precautions when entering the room where the resident is isolated.
- Staff in close contact with ill residents should monitor their health for symptoms of COVID-19. If a staff becomes ill, they should immediately stop working with residents and be sent home.
Hand Hygiene:
- Require residents and staff to perform hand hygiene appropriately and frequently by: (a) washing hands with soap and water for at least 20 seconds or, (b) using an alcohol-based hand sanitizer with at least 60% alcohol when hands are not visibly soiled or if soap and water are not available.
- Provide alcohol-based hand sanitizers that contain at least 60% alcohol at key points, including front desks, entrances/exits, and eating areas.
- Make sure bathrooms and other sinks are consistently stocked with soap and drying materials for handwashing.
- Provide hand sanitizer stations, especially in highly trafficked areas (elevators, entrances).
Environmental Cleaning:
- Clean and disinfect frequently touched surfaces at least daily and shared objects between use with an EPA-registered disinfectant.
- Clean high use areas/shared spaces daily; twice a day for bathrooms.
- Provide disposable gloves for cleaning.
Considerations for Improving Ventilation:
- Maximize ventilation in shared spaces by placing fans as close as possible to an open window blowing outside. Point fans away from people. Pointing fans toward people can possibly cause contaminated air to flow directly at them. Use ceiling fans to help improve air flow in the facility or home whether or not windows are open.
- Consider using air purifying devices such as portable high-efficiency particulate air (HEPA) filtration systems to help enhance air cleaning (especially in higher-risk areas such as rooms occupied by COVID-positive individuals).
- Consider using natural ventilation (i.e., opening windows if possible and safe to do so) to increase outdoor air dilution of indoor air when environmental conditions and building requirements allow. If temperatures outside make it difficult to leave multiple windows open, consider safely securing window fans or box fans (sealing the perimeter around the box fan) to blow air out of selected windows.
- Do not open windows and doors if doing so poses a safety or health risk (such as risk of falling, triggering asthma symptoms) to residents, staff, or visitors.
- Ensure exhaust fans in kitchens and restroom facilities are functional and operating at full capacity when the building is occupied. Consider running exhaust fans over stovetops and in bathrooms when visitors are in the facility or home. Keep exhaust fans turned on for at least an hour after visitors leave to help remove virus particles that might be in the air.
- Collaborate with local health departments and experts in heating, ventilation, and air conditioning (HVAC) to identify resources for improving ventilation and air quality.
Isolation and Quarantine:
Isolation:
- Facilities should develop a plan to isolate residents who are symptomatic or who test positive for COVID-19.
- Residents and staff who test positive for COVID-19 should:
- isolate for 5 days.
- Discontinue isolation after 5 days if asymptomatic or symptoms resolving.
- Continue to wear a mask around others for an additional 5 days.
- Remain in isolation if febrile until fever resolves without the use of fever-reducing medication.
Quarantine:
- Residents and staff who are not up to date with COVID-19 vaccination who are close contacts or exposed to someone with COVID-19 should quarantine for 5 days followed by strict mask use for an additional 5 days.
- If a 5-day quarantine is not feasible, it is imperative that an exposed person always wear a well-fitting mask when around others for 10 days after exposure.
- Residents and staff who are up to date with COVID-19 vaccination do not need to quarantine following an exposure or close contacts but should wear a mask for 10 days after the exposure.
- For all those exposed, best practice would also include a test for SARS-CoV-2 at day 5 after exposure.
- If symptoms occur, individuals should immediately isolate until a negative test confirms symptoms are not attributable to COVID-19.
Testing Plan and Response Strategy:
Administrators of shared or congregate housing in partnership with local health departments, should implement the testing plan outlined below to identify cases among symptomatic persons and asymptomatic persons, including those with and without known exposure to COVID-19. Key components of the testing plan include:
- Test as Soon as Possible for:
- individuals with signs or symptoms consistent with COVID-19.
- Test immediately, but not earlier than 24 hours after the exposure, if:
- asymptomatic individuals with recent known or suspected exposure to COVID-19, regardless of vaccination status, to control transmission.
- get tested at least 5 days after you last had close contact with someone with COVID-19
- testing is recommended immediately (but generally not earlier than 24 hours after the exposure) and, if negative, again 5-7 days after the exposure.
- Testing to identify if there is an outbreak is to be performed whenever a case is identified through immediate testing. After consultation with the local health department (LHD), facilities should conduct one of the following two outbreak testing options utilizing PCR tests (preferred) or Rapid Antigen tests (acceptable):
- Contact-tracing testing option: targeted testing of all residents and staff, regardless of vaccination status, who were close contacts to the COVID-19 case.
- Facility or Home-wide testing option: testing of all residents and staff, regardless of vaccination status.
- Repeat testing of all previously negative residents and staff (e.g., every 3-7 days or as directed by the local health department) until no new cases are identified over a period of at least 14 days.
Outbreak Response:
Because of the risk of unrecognized infections among residents or staff, a single new case of COVID-19 in any staff or resident should be evaluated as a potential outbreak. The Residence or home must contact their local health department promptly to report all positive case(s) for both staff and residents and develop a response plan.
Procedures for Resident Cases:
- Isolate the case for 5 days from symptom onset or from the positive test date (if asymptomatic); a bedroom with a private, or designated bathroom is preferred.
- Activate procedures for staff to perform daily symptom assessments and serve meals to the case wearing full PPE (N95 respirator, face shield, gown, gloves). If a fit-tested N95 respirator is not available, a well-fitted surgical mask with face shield is the next best option. Organizations can reach out to the LHD for assistance with a fit-testing program and obtaining the necessary respirators for staff.
- Assess the extent of potential exposures in the facility or home by identifying areas the case may have visited or communal activities that may have put others at risk. For facilities with shared spaces (e.g., bathrooms, eating areas, shared bedrooms) that make physical distancing challenging, everyone on the same unit/building/floor as the case should be considered a close contact.
- Identify any close contacts (staff or resident) to the case 2 days prior to symptom onset or 2 days prior to the positive test date (for asymptomatic cases). Close contact is defined as: persons who were within 6 feet of the case for a cumulative total of 15 minutes in a 24-hour period.
- Clean and disinfect all areas the infected resident encountered.
- Reinforce policies for residents regarding adherence to quarantine, universal masking, physical distancing, hand hygiene, and promptly reporting illness so that isolation and testing may be initiated.
- Reinforce policies for staff regarding adherence to universal masking, physical distancing, hand hygiene, staying home if sick, limited staff interacting with positive cases, proper and appropriate use of PPE when interacting with infected residents.
- Multiple cases may be cohorted in the same room or wing if space is limited.
Outpatient Monoclonal Antibody (mAb) - COVID-19 Treatment and Prevention:
Refer to the IDPH monoclonal antibody webpage for the most up-to-date information. Facilities or homes should identify a local source for providing monoclonal antibody (mAb) treatment for clients who develop COVID-19, regardless of vaccination status, to reduce the risk of severe illness and hospitalization.
- Persons who may benefit from mAb treatments include those who are older or who have chronic respiratory, cardiac, or renal disease; are overweight or obese; have immunosuppressive disease or treatment; have diabetes; and have other medical conditions or risk factors, including race and ethnicity associated with increased risk of severe COVID-19 disease.
- Monoclonal antibody (mAb) treatments can be administered either by intravenous or subcutaneous routes.
Monoclonal antibody treatment is available to individuals who:
- Have had a positive COVID-19 test within the past 10 days and
- are experiencing mild-to-moderate symptoms (i.e., not hospitalized for COVID-19) and
- are at high risk for developing severe COVID-19 and
- are not requiring oxygen and
- are 12 years of age or older (and at least 88 pounds).
Monoclonal antibodies may also be administered to prevent individuals from developing COVID-19 after exposure (known as "post-exposure prophylaxis").
Post-exposure preventive monoclonal antibodies are for those who have been exposed (consistent with the CDC's close contact criteria) and who are:
- High risk for developing severe COVID-19 and
- 12 years of age or older (and at least 88 pounds) and
- not fully vaccinated or vaccinated but immunocompromised.
Residents and staff who meet the criteria for monoclonal antibody (mAb) treatments should be referred to a medical provider. Facilities and homes are encouraged to consult with their local health department (LHD) for information on mAb treatments.
More information about mAb treatment is available from IDPH, CDC, CMS, and from the U.S. Department of Health and Human Services (HHS).
Oral Antivirals:
Facilities interested in providing Evusheld (for pre-exposure prophylaxis), Paxlovid (for treatment), or Molnupiravir (for treatment) should complete the COVID-19 Antiviral Survey. Please review the indications and safety profile for each of these therapies with your pharmacy and healthcare providers.
Pre-exposure prophylaxis agent Evusheld is a monoclonal antibody that is only for those who are not expected to mount a response to vaccination due to their immunosuppressed state or have a contraindication to receiving the vaccine. It is given as intramuscular injections every 6 months.
Paxlovid and Molnupiravir are oral antivirals that MUST be used within 5 days of symptom onset to prevent hospital admissions and death from Covid-19.
Visitation:
- There should be no restriction on visitation without a reasonable clinical or safety cause. Visitation may occur in resident rooms (without roommate(s) present), multipurpose rooms, designated visitation rooms, or outdoors.
- The safest practice is for residents and visitors to wear well-fitted masks and physically distance. Visitors and residents should wear well-fitted masks throughout the entire visit while indoors, regardless of vaccination status, and physically distance from staff, other residents, and other visitors while indoors.
- While it is safer for visitors not to enter the facility or home during an outbreak, visitors may still be allowed, subject to the screening processes described above.
- If residents or their representative would like to have a visit during an outbreak, they should wear face coverings or masks during the visit, regardless of vaccination status, and visits should ideally occur outdoors or in the resident's room.
- If a resident's roommate is unvaccinated or immunocompromised (regardless of vaccination status), visits should not be conducted in the resident's room, if possible.
- Visitors should be made aware of the potential risk of visiting during an outbreak and adhere to the core principles of Infection Prevention and Control.
References:
Centers for Disease Control and Prevention. 3/10/2022. Stay Up to Date with Your COVID-19 Vaccine. not up to date
Centers for Disease Control and Prevention. 1/27/2022. Isolation & Quarantine Guidelines.
Centers for Disease Control and Prevention. 3/11/2022. COVID-19 Community Level Guidelines.
Centers for Disease Control and Prevention. 11/15/2021. Cleaning & Disinfecting Your Facility: Every day and When Someone is Sick. Clean and disinfect
United States Department of Labor. Occupational Safety and Health Administration (OSHA). Protecting Workers: Guidance on Mitigating and Preventing Spread of COVID-19 in the Workplace. (n.d.). PPE per OSHA standards
EPA United States Environmental Protection Agency. 12/3/2021. About List N: Disinfectants for Coronavirus (COVID-19).
ASHRAE: Mechanical Ventilation. (n.d.)
Illinois Department of Public Health (IDPH). 2/22/22. COVID-19 Outpatient Treatment: Monoclonal Antibodies (mAb); Therapeutics. COVID-19 vaccine
