COVID-19: Long-Term Care Facilities and Services

This guidance is for all long-term care facilities, assisted living facilities, 1–2 bed adult family homes, supported living apartments, and facilities serving people with developmental disabilities in Wisconsin caring for patients who are elderly and/or have chronic medical conditions that place them at higher risk of developing severe complications from COVID-19. By helping facilities improve their infection prevention and control practices in order to prevent the transmission of COVID-19, together we can flatten the curve.

Recommendations will change as we move through Wisconsin's roadmap to reopen using public health principles of testing, tracing, and tracking the new coronavirus to decrease COVID-19 cases and death. 

DHS recommends the following actions in accordance with Wis. Stat. chs. 50 and 252, Wis. Admin. Code ch. DHS 145, and Centers for Medicare & Medicaid Services (CMS) guidance.

If a health care worker or resident of a facility is diagnosed with COVID-19, immediately contact your local public health department to receive further guidance on infection control.

 Visitors to Facilities

Restrictions on visitors:

  • Facilities should restrict all visitors and nonessential health care personnel, except for certain compassionate care situations, such as an end-of-life scenario. Facilities should notify potential visitors of the need to defer visitation until further notice (through signage, calls, letters, etc.).
  • In compassionate care situations, visitors will be limited to a specific room only. Facilities should require visitors to perform hand hygiene and use personal protective equipment (PPE), such as face masks. Decisions about visitation during an end-of-life situation should be made on a case-by-case basis, which should include careful screening of the visitor (including clergy, bereavement counselors, etc.) for fever or respiratory symptoms.
  • Individuals with symptoms of a respiratory infection (fever, cough, shortness of breath, or sore throat) should not be permitted to enter the facility at any time (even in end-of-life situations).
  • Visitors that are permitted to enter must wear a face mask while in the building and restrict their visit to the resident’s room or other location designated by the facility. Facilities should also remind visitors to frequently perform hand hygiene, especially after coughing or sneezing.

Health care workers. Facilities should follow CDC guidelines for restricting access to health care workers.

  • Other health care workers, such as hospice workers, EMS personnel, or dialysis technicians, who provide care to residents should be permitted to enter the facility as long as they meet the CDC guidelines for health care workers.
  • Facilities should contact their local health department for questions, and frequently review the CDC COVID-19, website for health care professionals.

Surveyors. All nonessential survey activities are suspended, in accordance with CMS direction.

For other ongoing survey activities, CMS and state survey agencies are constantly evaluating their surveyors to ensure they don’t pose a transmission risk when entering a facility. For example, surveyors may have been in a facility with COVID-19 cases in the previous 14 days, but because they were wearing PPE effectively per CDC guidelines, they pose a low risk of transmission in the next facility, and must be allowed to enter. However, there are circumstances under which surveyors should still not enter, such as if they have a fever.

 Guidance for all Facilities

Facilities should:

  • Cancel communal dining and all group activities, such as internal and external group activities.
  • Implement active screening of residents and staff for fever and respiratory symptoms.
  • Remind residents to practice social distancing and perform frequent hand hygiene.
  • Screen all staff at the beginning of their shift 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 myalgia, and sore throat.
  • If employees develop signs and symptoms of a respiratory infection while on the job they should:
    • Immediately stop work, put on a face mask, and self-isolate at home.
    • Inform the facility’s infection preventionist.
    • Contact their local health department for next steps.​
  • Facilities should 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 the reasons for these changes. References able to be shared with residents and families are available through links in this memo and on the DHS COVID-19 website.

In lieu of visits, facilities should consider:

  • Offering alternative means of communication for people who would otherwise visit, such as virtual communications (phone, video-communication, etc.).
  • 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.

When visitation is necessary or allowable (end-of-life scenarios), facilities should make efforts to allow for safe visitation for residents and loved ones. Facilities should suggest that visitors:

  • Refrain from physical contact with residents and others while in the facility.
  • Practice social distancing with no handshaking or hugging, and remain at least 6 feet apart.

Facilities should create dedicated visiting areas (for example, “clean rooms”) near the entrance to the facility where residents can meet with visitors in a sanitized environment, if possible. Facilities should disinfect rooms after each resident-visitor meeting.

For individuals allowed in the facility (end-of-life scenarios):

  • Before visitors enter the facility and residents’ rooms, provide instruction on hand hygiene, the importance of limiting surfaces touched, and the proper use of PPE according to current facility policy while in the resident’s room.
  • Individuals with fevers, other symptoms of COVID-19, or who are unable to demonstrate proper use of infection control techniques should be restricted from entry.

Facilities should advise visitors, and any individuals who entered 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 self-isolate at home, contact their health care provider, and immediately notify the facility of the date they were in the facility, the individuals they were in contact with, and the locations within the facility where they visited. Facilities should immediately screen the individuals of reported contact, and take all necessary actions based on their findings.

Facilities should identify staff who work at multiple facilities (for example, agency staff, regional or corporate staff) and actively screen and restrict them appropriately to ensure they do not place individuals in the facility at risk for COVID-19.

Facilities should review and revise how they interact with vendors and delivery drivers, agency staff, EMS personnel and equipment, transportation providers (for example, when taking residents to offsite appointments), and other non-health care providers (for example, food delivery), and take necessary actions to prevent any potential transmission. For example, do not have supply vendors transport supplies inside the facility. Have them dropped off at a dedicated location (loading dock). Facilities can allow entry of these visitors, if needed, as long as they are following the appropriate CDC guidelines for Transmission-Based Precautions.

Residents should still have the right to access the Ombudsman program. Ombudsman access should be restricted per the guidance above (except in compassionate care situations). However, facilities may review this on a case-by-case basis. If in-person access is not available due to infection control concerns, facilities need to facilitate resident communication (by phone or other format) with the Ombudsman program or any other entity listed in 42 CFR § 483.10(f)(4)(i).

Nursing Home Infection Prevention

Nursing homes and other long-term care facilities should prepare now to care for residents with COVID-19. A facility self-assessment tool is available to evaluate current readiness and guide development of a COVID-19 plan that addresses communications, supplies, resident management, visitors, occupational health, training, and surge capacity. Facilities can start by performing the self-assessment and direct questions about their results or necessary elements to dhswihaipreventionprogram@dhs.wisconsin.gov. DHS infection preventionists recorded a 30-minute overview of the self-assessment tool to explain each section. Long-term care facilities can also request a tele-infection control assessment and response (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.

All nursing homes should prepare their facilities by implementing the following five priorities.

  • Keep COVID-19 from entering your facility:
    • Restrict all visitors except for compassionate care situations (for example, end of life).
    • Restrict all volunteers and nonessential health care personnel (HCP), including consultant services (for example, barber).
    • Actively screen all HCP for fever and respiratory symptoms before starting each shift; send them home if they are ill.
    • Cancel all field trips outside of the facility.
    • Have residents who must regularly leave the facility for medically necessary purposes (for example, residents receiving hemodialysis) wear a face mask whenever they leave their room, including for procedures outside of the facility.
  • Identify infections early:
    • Actively screen all residents at least daily for fever and respiratory symptoms; immediately isolate anyone who is symptomatic. Long-term care residents with COVID-19 may not show typical symptoms, such as fever or respiratory symptoms. Atypical symptoms may include new or worsening malaise, new dizziness, diarrhea, or sore throat. Identification of these symptoms should prompt isolation and further evaluation for COVID-19 if it is circulating in the community.
    • Notify the health department if severe respiratory infection, clusters (≥3 residents and/or HCP) of respiratory infection, or individuals with known or suspected COVID-19 are identified.
  • Prevent spread of COVID-19:
    • Cancel all group activities and communal dining.
    • Enforce social distancing among residents.
    • When COVID-19 is reported in the community, implement universal face mask use by all HCP (source control) when they enter the facility. If face masks are in short supply, they should be prioritized for direct care personnel. All HCP should be reminded to practice social distancing when in break rooms or common areas.
    • If COVID-19 is identified in the facility, restrict all residents to their room and have HCP wear all recommended PPE for all resident care, regardless of the presence of symptoms. Refer to strategies for optimizing PPE when shortages exist.
      • This approach is recommended to account for residents who are infected but not manifesting symptoms. Recent experience suggests that a substantial proportion of long-term care residents with COVID-19 do not demonstrate symptoms.
      • When a case is identified, public health can help inform decisions about testing asymptomatic residents on the unit and in the facility.
  • Assess supply of personal protective equipment (PPE) and initiate measures to optimize current supply. For example, extended use of face masks and eye protection or prioritization of gowns for certain resident care activities.
  • Identify and manage severe illness. Facility to perform appropriate monitoring of ill residents (including documentation of pulse oximetry) at least three times daily to quickly identify residents who require transfer to a higher level of care.
Suspension of On-Site Home and Community-Based Settings Rule Compliance Assessments

The Wisconsin Department of Health Services (DHS) has suspended on-site home and community-based settings rule compliance assessments until further notice. DHS has implemented significant social distancing measures in response to the rising number of COVID-19 cases in Wisconsin, and this measure is to protect against widespread community transmission.

This temporary change applies to both heightened scrutiny and nonresidential settings.

DHS reviewers will continue to review documents submitted by providers as part of this process. Reviewers may be contacting providers for additional information during this time.

 New Admissions, Transfers, and Discharges

CMS’ Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes provides the following guidance about new admissions:

When should a nursing home accept a resident who was diagnosed with COVID-19 from a hospital?

  • A nursing home can accept a resident diagnosed with COVID-19 as long as the facility can follow CDC guidance for transmission-based precautions. If a nursing home cannot, it must wait until these precautions are discontinued. CDC has released Interim Guidance for Discontinuing Transmission-Based Precautions or In-Home Isolation for Persons with Laboratory-confirmed COVID-19.
  • Information on the duration of infectivity is limited, and the interim guidance has been developed with available information from similar coronaviruses. CDC states that decisions to discontinue transmission-based precautions in hospitals will be made on a case-by-case basis in consultation with clinicians, infection prevention and control specialists, and public health officials. Discontinuation will be based on multiple factors (see current CDC guidance for further details).

Note: Nursing homes should 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. Also, if possible, dedicate a unit or wing exclusively for any residents coming or returning from the hospital. This can serve as a step-down unit where they remain for 14 days with no symptoms (instead of integrating as usual on short-term rehab floor, or returning to long-stay original room).  
 
Discharge
If the resident has to be discharged and has been exposed, the resident requires a 14-day quarantine. Therefore, you must inform the facility that is accepting the resident. If the facility is unable to meet transmission-based precautions for those 14 days, then the resident cannot be transferred.

 Testing Criteria

Wisconsin Nursing Home and ICF/IID Testing Opportunity

In appreciation and support of the challenging work that nursing home and ICF/IID staff do every day to protect some of our most vulnerable individuals, Wisconsin is moving forward with a plan to test every nursing home resident and staff member in the state for COVID-19 by the end of May. This testing is necessary because growing evidence suggests that persons with COVID-19 become infectious days prior to developing symptoms, and many develop only mild symptoms or no symptoms at all. This means that in congregate living settings like nursing homes where physical distancing is difficult to maintain, moving beyond only symptom-based screening is unlikely to detect all cases. In order to accomplish this goal, please reference the following:

If you have questions about the nursing home and ICF/IID testing process, please email WI COVID-19 SNF Testing.

Other Long-Term Care Facilities

To enhance surveillance and quickly identify residents who may be infected with COVID-19, DHS is requesting that long-term care facilities who meet the definition of an outbreak collect clinical specimens from ill residents and send them to the Wisconsin State Laboratory of Hygiene (WSLH) instead sending them to private laboratories. Up to three (3) specimens will be tested for: influenza, a respiratory virus panel, and COVID-19 free of charge.

Follow these procedures to submit specimens:

  1. Notify your local public health department when a respiratory outbreak is suspected.
  2. Collect up to three nasopharyngeal (NP) or oropharyngeal (OP) swabs in viral transport media (VTM) or universal transport media (UTM).

Wisconsin State Laboratory of Hygiene
2601 Agriculture Drive
Madison, WI 53718

See the Testing Criteria for Patients Under Investigation section on the DHS Health Care Providers page.

 Planning for Staffing Shortages

Maintaining appropriate staffing in healthcare facilities is essential to providing a safe work environment for healthcare staff and safe resident care. As the coronavirus disease 2019 (COVID-19) pandemic progresses, staffing shortages will likely occur due to healthcare staff exposures, illness, or need to care for family members at home. Nursing homes and assisted living 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. Nursing homes and assisted living facilities can take steps to assess and improve their preparedness for responding to COVID-19.

Plan

The plan should include, at a minimum, surge capacity related to staffing as follows:

  • Developing a contingency staffing plan that identifies the minimum staffing needs and prioritizes critical and non-essential services based on residents’ health status, functional limitations, disabilities, and essential facility operations.
  • Assigning a person to conduct a daily assessment of staffing status and needs during a COVID-19 outbreak.
  • Contracting with staffing agencies, local hospitals, clinics, and health insurance companies to fill professional and nonprofessional roles.  
  • Exploring all state-specific emergency waivers or changes to licensure requirements or renewals that may allow for staffing flexibility.

Resource: CDC facility preparedness checklist

Strategies to Mitigate Staffing Shortages

As an organization deviates from their standard recruitment, hiring, and training practices, there may be higher risks to the staff and residents. Nursing homes and assisted living 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 t6he 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 nursing homes and assisted living facilities with multiple facilities or that 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 these areas that are new to them.

If other 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:

Regulations and Memorandums of Understanding (MOUs)

Review current regulations related to emergency preparedness and MOU templates to establish a mutual understanding of how and to what extent organizations will respond to and support each other during an emergency or pandemic. Current resources include:

Additional Resources

Questions

For questions regarding this information or for technical assistance, nursing home providers should contact The Division of Quality Assurance (DQA), Bureau of Nursing Home Resident Care (BNHRC) regional offices. Assisted living facilities should contact Bureau of Assisted Living (BAL) regional offices.

 Memory Care Individuals

The strategies used to “flatten the curve” and limit the spread of COVID-19 are especially difficult for memory care individuals. Due to their decreased cognitive ability, residents in memory care will require additional assistance adhering to quarantine and isolation. In particular, residents in memory care 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 in memory care 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 in memory care be kept to a minimum. If agitation or aggression occurs, respond by using standard calming techniques, such as distract and redirect, play personalized music, taking the person for a walk outside, or ask the person to complete a favorite task.

If residents express concern about the pandemic, memory care staff should:

  • Provide simple, truthful answers to their questions, explaining that everyone is doing all they can to help.
  • 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.

Inability to follow quarantine or isolation. If memory care residents are unable to follow quarantine or isolation measures, caregivers should redirect their attention to an appropriate activity.

Adherence to Infection Control Procedures

It is difficult for people in memory care to cooperate with prevention measures, such as instructions not to touch their eyes, nose, and mouth. Therefore, staff may need to provide memory care residents with additional support and closer supervision to ensure infection control procedures are followed.

Hand Hygiene (includes use of alcohol-based hand rub or handwashing). People living in memory care facilities may require extra supervision and support to perform appropriate hand hygiene.

  • 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.
  • 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 memory care resident cannot get to a sink to wash their hands. Alcohol-based hand rub is the preferred method of hand hygiene when indicated. Handwashing with soap and water is indicated when hands are visibly dirty and after using the toilet.
  • Be sure to use moisturizer on clean hands after repeated washing to ensure they do not get dry and irritated.

Refrain from touching face

  • 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 in memory care 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 through supervised and structured daily activities, including some form of daily exercise, such as individual walks outside with staff members.
Communication

Memory care residents 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.

  • For those who are aware of what is going on and concerned about it, provide information from authoritative sources (such as the Department of Health Services or the CDC). Take the time to listen to the person and their concerns, validate their feelings, and provide reassurance.
  • 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.
Restricting Unnecessary Visitors

It is essential to follow CMS guidance restricting visitation except for certain compassionate care situations, such as end-of-life. Any visitors that enter facilities in such situations should be required to perform hand hygiene and use personal protective equipment. Anyone exhibiting symptoms of a respiratory infection should not be permitted to enter a facility at any time, even in end-of-life situations.

Staying Connected
  • The use of available technology, such as online and smartphone options, to facilitate family interactions is encouraged. Instead of visiting in person, families can schedule a telephone call to keep connected and/or leave notes for the resident to read along with photos. It is important for facilities to ensure that adaptive devices are available to the resident where necessary, for example, hearing aids and eyeglasses.
  • Consider creating a buddy system between residents or between residents and staff to strengthen support networks.

 1-2 Bed Adult Family Homes and Supported Living Apartments

This guidance applies to providers of 1-2 bed adult family homes (AFH) and their residents, as well as supported living apartments and their household members. The guidance also applies to the staff (live-in and periodic) who work there.  

The purpose of this guidance is to provide the best information currently available to help providers prevent the spread of COVID-19 and additional guidance for responding to a suspected, probable, or confirmed case of COVID-19 in your home or facility. One and two-bed AFHs and supportive apartments should follow all appropriate provisions in the following sections on this page:

  • Visitors to Facilities
  • Guidance for all Facilities
  • Resources
Prevention strategies include:  

Preparedness

  • Assure residents, household members and staff have access to adequate supplies of soap, paper towels, tissues, hand sanitizers, cleaning supplies, and garbage bags and a supply of disposable gloves and face masks or face coverings.
  • Follow DHS guidance regarding the appropriate use of personal protective equipment (PPE), and consider strategies to best conserve PPE, when it is available.
  • Place alcohol-based hand sanitizer and trash containers throughout the home. Make sure tissues are available and any sink is well-stocked with soap and paper towels for handwashing.  
  • Monitor the temperatures of residents and staff and check for signs and symptoms of COVID-19 each day when individuals come into the home. 
  • Anyone who has a fever of 100.4 or above, or other signs of illness, should notify their physician. 
  • Notify your local public health department if a resident, household member or staff is suspected of having COVID-19. 
  • Ensure there is a backup plan if staff members become ill. 
  • Ask staff who become ill at work to immediately stop work, put on a face mask, and go home and self-isolate. 
  • Identify space within the home or apartment where a resident or household member may be isolated. If the home has more than one bathroom, be prepared to limit the use of one bathroom to anyone in the household who becomes ill.
  • Put communication plans in place with family members and legal guardians to ensure transparency and understanding of new safety protocols, including timely communication about new COVID-19 cases involving residents or staff. Communication with residents, families and/or guardians should be proactive and clearly explain the reasons for any changes to normal practices.
  • Identify methods of support for those residents who may require specialized understanding or who are likely to experience increased emotional or behavioral impact.

Infection Prevention and Control

Post signs and fact sheets. Social stories and visual task lists may be helpful for some individuals. See infographics and print materials.

  • Coronavirus disease
  • Please do not visit
  • Wash your hands!
  • Tips for staying safe
  • How to make a face cloth covering 
  • How to protect yourself
  • And more

Cleaning and Disinfecting Your Facility

  • Routinely, during the day, clean and disinfect surfaces and objects that are frequently touched in common areas (e.g., door handles, faucets, toilet handles, light switches, handrails, countertops, chairs, tables, remote controls, and shared electronic equipment).
  • Use all cleaning and disinfection products according to the directions on the label. 

Hygiene

  • You can spread COVID-19 to others even if you do not feel sick, so you should follow these hygiene practices.
  • Wash your hands often with soap and water for at least 20 seconds, especially after you have been in a public place, or after blowing your nose, coughing, or sneezing.
  • If soap and water are not readily available, use a hand sanitizer that contains at least 60% alcohol.
  • Avoid touching your eyes, nose, and mouth with unwashed hands.
  • CDC recommends wearing cloth face coverings in public settings where it is difficult to stay 6 feet away from others. Some people cannot wear a cloth face covering safely. Others with sensory or other disabilities may not be able to comply.  Cloth face coverings should not be placed on children under age 2, anyone who has trouble breathing, or anyone who is unable to remove the covering without assistance. In addition to medical considerations, individuals may fear racial profiling or discrimination based on wearing—or not wearing—a face covering. Businesses requiring cloth face coverings should allow for exceptions based on health and safety concerns of individuals. Accommodations due to disability should be made when appropriate. This does not apply when household roommates are together or for owners and residents in an owner-occupied AFH. 
  • Cover coughs and sneezes with your elbow, even if wearing a cloth face covering. 

Going out into the community

  • Discourage nonessential outings into the community. 
  • Every effort should be made to allow an individual to maintain their paid employment.
  • Follow WEDC guidance for outdoor gatherings.
  • Train residents if possible to follow appropriate social distancing and hygiene routines if they leave the home for work, day programs, or if they use public transportation. Follow specific guidance for Wisconsin businesses and transportation
  • Follow these recommendations for all outings into the community
    • Everyone should wear a cloth face covering when they have to go out in public, for example, to the grocery store or to pick up other necessities.
      • Staff should strongly encourage residents to comply with social distancing (i.e., remaining at least 6 feet part). This does not apply to household roommates who are living together.
      • The cloth face covering is not a substitute for social distancing.
      • The number of staff who support individuals who require personal cares, job coaching or other supports that don’t allow for social distancing should be limited.
      • The ability of someone to comply with wearing a mask should not mean they cannot interact with the community. Every effort should be made to ensure all residents are able to get outside, see family and friends while engaging in social distancing when possible, and engage in safe activities outside of the home that do not involve direct contact with the public. 
    • More information can be found at CDC Website: 
With suspected, probable, or confirmed case of COVID-19 follow these additional recommendations:  
  • Continue to follow all the recommendation above including monitoring family/residents/household members (member) and anyone entering the home for symptoms of COVID-19, including fever, cough, or shortness of breath. 
  • If you are concerned that you or a household member may have COVID-19, you may call your doctor or visit Wisconsin Health Connect, an online screening tool that can connect you with clinicians who can answer your care questions. More information can be found on the DHS website.

If an individual is suspected of, or has been confirmed to have COVID-19, follow these steps: 

  • Isolate the individual immediately.
  • Establish contact with the individual’s primary care physician and plan for check-ins as necessary, including through telehealth. 
  • Notify the local public health department.
  • Limit any visitors to the home to only those who are essential. 
  • Ensure regular communication with family, legal guardian, and care team about the individual’s health status. 
  • Educate all household members and any essential visitors about COVID-19 and the risks.  
  • Individuals with known or suspected COVID-19 should stay in one room, away from other people, including staff, as much as possible. 
  • Obtain testing for staff and residents when appropriate and applicable. 
  • If the individual requires personal cares, limit the specific staff who support that person and ensure use of appropriate PPE at all times. Establish strategies to conserve the use of PPE.
  • If possible, have the sick person use a separate bathroom. If a separate bathroom is not available, the bathroom should be cleaned and disinfected after each use by the sick person. 
  • Closely monitor roommates and other residents who may have been exposed to an individual with COVID-19 and, if possible, avoid placing unexposed residents into a shared space with them. Support both the sick person and other residents to understand importance of mask-wearing and social distancing when in shared spaces, if sharing of space cannot be avoided. 
  • Ensure guardians and family members are all informed of proper protocols to take with residents who are not sick, but live in a facility with confirmed cases of COVID, and provide additional communication methods if visits are not possible.
  • Move regularly used furniture and other household items to maintain 6-feet distance between people in any shared space. 
  • Wash laundry of COVID-19 patient thoroughly. If laundry is soiled, wear disposable gloves and keep the soiled items away from your body while laundering. Wash your hands immediately after removing gloves.
  • CDC - Cleaning & Disinfecting Your Home When Someone is Sick 

Continually monitor sick individual

  • Increase monitoring of sick individuals to at least three times daily in order to identify and quickly manage any serious infections. If exhibiting emergency warning signs, including trouble breathing, persistent pain or pressure in the chest, new confusion or inability to arouse, bluish lips or face, call 911 and seek medical attention immediately.
  • Keep the resident’s family, legal guardian, and care team informed at all times. Communications with residents, families and/or guardians should be proactive and clearly explain the reasons for any changes to normal practices.
  • If individuals must leave isolation for any reason, they should wear a cloth face covering (if tolerated), perform hand hygiene, and stay at least 6 feet away from others wherever possible. 
  • If the individual requires additional care beyond what the usual staff can provide, staff should seek medical attention from the individual’s health care provider. 

 Home Care Providers

This guidance applies to home care providers and staffs, including home health agencies, in-home hospice providers, personal care agencies, and supportive home care agencies. The purpose of this guidance is to provide the best information currently available to help home care providers prevent the spread of COVID-19 to the clients and/or patients they serve and to the staff who deliver their care.

The COVID-19 situation is constantly evolving and home care providers and workers should monitor the CDC, CMS, and Wisconsin DHS website for the most current information and resources related to COVID-19 and contact their local health department when needed.  See the links under “Additional Resources” for more information.

Regulatory and Policy Changes

DQA Waivers/Variances
The DHS Division of Quality Assurance (DQA) will notify providers through its existing notification process if any blanket waivers of Wisconsin Administrative Code are issued. Home care providers can apply for an individual waiver or variance to Wisconsin Administrative Code by completing the Waiver or Variance Request form (F-02527) and following the submission instructions on the DHS website. Home care providers are encouraged to notify the managed care organizations with which they contract if they receive DQA approval for an individual waiver or variance.  

DSPS Waivers/Variances
The Wisconsin Department of Safety and Professional Services (DSPS) is responsible for licensing requirements for registered nurses (RNs) and other health care professionals. Please watch the DSPS website for the most current information on waivers, etc.

ForwardHealth (Medicaid) Policy Changes
Home care providers should review the ForwardHealth Portal for information on ForwardHealth (Medicaid) policies that may have changed as a result of the COVID-19 outbreak. Please review ForwardHealth alerts to see which providers they pertain to. For specific questions about COVID-19 as it relates to ForwardHealth (Medicaid) coverage and policy, please contact DHS.

Federal Regulation Waivers
The Centers for Medicare & Medicaid Services (CMS) has issued blanket waivers of some federal regulations. Federal requirements without a blanket waiver remain in effect. In order to request a waiver of a federal requirement not covered under a blanket waiver, a provider must submit a request for a “Section 1135” waiver on an individual basis to CMS. In order for CMS to expedite their review of an individual waiver request, providers should review CMS’ 1135 waiver guide to ensure their request contains all necessary information and elements. Questions regarding Section 1135 waivers should be sent to CMS 1135 Waiver. For more information, please see the CMS webpage. Home care providers are encouraged to notify the managed care organizations with which they contract if they receive CMS approval for an individual waiver.  

Note: A federal waiver does not necessarily waive Wisconsin Administrative Code. Providers should review state policy pertaining to the services rendered.   

Infection Prevention and Control

Older individuals, individuals with disabilities, and medically vulnerable individuals have significantly increased risk of severe illness and death from COVID-19, necessitating that all reasonable efforts are taken to prevent introduction and spread of this infectious disease into each client’s or patient’s home. Health care workers, visitors, and others interacting with this population are the most likely sources of introduction of COVID-19 into client or patient residences.

Home care providers should review, implement, and reinforce infection prevention and control interventions for preventing communicable disease among all home care workers, staff, and clients or patients.

If one of your home care workers, staff, or clients or patients is diagnosed with COVID-19, immediately contact your local public health department to receive further guidance on infection prevention and control.

Staffing
All home care providers should immediately implement procedures for evaluating home care workers for symptoms of respiratory illness before every visit involving direct client or patient care. Monitoring should include temperature monitoring and query of symptoms of COVID-19-like illness, which include any of the following:

  • Measured temperature >100.0 F (37.8C) or subjective fever
  • New or worsening cough, new or worsening shortness of breath, unexplained muscle or body aches, and/or sore throat.

Monitoring may be performed either by designated staff at the providers’ office or remotely by employees themselves with allowances for documentation of the symptoms screen to supervisors (for example, via text, email, or other methods).  

Refer to DHS guidance for recommendations on when health care personnel without symptoms who were exposed to COVID-19 can return to work.

Any staff that develop signs and symptoms of a respiratory infection while on the job should:

  • Immediately stop work, put on a face mask, and self-isolate at home.
  • Inform the clinical manager of information on individuals, equipment, and locations the person came in contact with.
  • Contact their local health department for next steps.

Home care providers should take additional staffing precautions with any staff who work in multiple settings or multiple facilities as they pose a greater risk for contributing to intra- and inter-facility spread of COVID-19.  Home care providers should schedule or assign staff appropriately to ensure they do not place individuals in the facility at risk for COVID-19. Staff who work in multiple locations should be encouraged to tell facilities if they have had exposure to other settings with recognized COVID-19 cases.

Home care providers should have a contingency plan for continuing client or patient care if a large proportion of staff become sick. The contingency plan should identify minimum staffing needs and priorities for critical and nonessential services based on the health status, functional limitations, disabilities, and essential needs of their clients and patients.

Client/Patient Care
Home care providers should:

  • Consider limiting the number of in-person home care visits to prevent the introduction of the virus into the client or patient’s home, if appropriate, based on their care needs.  
  • Consider substituting telehealth (consultation by phone or video chat) for an in-person visit. While telehealth may not be appropriate for many types of visits, telehealth may be an alternative for certain visits, such as those done by personal care worker’s RN supervisors, social workers, etc. Providers should refer to federal and state guidance regarding telehealth.

Home care workers should:

  • Continue to follow all standard infection prevention and control protocols, including but not limited to, hand hygiene (handwashing or use of alcohol-based hand rub), cough etiquette, appropriate use of personal protective equipment (PPE), when available, etc.  
  • When not performing direct care, limit contact as much as possible with the client or patient and other individuals in the household by identifying ways to avoid direct contact and maintain physical distancing (6 feet or more).  
  • Limit contact with surroundings through measures such as placing a barrier between equipment and the object the equipment will rest on, placing a barrier on furniture before sitting down, etc.
  • Only bring in necessary supplies, equipment, and materials.
  • Wear the recommended PPE that is appropriate for the given situation. Due to PPE shortages, home care providers should identify ways to preserve PPE supplies and should develop protocols for managing clients or patients with limited or no PPE. If N95s or face masks are not available, home care providers should implement use of universal cloth face coverings by all home care workers (source control) when they enter the client or patient’s residence.  

Home care providers and/or workers should screen clients or patients before or immediately upon arrival to the home. Providers and/or workers should ask the client or patient if they or anyone who is in the residence currently, or in the past seven days, have new onset of fever OR cough OR shortness of breath OR sore throat that cannot be attributed to an underlying or previously recognized condition (for example, asthma, emphysema).  

  • If NO, then COVID-19 may be less of a risk. If the client or patient reports other illness, home care providers should manage as per their organization’s usual protocols.
  • If YES, then providers should manage per their organization’s COVID-19 protocols:
    • If the client or patient is sick and needs immediate medical attention (for example, difficulty breathing, persistent pain or pressure in the chest, new confusion or inability to arouse, bluish lips or face) call 911 for transport to a hospital and inform 911 that the client or patient may have COVID-19 to ensure appropriate infection control is implemented.
    • Notify the client or patient’s medical provider. If staff are unable to enter the residence and rescheduling the appointment may not be an acceptable option, the medical provider and your organization may need to evaluate whether the client or patient can still safely receive home care or should be transferred to a hospital or other health care facility. Also notify the client or patient’s managed care organization or other care coordinator, if applicable.
    • If direct care is not required, remember to maintain a distance of 6 feet or more from the person who is sick and any other persons in the residence.
    • When appropriate, postpone the visit for a time when the person who is ill has had at least seven days following onset of illness and 72 hours after being consistently afebrile without use of antipyretics and with resolving respiratory symptoms. If not possible, and it is the client or patient who is sick, prepare to manage them with appropriate PPE and in accordance with your organization’s COVID-19 protocols.
    • In some cases, telehealth (consultation by phone or video chat) may be substituted for an in-person visit.  

Home care providers should contact their local health department for questions and frequently review the CDC website dedicated to COVID-19 for health care professionals.  

Client/Patient Rights and Wellbeing

All clients and patients should continue to be made aware of their rights. If a client or patient’s visitation with family and friends is limited, efforts should be made to support them to continue their relationships through means such as phone calls.

Additional Resources

CDC Resources

CMS Resources

DHS Resources

 Resources

DHS Resources
CDC Resources

 

CMS Resources
BOALTC Resources
The Society for Post-Acute and Long-Term Care Medicine

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: June 1, 2020

 RESPONSE RESOURCES FOR WISCONSINITES — www.dhs.wisconsin.gov/covid-19/help.htm