COVID-19: Assisted Living

This guidance is for community-based residential facilities, 3-4 bed adult family homes, and residential care apartment complexes. Guidance for adult day care centers is located at COVID-19: Home Care and Home and Community-Based Service Providers; however, Adult Day Care Centers may also find the guidance on the Assisted Living page helpful.

Assisted living facilities care for residents who are elderly and/or have chronic medical conditions that place them at higher risk of developing severe complications from COVID-19. The guidance is designed to assist facilities in improving their infection prevention and control practices to prevent the transmission of COVID-19 and keep residents and the staff who care for them safe from infection. 

Based on guidance from the Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC), the Department of Health Services (DHS) recommends the following actions in accordance with Wis. Stat. chs. 50 and 252, Wis. Admin. Code ch. DHS 145. It is important to review the information highlighted in the hyperlinks, in the Resources section, and to routinely check this website and CDC resources for updates to the guidance. Facilities are also encouraged to use the COVID-19 Provider Self-Assessment Worksheet, F-02669 as a tool to guide their overall preparedness.  

Admissions and Discharges

Admissions

  • Assisted living facilities may admit any individuals that they would normally admit to their facility, including individuals from hospitals where a case of COVID-19 was or is present. Facilities should follow the CDC guidance for infection control when COVID-19 is identified or suspected in a resident found in Discontinuation of Transmission-Based Precautions and Disposition of Patients with COVID-19 in Healthcare Settings (Interim Guidance)
  • If facilities admit or retain multiple residents diagnosed with COVID-19, they should consider the possibility of a dedicated wing or unit. 
  • Facilities should create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19. 
  • Testing residents upon admission could identify those who are infected but otherwise without symptoms and might help direct placement of asymptomatic residents into a designated COVID-19 area in the facility. However, a single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE.

Discharge

  • If a resident has been exposed and is being discharged, the resident requires a 14-day quarantine at the receiving facility. Therefore, you must inform the facility that is accepting the resident. If the facility is unable to meet transmission-based precautions and quarantine for those 14 days, then the resident cannot be transferred. 
  • Facilities must follow all regulations related to discharges, including involuntary discharges. A diagnosis of COVID-19 in and of itself does not meet the regulatory standard for an involuntary discharge. 

Guidance from the State Disaster Medical Advisory Committee  
Assisted living providers may benefit from reviewing the following memos that were prepared by the State Disaster Medical Advisory Committee (SDMAC) to provide recommendations to nursing homes and hospitals regarding the transfer, discharge and management of patients from hospitals to nursing homes. The purpose of the SDMAC is to advise the DHS Secretary regarding medical ethics during a declared disaster or public health emergency and to recommend policy relating to the equitable and fair delivery of medical services to those who need them under resource-constrained conditions.

Caring For Residents with Dementia

The strategies used to limit the spread of COVID-19 are especially difficult for residents with dementia. Due to their decreased cognitive ability, residents with dementia will require additional assistance adhering to quarantine and isolation. In particular, residents with dementia may have an impaired ability to follow or remember instructions regarding:

  • Refraining from touching face
  • Handwashing
  • Wearing a mask
  • Refraining from placing things in their mouth
  • Social distancing - staying in a particular area
  • Other interventions requiring individual follow-through or accountability

General Guidance:
Everyone living with a dementia will respond to this situation differently. Be prepared to try a variety of approaches to help residents feel safe and reassured and to comply with best practice guidelines related to COVID-19. Residents with dementia are at an increased risk for agitation, frustration, and even “catastrophic” reactions during a crisis situation as they are less able to negotiate changes in their environment. Therefore, it is highly recommended that any changes in routine, environment, and daily structure for residents with dementia be kept to a minimum. If agitation or aggression occurs, respond by using standard calming techniques, such as distract and redirect, play personalized music, take the person for a walk outside, or ask the person to complete a favorite task.

CDC Guidance:
CDC guidance for facilities caring for residents with dementia can be found in Considerations for Memory Care Units in Long-term Care Facilities.

Adherence to Infection Control Procedures:
It is difficult for residents with dementia to cooperate with prevention measures, such as instructions not to touch their eyes, nose, and mouth. Therefore, staff may need to provide residents with dementia with additional support and closer supervision to ensure infection control procedures are followed.

Residents with dementia may require extra supervision and support to perform appropriate hand hygiene (alcohol based hand sanitizer or handwashing):

  • Place residents on a supervised “hand hygiene schedule.” Have staff stand with the resident and wash their own hands to provide encouragement. Staff can also give demonstrations of thorough handwashing techniques.
  • Put dementia-friendly instructional signs with pictures on the bathroom window or wall reminding everyone to wash their hands with soap for 20 seconds.
  • Encourage residents to sing a song to remind them to wash their hands for at least 20 seconds.
  • Break down required tasks and guide residents step-by-step through the process.
  • Prompt with words or pictures.
  • Encourage and cultivate a sense of accomplishment.
  • If the resident is unable to complete handwashing to this extent on their own or with prompting, wear gloves and use soap and a washcloth to perform this task for the person.
  • Use an alcohol-based hand sanitizer if there is concern that good hygiene is not being practiced, or if staff or the resident cannot get to a sink to wash their hands.
  • Be sure to use moisturizer on clean hands after repeated washing to ensure they do not get dry and irritated.

Residents with dementia may also need assistance to refrain from touching their faces.

  • Ensure the skin on the resident’s face is clean and moisturized, not dry and irritated.
  • Ensure eyeglasses are clean and comfortable.
  • Ensure men are shaven, if they shave regularly.
  • Ensure there are no sores or other causes of pain within the mouth, and that regular oral hygiene is completed.
  • Ensure lips are adequately hydrated, and not chapped or dry.

Keeping Individuals in Particular Areas:
Wandering can cause residents with dementia to leave a safe environment. The risk for wandering increases when residents become upset, agitated, or face stressful situations.

  • Provide residents with safe spaces to wander. Consider placing familiar items around residents who wander to reduce any anxiety caused by unfamiliar environments.
  • Use visual prompts to remind residents of restricted access.
  • Secure the perimeter of unsafe areas with security personnel or other security systems.
  • Provide distraction and redirection through supervised and structured daily activities, including some form of daily exercise, such as individual walks outside with staff members.

Communication:
Residents with dementia may possess a limited ability to understand the information they are receiving about COVID-19, which could lead to a range of responses, including fear and anxiety. If residents express concern about the pandemic, facility staff should:

  • For those who are aware of what is going on and concerned about it, provide information from authoritative sources (such as DHS or the CDC.) Take the time to listen to the person and their concerns, validate their feelings, and provide reassurance.
  • Provide simple, truthful answers to their questions, explaining that everyone is doing all they can to help.
  • Consider minimizing the flow of media information by turning off the 24-hour news cycle on TV in shared areas. Ask news watchers to do so in their rooms.
  • Staff should not discuss their own anxieties and opinions in front of residents.

Guidance for Providing On-Site Hair Salon and Barber Services

In accordance with CDC guidance, long-term care facilities have closed onsite hair salons and barber services in their facilities to reduce the risk of spreading of COVID-19. Minimizing resident contact with outside individuals remains the best approach to prevent introduction of COVID-19 into long-term care settings. This guidance provides information to long-term care providers regarding resumption of on-site hair salon and barber services in the safest way possible. Facilities may resume onsite cosmetology services while ensuring the health, safety and welfare of residents and staff. In order to resume services safely, facilities should consider the following guidance.

Policies, Procedures, and Supplies

The facility should:

  • Follow facility policies and procedures as well as guidance from the CDC regarding cleaning and disinfecting protocols as well as employee screening.
  • Develop and implement procedures that address infection control measures and the management of safe salon services.
  • Implement an ongoing facility monitoring system for compliance with the facility’s policies and procedure for safe salon services.
  • Limit contact of the cosmetologist with other residents and staff as much as possible. This may be accomplished by having a separate area for salon services close to the entrance of the facility but is not required. Try to develop a path that avoids walking through resident care areas.  
  • Have an adequate supply of PPE and essential cleaning and disinfection supplies for facility staff and cosmetologists.  
  • Develop a process for cleaning cosmetology equipment (scissors, comb, brushes, etc.) 
  • Have adequate staff. 

Licensed Cosmetologist Services

To help control and prevent the spread of the virus the cosmetologist that provides salon services to the facility may also provide salon services to:

  1. Another care facility on the grounds of the facility, and 
  2. At one other salon. The other salon where the cosmologist provides services may be in the cosmetologist’s residence or in a public salon.  

The cosmetologist should: 

  • Receive COVID-19 infection control training from the facility.
  • Test negative for COVID-19 prior to resuming services in the facility, and follow any ongoing testing guidance specific to facility-type.  
  • Be screened for signs and symptoms of illness before each visit including no signs or symptoms of COVID-19, such as cough, fever or chills, shortness of breath or difficulty breathing or any other respiratory symptoms. Also, verify that they have had no contact with individuals with suspected or confirmed COVID-19. 
  • Wear proper PPE including a facemask, gown, and gloves provided by the facility upon entering and for the duration of their time in the facility.  
  • Be trained to self-monitor after each visit and report any symptoms of COVID-19 to the facility promptly as well as notifying healthcare providers and the local/tribal public health department. 
  • Sign a statement attesting that he or she will follow all facility policies and procedures regarding salon and barber services to ensure facility safety.
  • Clean and disinfect the area and equipment between resident appointments.

The cosmetologist should not:

  • Dry hair using a hand held hair dryer.

The facility should:

  • Verify that the resident is well with no signs or symptoms of COVID-19, such as cough, fever or chills, shortness of breath or difficulty breathing or any other respiratory symptoms before coming to their appointment.   
  • Ensure that each appointment is prescheduled, no walk-ins.  
  • Keep a record of the name, time and date of each resident that visits the salon.
  • Based on the resident’s abilities, escort the resident by a staff member to the salon at the designated appointment time and back to their room after the appointment. The resident’s arrival time should not coincide with the departure time of any resident exiting the salon, schedule in enough time in between the end and start of appointments to avoid residents congregating at the salon or in hallways. 
  • Call each resident to the salon area individually, only one resident in the salon at a time.
  • If the salon has doors, keep the salon doors closed unless a resident is entering or exiting the salon. Do not establish or use a waiting room or area or allow congregate gathering in or around the salon at any time. 
  • Ensure that each resident wears a face covering (preferably a face mask rather than a cloth face cover) while in transit to and from the salon and while in the salon at all times, including during  washing, cutting, perming, and coloring.  
  • Clean and disinfect the salon at the end of the day. 

Facilities will need to determine whether they can follow these guidelines to ensure they can provide salon and barber services safely. This may not be a safe option for all facilities due to availability of PPE, staffing patterns and facility layout and/or location as outlined in the above guidance.

Infection Prevention

Assisted living facilities should maintain preparations to care for residents with COVID-19. CDC’s COVID-19 Infection Control Assessment and Response (ICAR) tool was developed to help nursing homes prepare for COVID-19. Nursing homes and other long-term care facilities can take steps to assess and improve their preparedness for responding to COVID-19. The ICAR tool should be used as one tool to develop a comprehensive COVID-19 response plan. Areas assessed in the ICAR include:

  • Visitor restriction
  • Education, monitoring, and screening of healthcare personnel
  • Education, monitoring, and screening of residents
  • Ensuring availability of PPE and other supplies
  • Ensuring adherence to recommended infection prevention and control practices
  • Communicating with the health department and other healthcare facilities

DHS infection prevention specialists recorded a 30-minute overview of the self-assessment tool to explain each section. Facilities can complete the self-assessment and direct questions about their results or necessary elements to dhswihaipreventionprogram@dhs.wisconsin.gov. Facilities can also request a tele-ICAR evaluation by the HAI Prevention Program, which involves a more detailed phone-based infection control assessment of elements for COVID-19 readiness. The tele-ICAR is estimated to be 30 to 60 minutes in length. 

Universal Screening:
Assisted living facilities should actively screen and anyone entering the facility for fever and symptoms of COVID-19 or known exposure to someone with COVID-19.

  • The required screening includes, all staff, visitors, hospice, clergy, external health care personnel, surveyors, and all vendors. Every individual should be asked about COVID-19 symptoms (e.g., fever (measured temperature ≥100.0 °F or subjective fever), cough, shortness of breath, sore throat, or muscle aches, and must have their temperature checked daily). Emergency Medical Service (EMS) staff responding to an urgent medical need are exempt and do not need to be screened since they are typically screened separately.
  • Visitors who have a fever and/or are symptomatic for COVID-19 should not be allowed to enter the facility. 
  • Staff who have a fever and/or are symptomatic for COVID-19 prior to or during their shift, should be excluded from work. Decisions about when staff can return to work should be made using Criteria for Return to Work for Healthcare Personnel with SARS-CoV-2 Infection
  • Facilities should limit access points and ensure that all accessible entrances have a screening station. 
  • Facilities should contact their local health department for questions and frequently review the CDC COVID-19 website for health care professionals. 
  • Pursuant to Wis. Admin. Code ch. DHS 145 the local health department should be notified about residents or staff with suspected or confirmed COVID-19, residents with severe respiratory infection resulting in hospitalization or death, or ≥ three (3) residents or staff with new-onset respiratory symptoms within 72 hours of each other. Questions about reporting requirements should be directed to the local health department.

Educate residents, staff, and visitors about COVID-19, current precautions being taken in the facility, and actions they should take to protect themselves:

Encourage Source Control:

  • Everyone in the facility should practice source control.
  • Personnel should wear a facemask (or cloth face covering if facemasks are not available or only source control is required) at all times while they are in the facility.
    • When available, facemasks are generally preferred over cloth face coverings for healthcare personnel as facemasks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others. Guidance on extended use and reuse of facemasks is available in Strategies for Optimizing the Supply of Facemasks. Cloth face coverings not personal protective equipment (PPE) and should NOT be worn instead of a respirator or facemask if more than source control is required.
  • Visitors, if permitted into the facility, should wear a cloth face covering while in the facility.
  • Encourage residents to wear a cloth face covering (if tolerated) whenever they are around others, including when they leave their rooms and when they leave the facility.

Encourage Social (Physical) Distancing:

  • Modify or cancel group activities: 
    • Instead of communal dining, consider delivering meals to rooms, creating a “grab n’ go” option for residents, or staggering mealtimes to accommodate social distancing while dining (e.g., a single person per table).
    • Schedule group activities in a staggered fashion to limit number of residents participating and allow them to remain at least 6 feet apart from each other.
    • Remind residents to remain at least 6 feet apart from others when they are outside their room.
  • Remind personnel to practice social distancing while in break rooms and common areas, cancel non-essential meetings, and consider alternate methods for essential meetings (e.g., virtual).

Provide Access to Supplies and Implement Recommended Infection Prevention and Control Practices:

  • Provide access to alcohol-based hand sanitizer with at least 60% alcohol and keep sinks stocked with soap and paper towels.
    • Remind residents, visitors, and personnel to frequently perform hand hygiene.
  • Ensure adequate cleaning and disinfection supplies are available. Provide EPA-registered disposable disinfectant wipes so that commonly used surfaces can be wiped down. 
    • Routinely (at least once per day) clean and disinfect surfaces and objects that are frequently touched in common areas. This may include cleaning surfaces and objects not ordinarily cleaned daily (e.g., door handles, faucets, toilet handles, light switches, elevator buttons, handrails, handicap access door panels, countertops, chairs, tables, remote controls, shared electronic equipment, and shared exercise equipment).
    • Use regular cleaners, according to the directions on the label. For disinfection, refer to List N on the EPA website for a list of products that are EPA-approved for use against the virus that causes COVID-19. Follow the manufacturer’s instructions for all cleaning and disinfection products (e.g., concentration, application method and contact time).

Rapidly Identify and Properly Respond to Residents with Suspected or Confirmed COVID-19:

  • Older adults with COVID-19 may not show common symptoms such as fever or respiratory symptoms. Less common symptoms can include new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell. Additionally, more than two temperatures of >99.0°F might also be a sign of fever in this population. Identification of these symptoms should prompt isolation and further evaluation for COVID-19.
  • Designate one or more facility employees to ensure all residents have been screened at least daily for fever and symptoms consistent with COVID-19
  • Implement a process with a facility point of contact that residents can notify (e.g., call by phone) if they develop symptoms.
  • If COVID-19 is identified or suspected in a resident (i.e., resident reports fever and/or symptoms consistent with COVID-19):
    • Immediately isolate the resident in their room and notify the health department. The resident should be prioritized for testing.
    • Encourage all other residents to self-isolate, if not already doing so, while awaiting assessment to determine if they are also infected or exposed.
    • Maintain social distancing (remaining at least 6 feet apart) between all residents and personnel, while still providing necessary services.
    • For situations where close contact with any (symptomatic or asymptomatic) resident cannot be avoided, personnel should at a minimum, wear: 
      • Eye protection (goggles or face shield) and an N95 or higher-level respirator (or a facemask if respirators are not available). Cloth face coverings are not PPE and should not be used when a respirator or facemask is indicated.
      • If personnel have direct contact with a resident, they should also wear gloves. If available, gowns are also recommended but should be prioritized for activities where splashes or sprays are anticipated, or high-contact resident-care activities that provide opportunities for transfer to pathogens to hands and clothing of personnel (e.g., dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, wound care).
    • Personnel who do not interact with residents (e.g., not within 6 feet) and do not clean resident environments or equipment do not need to wear PPE. However, they should wear a cloth face covering or, if PPE supplies are sufficient, a facemask for source control.
    • Personnel who are expected to use PPE should receive training on selection and use of PPE, including demonstrating competency with putting on and removing PPE in a manner to prevent self-contamination.
    • CDC has provided strategies for optimizing personal protective equipment (PPE) supply that describe actions facilities can take to extend their supply if, despite efforts to obtain additional PPE, there are shortages. These include strategies such as extended use or reuse of respirators, facemasks, and disposable eye protection.
  • If the resident with COVID-19 requires more assistance than can be safely provided by the facility, they should be transferred (in consultation with public health) to another location (e.g., alternate care site, hospital) that is equipped to adhere to recommended infection prevention and control practices. Transport personnel and the receiving facility should be notified about the suspected diagnosis prior to transfer. 
    • While awaiting transfer, residents should be separated from others (e.g., remain in their room with the door closed) and should wear a cloth face covering or facemask (if tolerated) when others are in the room and during transport.
    • Appropriate PPE (as described above) should be used by personnel when coming in contact with the resident.
  • If residents are transferred to the hospital or another care setting, actively follow up with that facility and resident family members to determine if the resident was confirmed or suspected to have COVID-19. This information will inform need for contact tracing or implementation of additional infection prevention and control recommendations.

For additional information see: Considerations for Preventing Spread of COVID-19 in Assisted Living Facilities.

Planning for Staff Shortages

Maintaining appropriate staffing is essential to providing a safe work environment for facility staff and safe resident care. As COVID-19 progresses, staffing shortages will likely occur due to healthcare staff exposures, illness, or need to care for family members at home. Facilities must be prepared for potential staffing shortages and have plans and processes in place to mitigate these, including communicating with staff about actions the facility is taking to address shortages and maintain resident and staff safety, and providing resources to assist staff with anxiety and stress. Facilities can take steps to assess and improve their preparedness for responding to COVID-19.

Minimum Planning Should Include:
Developing a contingency staffing plan that identifies the minimum staffing needs and prioritizes critical services based on residents’ needs. 

  • Assigning a person to conduct a daily assessment of staffing status and needs during a COVID-19 outbreak.
  • Contracting with staffing agencies, local hospitals, and clinics to fill roles as appropriate.   
  • Exploring all state-specific emergency waivers or changes to licensure requirements or renewals that may allow for hiring and staffing flexibility.

Strategies to Lessen Staffing Shortages
As a facility deviates from their standard recruitment, hiring, and training practices, there may be higher risks to the staff and residents. Facilities should carefully review their emergency plans and cautiously move from one staffing strategy to the next, balancing risk and benefits with each decision.   

Consider implementing strategies to mitigate staffing shortages, including the following:

  • Over-communicate with staff. Staff need to know what is happening and what to expect.   
  • Understand your staffing needs and the minimum number of staff needed to provide a safe work environment and resident care.
  • Communicate with local healthcare coalitions; federal, state, and local public health partners; and Wisconsin Healthcare Readiness Coalition (HERC) to identify additional local staff.
  • Make sure all staff are working to their full scope of licensure.
  • Work with staffing agencies to bring in temporary staff.
  • Hire additional staff by recruiting retired staff, students, or volunteers when applicable.
  • Cross-train staff so that they are able to work in multiple roles.
  • Adjust staff schedules. 
    • Create flexible schedules with 4, 8, 10, or 12-hour shifts.
    • Vary shifts depending on responsibilities. For example, shorter shifts could be set aside for duties such as performing assessments or dispensing medications, while longer shifts could be used for cleaning and disinfecting the facility. 
  • Address barriers and social factors that might prevent staff from working. Examples include: 
    • Transportation—Provide ride service to and from work. Provide a rental vehicle. Provide zero or low interest loans to purchase a used vehicle.
    • Housing—Provide temporary housing to staff who live with vulnerable individuals. This could be a hotel, local dormitories that are not being utilized, recreational vehicles (RVs) on the premises, or a live-in model in unoccupied wings of the facility.
    • Mental well-being—Provide resources to ensure individuals are able to cope with working in nursing homes and assisted living facilities during a pandemic. This may include counseling, online resources such as COVID-19: Resilient Wisconsin, or other resources for coping with stress.
    • Compensation—Consider providing additional pay for working in a COVID unit or in a COVID-positive facility (for example, increasing hourly pay for every hour worked during the pandemic or providing a bonus for staff that work during the pandemic). Consider paying staff who may need to be quarantined following an exposure at work.
    • Recognition—Find non-monetary ways to recognize staff for their efforts and boost morale.
    • Provide uniforms that can be left at work.
    • Provide meals and snacks to staff.
  • For campuses or organizations with multiple facilities or are part of health systems, consider redeploying staff to the areas with the most critical needs. Facilities will need to ensure these staff have received appropriate orientation and training to work in the areas that are new to them.

If options listed above are exhausted, explore assistance from the Wisconsin Emergency Assistance Volunteer Registry (WEAVR). WEAVR is a web-based online registration system for Wisconsin's health professional volunteers willing to serve in an emergency. WEAVR facilitates health and medical response through identification, credentialing and deployment of volunteers. Facilities who may be in need of WEAVR support should work with local public health and emergency management to identify needs and available resources. Information from facilities that would expedite this process includes:

  • Contact information at the facility.
  • A brief description of the situation at the facility.
  • The skill set(s)/profession(s) that are needed.
  • The duration of time you will need the volunteers for.
  • A brief description of duties.
  • Information on whether you will compensate people or are looking for volunteers.
  • The date you need people to start.

Resources:

Additional Resources

Wisconsin Assisted Living Facility Regulations: 

Questions
For questions regarding this information or for technical assistance, providers should contact The Division of Quality Assurance (DQA), Bureau of Assisted Living (BAL) regional offices.

Return to Work Guidance for Asymptomatic Health Care Workers who Tested Positive for COVID-19

Purpose: To provide additional information and guidance regarding CDC’s healthcare worker crisis staffing plan for long-term care facilities (LTCFs), specifically around the recommendation to let asymptomatic, COVID positive healthcare workers return to work before finishing the recommended isolation. This guidance describes the steps that must be taken prior to implementing this practice and precautions that must be in place within the facility prior to allowing asymptomatic positive staff to return to work.

  1. Education, planning and communication are key components necessary for continued successful LTCF operations during a COVID-19 outbreak. 
    • Utilizing CDC and DHS COVID-19 resources, develop educational communications for internal and external use. This involves frequent communication with residents, families, staff and legal representatives on COVID-19 and the facility’s plan to manage COVID-19.
    • Prior to any COVID-19 positive residents or staff being identified in the facility or any facility-wide COVID testing, LTCFs should be reviewing and revising their emergency staffing plans to ensure adequate staffing in the event positive staff are identified.
    • Facilities should also identify how the facility can establish a COVID-19 unit within their facility and how that would impact their staffing plan.
  2. When COVID-19 positive staff are identified (regardless of whether the staff member is showing symptoms or not), they should be excluded from work until they have met the criteria set by DHS and CDC Criteria for Return to Work for Healthcare Personnel with Confirmed or Suspected COVID-19 (Interim Guidance) for discontinuation of isolation. Making exceptions to this recommended practice will increase the risk of COVID-19 to residents of long-term care facilities, but may be necessary in a crisis situation.
  3. As COVID-19 positive staff are identified and additional staffing resources need to be found, the facility should work through their emergency staffing plan, as well as the crisis staffing plan outlined above. The facility should work with DQA through the rapid assistance and support team process (RAST).
  4. *After exhausting all other opportunities the facility would submit a variance request to DQA to utilize asymptomatic COVID-19 positive staff. As soon as the facility feels they have exhausted all resources described above in the DQA crisis staffing plan and still does not have adequate staff to provide the care, treatment and services to the residents, they should submit a variance request to their DQA regional office.
    • The variance request should include the code reference CBRF, DHS 83.17(2)c; AFH, DHS 88.03(2)g(2) and all steps the provider has taken prior to arriving at this phase. 
    • Upon receipt of the variance request, the DQA regional office will consult with the LHD, DPH, and Bureau/Deputy Director. If the request contains sufficient information the request will be approved for a limited time period with reporting to the DQA regional office. DQA regional office will share reporting with LHD and DHS. The following criteria should be met if this is allowed.
      • Asymptomatic COVID-19 positive staff would only be allowed to work on the COVID-19 unit. There needs to be a separate entrance and break area for staff. To prevent transmission between staff, only asymptomatic COVID-19 positive staff should be working on this wing once it is allowed, and should not leave the unit for any reason.
      • The facility should have enough of the proper personal protective equipment to prevent transmission of the virus, including facemask, gowns, gloves, and face shields.
      • Facemasks must be worn by asymptomatic COVID-19 positive staff at all times including as they walk in the building and other non-patient care areas in the facility.
      • Strict symptom monitoring (prior to and during their shift) of these staff needs to be implemented. If they develop even mild symptoms consistent with COVID-19 including fever, chills, cough, shortness of breath, fatigue, muscle/body aches, headache, new loss of taste or smell, sore throat, congestion or running nose, nausea, vomiting, or diarrhea the employee should immediately be excluded from work.
  5. Facility representatives should meet daily with their LHD to assess current staffing levels to determine when allowing asymptomatic COVID staff to return to work prior to completion of isolation should be discontinued.

*If any agency (DQA, DPH, LHD) is made aware of a facility that is allowing asymptomatic positive COVID staff to return to work prior to completion of isolation without having gone through the approval process, a meeting should be scheduled to obtain approval ASAP.

Resources

Staffing and Designating Separate Areas for COVID-19 Positive Residents

The following practices reduce transmission of COVID-19 within facilities or units. 

Facilities should consider approaches to decrease the number of different staff interacting with each resident as well as the number of interactions among those staff and residents. 

  • Facilities should use separate staffing teams for COVID-19 positive residents, to the best of their abilities. 
  • To the extent possible, facilities should consider making consistent assignments throughout the facility, regardless of COVID-19 status. This may include the assignment of staff to specific residents. When feasible, staff should not work across floors or units/wings.
  • Consistent staff assignments also serve to enhance staff’s ability to detect emerging condition changes among residents, which staff with less familiarity may not notice.

When multiple cases are identified and if feasible, facilities should consider dedicated wings or units, or a group of rooms at the end of a wing or unit for residents with known or suspected COVID-19, ensuring that they are separate from other residents. Facilities must maintain strict infection prevention and control practices in these dedicated areas. 

BAL has established a process for licensure/certification applications for temporary expansion units. This process is outlined in DHS Licensure/Certification Application for Temporary Assisted Living Facility Expansion
Units and Transfer Options during the COVID-19 Public Health Emergency State Memo, 20-009
(PDF) .

Smaller assisted living settings should consider the following steps to increase separation:

  • Residents with known or suspected COVID-19 should stay in one room, away from other people, as much as possible. Have the sick person use a separate bathroom. If a separate bathroom is not available, staff should clean and disinfect the bathroom after each use by the sick person.
  • If possible, avoid having residents in shared spaces. Help all residents understand importance of and social distancing when in shared spaces, if sharing of space cannot be avoided. 
  • If feasible, move regularly used furniture and other household items to maintain 6-feet distance between people in any shared space. 

Testing Criteria

The Assisted Living COVID-19 Testing Guidance, P-02768 (PDF) is based on the State of Wisconsin Testing Framework, P-02709 (PDF)

The state testing framework describes the state’s containment strategy, known as “Box it in” and focuses on supporting and sustaining local capacity for testing, tracing, isolation, and quarantine. Testing and contact tracing are vital to identify where further isolation and quarantine efforts are needed.

Based on the Assisted Living COVID-19 Testing Guidance, P-02768 (PDF), facilities should develop plans to:

  • Ensure testing of residents or staff with symptoms of COVID-19 and any residents or staff who have had close contact with someone who tested positive for COVID-19.
  • Ensure notification to local/tribal public health department to coordinate facility wide testing if an outbreak occurs (defined as 1 or more staff or residents that tests positive). To prepare for the possibility of outbreak testing, facilities should review the asymptomatic testing information outlined in the Assisted Living COVID-19 Testing Guidance, P-02768 (PDF). Facilities may also contact their local/tribal public health department to identify community resources if they anticipate they will need assistance with sample collection.

If residents or staff are symptomatic or test positive for COVID-19, facilities are also encouraged to review DHS guidance for:

•    Infection Prevention
•    Planning for Staff Shortages
•    Return to Work Guidance for Asymptomatic Health Care Workers who Tested Positive for COVID-19 
•    Staffing and Designated Areas for COVID-19 Positive Residents
•    CDC Criteria for Return to Work for Healthcare Personnel with SARS-CoV-2 Infection 

Testing forms

Visitors to Facilities

Restrictions on visitors

The safety and wellbeing of the residents and staff in assisted living facilities, continues to be a top priority for DHS. COVID-19 is a serious viral infection and based on currently available information and clinical expertise, older adults and people of any age who have serious underlying medical conditions might be at higher risk for severe illness from COVID-19 (HHS, 2020). This increases the need for vigilance in avoiding the introduction and transmission of COVID-19 into congregate living settings, such as assisted living facilities. Assisted living facilities should develop a plan for visitor restrictions, and should rely on guidance from state and local officials when making decisions about relaxing restrictions. 

Facilities should: 

  • Restrict all visitors and nonessential health care personnel, except for certain compassionate care situations, such as an end-of-life scenario.
  • Communicate through multiple means to inform individuals and nonessential health care personnel of the visitation restrictions, such as signage at entrances and exits, letters, emails, phone calls, and recorded messages for receiving calls. Communications with residents and families should be proactive and clearly explain that visitor restrictions are to protect them and others in the facility who might have conditions making them more vulnerable to severe illness from COVID-19. 
  • Utilize a person-centered approach when making decisions about compassionate care visits.
  • Provide educational information about COVID-19, such as CDC’s How to Protect Yourself & Others, to potential visitors and residents.
  • Screen compassionate care visitors for fever and respiratory symptoms, including new or worsening cough, unexplained muscle weakness or pain, and sore throat. If screening discovers signs and symptoms for fever or respiratory infection, visitation should be cancelled. The visitor should self-isolate at home and inform their medical provider. 
  • Limit the distance a visitor travels in the assisted living facility. This may be accomplished by having a separate visiting room close to the entrance that is disinfected between each visit or developing paths that avoid walking through care areas. Ask visitors to avoid interacting with anyone other than the resident they are visiting.
  • Provide compassionate care visitors instruction on hand hygiene, the importance of limiting surfaces touched, and the proper use of PPE or cloth face covering, according to current facility policy. Provide education about actions residents and visitors can take to protect themselves, emphasizing the importance of social distancing and respiratory hygiene/cough etiquette. 
  • Advise visitors, and any individuals who enter the facility (for example, hospice staff), to monitor for signs and symptoms of respiratory infection for at least 14 days after exiting the facility. If symptoms occur, advise them to immediately inform the assisted living facility, notify their medical provider, if they have one, and local/tribal Public Health Department. Facilities should immediately screen the individuals of reported contact, and take all necessary actions based on their findings.

In lieu of visits, facilities should consider:

  • Offering alternative methods for visitation for people who would otherwise visit. It is especially important for facilities to ensure that adaptive devices such as hearing aids and eyeglasses are available to residents while using alternative forms of communication. Possible forms of alternative communication include: 
    • Scheduled phone calls
    • Online and smartphone video technology (e.g. Zoom, Skype, Face Time)
    • Letters with accompanying photos. Have facility staff read the letters to residents if they need assistance.
    • While being mindful of social distancing, creating a buddy system between residents or between residents and staff to strengthen support networks. 
  • Creating and/or increasing listserv communication to update families, such as advising them to not visit.
  • Assigning staff to serve as the primary contact to families for inbound calls, and conducting regular outbound calls to keep families up to date.
  • Offering a phone line with a voice recording updated at set times (for example, daily) with the facility’s general operating status, such as when it is safe to resume visits.

Health care workers: 

Essential health care workers, such as hospice workers or dialysis technicians, who provide care to residents, should be permitted to enter the facility as long as they are screened and do not exhibit symptoms of COVID-19 or have a known exposure to someone with COVID-19.

Utilize telehealth services when possible to maintain continuity of care and avoid additional negative consequences from delayed preventative, chronic, or routine care. For more information, see the CDC guidance Using Telehealth to Expand Access to Essential Health Services during the COVID-19 Pandemic.

Ombudsman: Residents still have the right to access the Ombudsman Program with the Board on Aging and Long Term Care. They can be reached at 1-800-815-0015 or via email at BOALTC@wisconsin.gov

Safer Visits in Assisted Living Facilities - Relaxing Restrictions

The safest approach to prevent COVID-19 from entering your facility is to restrict visitors and nonessential health care personnel from entering the facility. If an assisted living facility determines they can effectively mitigate the risks associated with relaxed visitation restrictions and have no known or suspected COVID-19 cases, our recommendations for safer visits are listed below. 

Facilities may choose to have a longer waiting period before relaxing restrictions. The pandemic is affecting communities in different ways and facilities should use their best judgment, regularly monitor the factors for reopening and adjust their plans accordingly. Resources for monitoring local disease activity levels include:

This guidance for safer visits is intended for assisted living facilities (community-based residential facilities, licensed adult family homes, and residential care apartment complexes) with no known or suspected COVID-19 cases. The guidance includes preventative measures to reduce the chances of the introduction of COVID-19 into the facility, while mitigating the unintentional consequences of social isolation from family and loved ones.

Rationale

COVID-19 is a serious viral infection and based on currently available information and clinical expertise, older adults and people of any age who have serious underlying medical conditions might be at higher risk for severe illness from COVID-19. This increases the need for vigilance in avoiding the introduction and transmission of COVID-19 into congregate living settings, such as assisted living facilities. 

Safe visiting practices are already in place in assisted living facilities but are designated for “compassionate care situations” such as end-of-life visits. Recommended infection prevention and control practices can provide an opportunity for expanded visitation for residents, specific to their person-centered plan, while maintaining the goal of avoiding introduction and/or transmission of COVID-19 to our most vulnerable citizens.

Guiding Principles

This guidance is intended for assisted living facilities that are able to develop and implement a Safer Visiting Policy that includes effective infection prevention and control measures and addresses the psychosocial needs of the resident. Facilities’ practices must be consistent with current CDC and local/tribal public health departments. (See Key Strategies to Prepare for COVID-19 in Long-Term Care Facilities (LTCFs); CDC Assisted Living Guidance; contact for local health departments.)

Physical distancing and use of cloth face coverings have proven to be a significant infection prevention and control practice to prevent the spread of COVID-19. These can be accomplished by providing a 6-foot distance or other barriers between individuals, and ensuring that all individuals wear either a face mask or cloth face covering.

However, there are valid concerns that may prevent an individual from wearing one safely. Cloth face coverings should not be placed on young children under age 2, anyone who has trouble breathing, or is unconscious, incapacitated, or otherwise unable to remove the covering without assistance. Medical considerations, including respiratory conditions, as well as traumatic personal experiences, mean some individuals are not able to wear a face covering safely. Wearing a cloth face covering may be dangerous or stressful for individuals with disabilities and young children. Individuals may also fear racial profiling or discrimination based on wearing—or not wearing—a face covering. Access to clean, multiple, or appropriate face coverings may also be a barrier. Similarly, facilities should consider the unique needs of people who are hard of hearing when developing and implementing policies to adopt the use of cloth face coverings. 

Screening of visitors and staff have shown to provide an early detection and surveillance method to impede the spread of COVID–19 in assisted living facilities. This screening allows for the prohibition of individuals entering assisted living facilities with even minor changes in health status.

Education of residents and families is important to ensure all parties understand the need to follow infection prevention and control practices. Education should include: 

Recommendations for Safer Visits
  1. Each facility should develop a procedure that takes into consideration the recommendations for infection prevention and control measures and management of safer visits, as desired or needed by residents. 
  2. Assisted living facilities should develop policies on visitation based on the following considerations: 
    • Expressed or observed desires and needs of the individual resident for whom visits are being considered.
    • Current CDC guidance, local/tribal public health requirements and based on care team review.
    • Safe visits are listed in a hierarchy of most safe visits to least safe visits as follows:
      • Virtual visits, such as Skype, Zoom, etc.
      • Outside visits, maintaining physical distancing and face covering. If inclement weather is present, the outside visit should be rescheduled rather than moving the visit into the facility.
      • Inside visits if dedicated room is available and only if the resident is unable to visit virtually or by an outside visit. 
      • Resident room visits if the resident has single room and only if the resident is unable to visit in any of the above-noted ways.
  3. Care team (as required under applicable regulations that must include the resident or resident’s surrogate decision maker) determines the safest type of visit based on resident’s need and/or desire.
  4. Assisted living facilities should provide educational information about COVID-19, such as CDC’s How to Protect Yourself & Others, to potential visitors and residents.
    • Use signs to convey messages. Make sure the signs use plain language and imagery to convey their messages. Provide signs in English, Spanish, and other languages your residents, their families, and those in the community primarily speak.  
  5. Infection prevention and control measures should include: 
    • Screening prior to visitation for any COVID-19 symptoms.
      • CDC guidance for COVID -19 symptoms according to current federal, state, or local public health guidelines. 
      • Implement active screening of visitors for fever and respiratory symptoms. Actively take their temperature and document the presence of a fever and respiratory symptoms including: new or worsening cough, unexplained muscle weakness or pain, and sore throat.
      • If screening discovers signs and symptoms for fever and respiratory infection, visitation should be cancelled. The visitor should self-isolate at home and inform their medical provider.
    • Limit the distance a visitor travels in the assisted living facility. This may be accomplished by:
      • Having a separate visiting room close to the entrance that is disinfected between each visit.
      • Developing paths that avoid walking through care areas.
      • Asking visitors to avoid interacting with anyone other than the resident they are visiting.
    • Ensure physical distancing between the visitor and resident by designating a 6-foot distance, such as using plexiglas barriers, outdoor visits with 6-foot distance, placing taping or signage to identify 6-foot clearances. Consider environmental changes such as hard surface furniture with 6-foot spacing and removing all extraneous items such as magazines and books from visiting areas. 
    • Ensure visitor and resident complete frequent hand hygiene by using hand sanitizer with at least 60% alcohol before, during, and after their visit.
    • Ensure visitor and resident are using source control measures such as cloth face covering or face mask for the entire visit, even if social distancing. Ensure visitor and resident use cloth face coverings and/or PPE as required per facility policy and resident need.
    • Between each visit, the visitation area must be disinfected according to current guidelines.
  6. Administrative controls to monitor compliance and provide instruction:
    • The assisted living facility should continually review its visitation policy based on local transmission of COVID-19 and adjust as needed to ensure maximum protection for residents. This includes temporarily stopping all inside visitation when a COVID-19 case is identified in a staff member or resident. 
    • Consider prescribing date and time limitations on the number of visitors in the setting at any one time, limit the number of visitors per resident and limit length of the visit. 
    • The visits should occur at scheduled times when there are adequately trained staff available to provide education on COVID-19 mitigation procedures and facility expectations. 
    • The length of visits should be established by the assisted living facility policy to ensure continuous compliance with infection prevention and control procedures. 
    • The facility should develop and implement an ongoing self-monitoring system to ensure staff, residents, and visitors are complying with all procedures for safer visitations. 
    • The facility should revise visitation plans based on resident responses, the facility’s data, the facility’s and the local community’s COVID-19 status, and current local, state and federal guidelines.
  7. Visitor and resident education shall be conducted prior to each visit and include: 
    • Facility’s procedure for visitation. 
    • Screening process for COVID-19 symptoms per CDC guidelines
    • Education to self-monitor after the visit for 14 days and report any symptoms of illness to the assisted living facility immediately as well as notifying their Medical Provider, if they have one, and local/tribal Public Health Department. 
    • Reminder that subsequent visits must be pre-arranged and will not occur if the setting experiences any incidence of COVID-19.

Assisted living facilities will need to determine whether they can follow these guidelines to ensure they can provide safer visitations. Due to PPE availability, staffing patterns, and facility lay-out and/or location, every facility may not be able to meet the guidance requirements necessary to offer all of the safer visit options, nor will the options available at each facility necessarily be available at all times.

References

Resources

DHS Resources
Webinars

See the Assisted Living Forums page for recordings, agendas, and handouts from all Assisted Living forums.

CDC Resources
Wisconsin Board on Aging and Long Term Care Resources
The Society for Post-Acute and Long-Term Care Medicine

Caring for PALTC Residents with Dementia During the COVID-19 Outbreak

Ways to keep your residents engaged

What we know

  • Residents in long-term care and other residential facilities are experiencing reduced opportunities to connect with family and friends due to “no visitor” rules.
  • Meal sites and other community engagement opportunities are now closed or otherwise unavailable.
  • Staffing patterns at long-term care and other residential facilities are experiencing reduced workforce for multiple reasons.
  • Staff and facility infrastructure can create physical and interactional barriers to communication and connection with society.
  • Resident barriers to communication may include hearing loss, vision loss, learning and cognition disabilities, dementia, physical and dexterity disabilities, and speech disabilities. This is not an all-inclusive listing.

Facility and infrastructure barriers

  • Resident access to external windows based on room floor and location.
  • Resident access to direct phone lines in individual rooms (along with appropriate electrical access).
  • Facility provision of free wireless internet.
  • Staff availability and knowledge to provide one-to-one assistance for communication support for residents.
  • Lighting and electrical access.
  • Not recognizing the impact that the use of PPE may have on residents; for example, the use of face masks will impact communication with residents who are deaf or hard of hearing.

Ways to address isolation

  • Technology (communication devices and other assistive technology)
    • Tablets, laptops, and smartphones capable of connecting to WIFI
    • Smarthome visual devices (Amazon Echo/Alexa, Facebook Portal, Nest Hub)
    • Smarthome control technology (thermostats, doorbells, lights)
    • Simplified tablets (GrandPad for example – see resources section)
    • Amplified telephones
    • Personal listening devices
    • Handheld or desktop style magnifiers
    • Tablet holders and cases
    • Wheelchair trays
    • Walker bags
    • Recreational assistive technology, such as card holders, pencil grips, or other needs for participation in activities
    • Remote volunteers to facilitate communication and skill building
    • Video meetings (Zoom, Facetime, Facebook Messenger, Google Meet/Hangouts, Skype)
    • Apps for communication (Facebook, Instagram, text messaging, email, Skype, TIkTok)
    • Apps specific for disabilities (Glide and Marco Polo for consumers who are deaf for example)
    • Apps for creative ideas (Facebook, Instagram)
    • Apps for mental health (meditation guidance, soothing sounds, drawing apps)
    • Account setup tips: When creating accounts, keep written documentation in multiple places or online in Google Drive or similar. This includes user name, password, and security questions. If help is needed, either in person or remote, the consumer or caregiver has access to the needed information.
  • Nontechnology strategies (programming, structural, and instructional)
    • Face-to-face visits via windows and signs
    • Creativity with activities (Pinterest for ideas)
    • Mailing cards and letters
    • Sending books, photos, photo albums, puzzles, games
    • Ordering groceries and meals to be delivered
    • Communication Board (printable)

Donation requests (technology)

Ensure all donations power up, function, and include a power source so that it does not become a waste burden or issue that requires disposal.

  • Tablets, laptops, and smartphones capable of connecting to WIFI
  • Amplified telephones
  • Personal listening devices
  • Handheld or desktop-style magnifiers
  • Tablet holders and cases
  • Wheelchair trays
  • Walker bags
  • Recreational assistive technology such as card holders, pencil grips, or other needs for participation in activities
  • UV Wands
  • Cleaning wipes and hand sanitizer
  • Remote volunteers to facilitate communication and skill building
  • Donation of video conferencing services (Zoom for example)

Cleaning recommendations for donated devices (technology)

Facility solutions

  • Activation of individual telephone lines within rooms as needed or requested.
  • Provision of sitewide wireless internet access.
  • Review of activities to introduce modifications in programming structure. Examples might include hallway bingo where residents each sit within their respective doorways to play group bingo to ensure social distancing.
  • Subscription and provision of paid video conferencing applications such as Zoom for resident access.
  • Provision of free video conferencing applications such as Zoom, FaceTime, Skype, and others to residents and family and friends to encourage distance communication.
  • Emergency Preparedness should be evaluated. The Council for Physical Disabilities has an Emergency Toolkit.
  • Ensure availability of simple communication boards in resident rooms for those with communication disabilities. Download and print a communication board from Temple University Institute on Disabilities to assist those who cannot speak.
  • Provision of assistive technology solutions, where needed and available, to support communication and participation in activities. DHS WisTech staff can assist with this.

 

Funding options

  • Telecommunications Equipment Purchase Program (TEPP). This fund is available to assist with the acquisition of basic and essential telecommunications for distance communication for people who are hard of hearing, deaf, combined hearing and vision loss, a speech disability, or a mobility impairment. The disability must prevent the use of regular telecommunications equipment. Copayments and specific equipment is eligible. Program specific rules apply and staff from the Independent Living Centers and DHS WisTech staff are available to answer questions or assist with applications.
  • Telecommunications Assistance Program (TAP). This fund is available to assist with the acquisition of basic and essential telecommunications for distance communication for people who are hard of hearing, deaf, or have a combined hearing and vision loss that prevents the use of regular telecommunications equipment. Program specific rules apply and staff from the Independent Living Centers and DHS WisTech staff are available to answer questions or assist with applications.
  • iCanConnect (ICC). This fund is available to assist with the acquisition of technology needed for distant communication for people with combined hearing and vision disabilities. Financial eligibility must also be met. Staff from the Center for Deaf-Blind Persons can provide information, assist with applications, and provide assessments.

Family tips

  • Send cards and letters (consider sanitization and wait time for delivery as COVID19 can remain on paper).
  • Send books or other small, random gifts from Amazon or other online stores.
  • Assist with online grocery or person item orders for residents isolated in apartments.
  • Send photos from an online service; could also be photo book, calendar, or other photo mug for example.
  • Keep in mind that staff at these facilities are operating under extraordinary circumstances and that they may be leaving their own families behind to care for yours. It is okay to ask for help connecting with your parent and to ask for updates on their well-being.
  • Set up accounts for your family member or friend who is a resident in a long-term care facility.
  • Write down account login details, including “secret questions” responses and leave with the resident so that if login support is needed, staff and the resident have access to the necessary information. Please keep confidentiality in mind; however, and do not set up accounts with common user names and passwords used for other accounts.

Example scenario

Long-term care facility:

  • Identifies residents without access to telecommunications or other mechanisms for communication with family and friends. Who has a tablet, smartphone, laptop or room telephone and who does not.
  • Identifies residents who are without these methods of communication but have the interest and capability to use technology. Capability includes independent use, supported use, and passive use.
  • Identifies staff and other residents and/or their family members who can provide training and support or assistance to residents in the use of communication technology.
  • Determines types and numbers of devices needed to meet resident needs.
  • Solicits donations from family and the community for tablets, smartphones, laptops, and telephones (amplified if possible). This includes isolated donation location to ensure sanitization can occur prior to distribution or use.
  • Accesses training resources available online and through the Wisconsin Department of Health Services. Remote training and assistance is available for residents and staff.
  • Conducts thorough cleaning of technology prior to distribution. See recommendations.
  • Determines match of device to resident based on interest, skills, and needs.
  • Reviews activity modifications that will allow for engagement and participation by residents while adhering to protocols for social distancing. DHS staff may be available to discuss alternatives and solutions.

Resources

Last Revised: September 23, 2020