COVID-19: Nursing Homes

This guidance is for Wisconsin Nursing Homes and Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID). Nursing homes and ICF/IIDs care for residents who are elderly and/or who have chronic medical conditions that place them at higher risk of developing severe complications from COVID-19. This guidance is designed to assist facilities to improve their infection prevention and control practices, to prevent the transmission of COVID-19 and keep residents and the health care personnel (HPC) 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 chs. DHS 132, DHS 134 and DHS 145. CMS and CDC continue to provide guidance for nursing homes and other long-term care facilities.

Facilities are encouraged to routinely check the CMS and CDC websites for additional guidance.  In addition to reading and understanding the guidance offered here, it is important to review the information highlighted in the hyperlinks and in the Resources section. Facilities are also encouraged to use the COVID-19 Provider Self-Assessment Worksheet, F-02669 as a tool to guide their overall preparedness.

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.

Federal COVID-19 Reporting Requirements

On May 6, 2020, CMS issued Interim Final Rule Updating Requirements for Notification of Confirmed and Suspected COVID-19 Cases Among Residents and Staff in Nursing Homes Memo, QSO-20-29-NH (PDF). This requires nursing homes to report COVID-19 facility data to the CDC and to residents, their representatives, and families of residents in facilities. The memo states that failure to report in accordance with 42 CFR §483.80(g) can result in an enforcement action. CMS will begin posting data from the CDC National Healthcare Safety Network (NHSN) for viewing by facilities, stakeholders, or the public. The COVID-19 public use file will be available at COVID-19 Nursing Home Data. The memo includes updated COVID-19 focus survey forms and regulatory tags.

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

Nursing homes 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. Nursing homes should complete the self-assessment and direct questions about their results or necessary elements to dhswihaipreventionprogram@dhs.wisconsin.gov. Nursing homes can also request a tele-ICAR evaluation by the Healthcare-Associated Infections (HAI) 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. 

The HAI Program has released a series of messages highlighting common recommendations and clarifications made during ICARs. The “Early ICARs Lessons Learned” messages are sent to providers that have subscribed to receive DQA Notifications & Updates messages. Archived messages can also be viewed on the DQA Email Subscription webpage.  

Universal Screening:
Nursing homes 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 information in Preparing for COVID-19 in Nursing Homes
  • 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. 

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

  • Provide information about COVID-19 from Get the Facts About Coronavirus (including information about signs and symptoms) and strategies for managing stress and anxiety.
  • Regularly review CDC’s Infection Control Guidance for Healthcare Professionals about COVID-19 for current information and ensure staff and residents are updated when this guidance changes.
  • Educate and train staff, including facility-based and consultant personnel. Including consultants is important, since they commonly provide care in multiple facilities where they can be exposed to and serve as a source of COVID-19. 
  • Educate residents and families on topics including information about COVID-19, actions the facility is taking to protect them and/or their loved ones, any visitor restrictions that are in place, and actions residents and families should take to protect themselves in the facility, emphasizing the importance of hand hygiene and source control.
  • Have a plan and mechanism to regularly communicate with residents, families and staff, including a communication plan in the event confirmed cases of COVID-19 are identified in the facility.

Implement Source Control Measures:

  • Staff should wear a facemask at all times while they are in the facility.
    • When available, facemasks are generally preferred over cloth face coverings for staff 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 should NOT be worn by staff instead of a respirator or facemask if PPE is required.
  • Residents should wear a cloth face covering or facemask (if tolerated) whenever they leave their room, including for procedures outside the facility. Cloth face coverings should not be placed on anyone who has trouble breathing, or anyone who is unconscious, incapacitated, or otherwise unable to remove the mask without assistance. In addition to the categories described above cloth face coverings should not be placed on children under age two.
  • Visitors, if permitted into the facility, should wear a cloth face covering while in the facility.

Implement Social Distancing Measures:

  • Implement aggressive social distancing measures (remaining at least six feet apart from others).
    • Cancel communal dining and group activities, such as internal and external activities.
    • Remind residents to practice social distancing, wear a cloth face covering (if tolerated), and perform hand hygiene.
    • Remind staff to practice social distancing and wear a facemask (for source control) when in break rooms or common areas.

Provide Supplies Necessary to Adhere to Recommended Infection Prevention and Control Practices:

  • Hand Hygiene Supplies
    • Put alcohol-based hand sanitizer with 60-95% alcohol in every resident room (ideally both inside and outside of the room) and other resident care and common areas (e.g., outside dining hall, in therapy gym). Unless hands are visibly soiled, an alcohol-based hand sanitizer is preferred over soap and water in most clinical situations.
    • Make sure that sinks are well stocked with soap and paper towels for handwashing.
  • Respiratory Hygiene and Cough Etiquette
    • Make tissues and trashcans available in common areas and resident rooms for respiratory hygiene, cough etiquette, and source control.
  • Personal Protective Equipment (PPE)
    • Perform and maintain an inventory of PPE in the facility.
  • Make necessary PPE available in areas where resident care is provided.
    • Consider designating staff responsible for stewarding those supplies and monitoring and providing just-in-time feedback promoting appropriate use by staff.
    • Facilities should have supplies of facemasks, respirators (if available and the facility has a respiratory protection program with trained, medically cleared, and fit-tested staff), gowns, gloves, and eye protection (i.e., face shield or goggles).
  • Position a trash can near the exit inside the resident room to make it easy for staff to discard PPE prior to exiting the room or before providing care for another resident in the same room.
  • Implement strategies to optimize current PPE supply even before shortages occur, including bundling resident care and treatment activities to minimize entries into resident rooms. Additional strategies might include:
    • Extended use of respirators, facemasks, and eye protection, which refers to the practice of wearing the same respirator or facemask and eye protection for the care of more than one resident (e.g., for an entire shift).
      • Care must be taken to avoid touching the respirator, facemask, or eye protection. If this must occur (e.g., to adjust or reposition PPE), staff should perform hand hygiene immediately after touching PPE to prevent contaminating themselves or others.
    • Prioritizing gowns for activities where splashes and sprays are anticipated (including aerosol-generating procedures) and high-contact resident care activities that provide opportunities for transfer of pathogens to hands and clothing of staff.
      • If extended use of gowns is implemented as part of crisis strategies, the same gown should not be worn when caring for different residents unless it is for the care of residents with confirmed COVID-19 who are cohorted in the same area of the facility and these residents are not known to have any co-infections (e.g., Clostridioides difficile).
    • Implement a process for decontamination and reuse of PPE such as face shields and goggles.
    • Facilities should continue to assess PPE supply and current situation to determine when a return to standard practices can be considered. 
  • Implement a respiratory protection program that is compliant with the OSHA respiratory protection standard for employees if not already in place. The program should include medical evaluations, training, and fit testing.
  • Environmental Cleaning and Disinfection
    • Develop a schedule for regular cleaning and disinfection of shared equipment, frequently touched surfaces in resident rooms and common areas.
    • Ensure EPA-registered, hospital-grade disinfectants are available to allow for frequent cleaning of high-touch surfaces and shared resident care equipment.
  • Use an EPA-registered disinfectant from List N on the EPA website to disinfect surfaces that might be contaminated with SARS-CoV-2. Ensure staff are appropriately trained on its use.
  • Nursing homes should ensure all staff are using appropriate PPE when interacting with residents, to the extent PPE is available and per CDC guidance on conservation of PPE.
    • Full PPE should be worn per CDC guidelines for the care of any resident with known or suspected COVID-19 and per CDC guidance on conservation of PPE.
    • If COVID-19 is identified in the facility, restrict all residents to their room and have staff wear all recommended PPE (gloves, facemask, face shield, and gown) for all resident care, regardless of the presence of symptoms. Resident care includes personal care, meals, and exercise, such as walking. 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 nursing home residents with COVID-19 do not demonstrate symptoms.
  • When possible, all nursing home residents, regardless of COVID-19 status, should cover their noses and mouths when staff are in their room. Tissues or cloth face coverings may be used for this purpose. Residents should not use medical facemasks unless they are COVID-19 positive or assumed to be so.

Evaluate and Manage Residents with Symptoms of COVID-19:

  • Ask residents to report if they feel feverish or have symptoms consistent with COVID-19.
  • Actively monitor all residents upon admission and at least daily for fever (T≥100.0oF) and symptoms consistent with COVID-19. Ideally, include an assessment of oxygen saturation via pulse oximetry. If residents have fever or symptoms consistent with COVID-19, implement Transmission-Based Precautions as described below.
    • 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 >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.
  • The 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 ≥ 3 residents or staff with new-onset respiratory symptoms within 72 hours of each other.
  • Information about the clinical presentation and course of patients with COVID-19 is described in the Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease 2019 (COVID-19). The CDC has also developed guidance on Evaluating and Reporting People Under Investigation (PUI).
  • If COVID-19 is suspected, based on evaluation of the resident or prevalence of COVID-19 in the community, follow the Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. This guidance should be implemented immediately once COVID-19 is suspected.
    • Residents with suspected COVID-19 should be prioritized for testing.
    • Residents with known or suspected COVID-19 do not need to be placed into an airborne infection isolation room (AIIR) but should ideally be placed in a private room with their own bathroom.
    • Residents with COVID-19 should, ideally, be cared for in a dedicated unit or section of the facility with dedicated staff.
    • As roommates of residents with COVID-19 might already be exposed, it is generally not recommended to place them with another roommate until 14 days after their exposure, assuming they have not developed symptoms or had a positive test.
  • Residents with known or suspected COVID-19 should be cared for using all recommended PPE, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. Cloth face coverings are not considered PPE and should not be worn when PPE is indicated.
  • Increase monitoring of ill residents, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to at least 3 times daily to identify and quickly manage serious infection.
    • Consider increasing monitoring of asymptomatic residents from daily to every shift to more rapidly detect any with new symptoms.
  • If a resident requires a higher level of care or the facility cannot fully implement all recommended infection control precautions, the resident should be transferred to another facility that is capable of implementation. 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., in a private 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.
    • All recommended PPE should be used by healthcare personnel when coming in contact with the resident.
  • Because of the higher risk of unrecognized infection among residents, universal use of all recommended PPE for the care of all residents on the affected unit (or facility-wide depending on the situation) is recommended when even a single case among residents or staff is newly identified in the facility; this could also be considered when there is sustained transmission in the community. The health department can assist with decisions about testing of asymptomatic residents.
  • For decisions on removing residents who have had COVID-19 from Transmission-Based Precautions refer to the Interim Guidance for Discontinuation of Transmission-Based Precautions and Disposition of Hospitalized Patients with COVID-19.

For additional information see: Preparing for COVID-19 in Nursing Homes.

New Admissions, Transfers, and Discharges

Note: See additional guidance regarding admissions in the Resources to Support Skilled Nursing Facilities in Determining Admission Policies during a COVID-19 Outbreak section of this page.   

Nursing homes should admit any individuals that they would normally admit to their facility. Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes Memo, QSO-20-14-NH (PDF) provides the following guidance about the ability of nursing homes to accept a resident diagnosed with COVID-19 from a hospital:

Additionally CDC guidance recommends the following:

  • 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.
  • All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown.
  • DHS Updated Guidance on Infection Control during Specimen Collection for COVID-19 in Outpatient Settings Memo, BCD 2020-06 (PDF) states that N95 respirators do not need to be worn for specimen collection or resident care other than during aerosol generating procedures.
  • Testing residents upon admission could identify those who are infected but otherwise without symptoms and might help direct placement of asymptomatic SARS-CoV-2-infected residents into the COVID-19 care unit. 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 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.

Guidance from the State Disaster Medical Advisory Committee
The following memos 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.

Outdoor Visitation Guidance for Nursing Homes

The safest approach to prevent COVID-19 exposure to nursing home residents and staff is to not conduct indoor or outdoor visitation. However, if an organization wishes to proceed with outdoor visitation, recommendations for safer outdoor visits are listed below. Nursing homes may choose to wait longer before implementing outdoor visitation. Because the pandemic is affecting communities in different ways, facilities should use their best clinical judgment, regularly monitor the factors for outdoor visitation, work with local and tribal public health departments, and adjust their plans accordingly.

DHS recognizes that the effects of isolation can have serious impact on the health and well-being of residents in nursing homes. This guidance contains recommendations that we strongly encourage nursing homes to follow and implement. See Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes Memo, QSO-20-14-NH (PDF).

Facility criteria

  • Establish a schedule for visitation hours. Facilities should work with prospective visitors individually to schedule an appointment to visit a resident, and should discuss in advance the length of the appointment.
  • Have adequate staff present to allow for help with outdoor transition of residents, and to assist with cleaning and disinfecting any visitation areas as necessary.
  • Clean and disinfect the visitation area, including tables, chairs, and other shared surfaces between visits.
  • Clearly communicate and supervise each visit to ensure the use of face masks or cloth face coverings by visitors, and social distancing of six feet between residents and all visitors.
  • Staff should maintain visual observation but provide as much distance as necessary to allow for privacy of the visit conversation.
  • Have a system to ensure all visitors are prescreened for fever and any other symptoms of COVID-19 not more than 24 hours in advance. Ill visitors must not visit.
  • Have a system to screen visitors on arrival for fever and any other symptoms of COVID-19 at a screening location designated outside the building, and exclude those with these symptoms from visiting.
  • Have a system to ensure residents and visitors wear a face mask or other cloth face covering at all times, as tolerated.
  • Outdoor visitation may take place under a canopy or tent with not more than two walls.
  • Outdoor visitation spaces must be designed to be accessible without visitors having to walk through the facility.
  • Outdoor visitation spaces must ensure that a minimum distancing of at least six feet between the visitors and resident is achievable in the outdoor space when determining the maximum number of residents and visitors who can simultaneously occupy the outdoor space.
  • Provide alcohol-based hand sanitizer to people visiting residents and provide signage and verbal reminders of correct use.
  • Establish additional guidelines as needed and as determined by the facility to ensure the safety of visitations and their facility operations. These guidelines must be reasonable and must take into account the individual needs and wishes of residents.

Resident criteria

  • Current COVID-19 positive residents, residents with COVID-19 signs or symptoms, and residents in a 14-day quarantine or observation period due to their admission or re-admission status are not eligible for outside visits.
  • Residents who have had COVID-19 must no longer require transmission-based precautions as outlined by the CDC and DHS guidelines to be eligible for outside visits.
  • Residents must wear a mask (or other face covering to prevent spread of respiratory secretions when they are talking, sneezing, or coughing) at all times, as tolerated.

Visitor criteria

  • Visitors must wear a mask (or other face covering to prevent spread of respiratory secretions when they are talking, sneezing, or coughing) during the entire visit unless they are unable to do so for medical reasons.
  • Visitors must use alcohol-based hand sanitizer upon entering and exiting the visitation area.
  • Visitors must be prescreened and actively screened for fever and any other symptoms of COVID-19, and must attest to COVID-19 status if known. This should be done during prescreening and again upon arrival at a designated location outside the building. Any individual with symptoms of COVID-19 should be excluded from visitation.
  • Any gifts or packages for the resident should be dropped off with staff to give to the resident.
  • Visitors should not walk through the facility to get to the outdoor visitation area.
  • Visitors must sign in and provide contact information.
  • Due to the risk of exposure, holding hands, hugging, kissing, or other physical contact is not allowed during family visits. Physical distancing of six feet must be maintained for the duration of the visit.
    • Visitors under age 12 years must be in the control of adults who bring them and must also comply with physical distancing requirements. Visitors under age 12 years must wear a mask.
  • Pets must be under the control of the visitor bringing them.
  • Visitors must stay in designated visitation locations.

Weather

Visits should occur only on days when there are no weather warnings that would put either the visitor or resident at risk.


Facilities that meet the criteria above and elect to permit outdoor visits must make this option available to all residents unless they believe:

  1. Circumstances pose a risk of transmitting COVID-19 to the facility because the resident or visitor does not comply with infection prevention and control guidance, or
  2. The resident or visitor is at risk of abuse/harm.

Residents and their loved ones may contact providers with questions about outdoor visits. Facilities should ensure residents, and their loved ones, have access to the Ombudsman Program at the Board on Aging and Long Term Care at 1-800-815-0015.

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

Questions
For questions regarding this information or for technical assistance, providers should contact The Division of Quality Assurance (DQA), Bureau of Nursing Home Resident Care (BNHRC) regional offices.

Resources to Support Skilled Nursing Facilities in Determining Admission Policies During a COVID-19 Outbreak

This information serves as a decision support tool for Skilled Nursing Facilities (SNF). It is a companion document to “Prevention and Control of Acute Respiratory Illness Outbreaks in Long-Term Care Facilities," BCD Memo 2020-27 (PDF).   
 
Following CDC guidance, and “Prevention and Control of Acute Respiratory Illness Outbreaks in Long-Term Care Facilities," BCD 2020-27 (PDF), “When a suspected or confirmed case of COVID-19 is identified in a facility, the CDC recommends temporary restriction of admissions to the facility, at least until the extent of transmission can be clarified and interventions can be implemented.” 

While COVID-19 remains a threat in Wisconsin, a SNF’s administrator, in consultation with their medical director and/or director of nursing, may determine that the facility can safely admit a resident if certain considerations are taken into account. Before proceeding with resuming admissions, facility leadership should carefully review the considerations below, in consultation with the local public health officer when possible, taking into account all necessary infection prevention and control protocols. 

For purposes of determining whether it is appropriate to accept admissions prior to the completion of the recommended 14-day temporary halt on admissions to affected wings or units, facilities should assess the following information: 

  1. After subsequent facility-wide testing and contact tracing, either no units are impacted, or the outbreak is limited to a single unit, floor, or wing. The facility may admit to a nonaffected unit, may establish an alternate temporary quarantine area, or may consider admissions within a wing or floor where an outbreak was identified if the outbreak is contained, and interventions are in place for continued containment. 
  2. The facility has determined it has adequate caregiver staffing levels to safely allow admissions while in its current outbreak status. 
  3. The facility has determined it has an adequate supply of PPE, based on CDC guidance, to safely allow admissions while in its current outbreak status. 
  4. The facility has addressed or mitigated other extenuating circumstances that would preclude it from admitting new residents in less than 14 days. 
  5. The facility will inform new admissions of the outbreak and steps it has taken to ensure patient safety.  

A facility admitting a resident following review and analysis of the above considerations must document and keep record of the findings of the assessment that are being used to support a decision to allow admissions during the outbreak status, including notification to their local public health department.

Sample Language for Notification of Local Health Departments 
Facilities opening in consultation with local health departments do not need to submit a notification form. 

I hereby notify [local health department] that [name of facility] has experienced an outbreak and, after completing a round of facility-wide testing, have determined the facility can be open for new admissions. [Name of facility] has taken the following steps to ensure patient safety: 

  • The outbreak has either not affected any units or has been limited to a single unit, floor, or wing. The nonaffected unit, floor, or wing will open for admission. 
  • If the unit, floor, or wing affected by an outbreak will open for admissions, the facility has established that the outbreak is contained and interventions are in place for continued containment. 
  • In the event the positive case occurred in a staff member working on the facility’s quarantine unit, the facility has established an alternative temporary quarantine area where there has been no infection. 
  • The facility has determined it has adequate caregiver staffing levels to safely allow admissions while in its current outbreak status. 
  • The facility has determined it has an adequate supply of PPE, based on CDC guidance, to safely allow admissions while in its current outbreak status. 
  • The facility has addressed or mitigated other extenuating circumstances that would preclude it from admitting new residents in less than 14 days. 
  • The facility will inform new admissions of the outbreak and steps it has taken to ensure patient safety. 

 We plan to re-evaluate this on an ongoing basis. 

[Signature of Administrator/Medical Director/Director of Nursing, Date]

See DPH Communicable Diseases Memos for additional memos. 

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.
    • Facilities should review the Planning for Staff Shortages section of this page for guidance regarding “Strategies to Lessen Staffing Shortages.”  
    • 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. Review COVID-19 Health Alert #18: Return to Work for Health Care Personnel. COVID-19 Health Alert #18 provides guidance for health care facilities during a crisis situation to determine whether and how health care staff exposed to SARS-CoV-2 may be asked to return to work before completion of a 14-day quarantine.   
  5. If a facility has exhausted the resources listed in their crisis staffing plan and still does not have adequate staff to provide care and services to their residents, the facility may consider using asymptomatic, COVID-19 positive staff before they have completed the CDC recommended isolation. Facilities are encourage to implement the following strategies to address staffing shortages before using asymptomatic, COVID positive staff to provide care.
  • Review the Planning for Staff Shortages section of this page and implement the “Strategies to Lessen Staffing Shortages.”
  • Communicate with WEAVR to increase staffing at the facility.
  • Allow quarantined staff exposed to COVID-19 to come back to work as indicated in HAN 18 before completing the full 14-day quarantine.
  • Assess their PPE supply and have an adequate supply to care for residents.
  • Educate asymptomatic, COVID positive staff to self-monitor for symptoms and to immediately report any symptoms of COVID-19 to their supervisor.
  • Educate asymptomatic, COVID positive staff to limit their presence in the facility to the COVID-19 unit.
  • Provide a separate staff entrance and break area for asymptomatic staff who have tested positive for COVID-19.

When asymptomatic, COVID positive staff return to work, they should:

  • Report a temperature and absence of symptoms before each shift.
  • Wear a facemask at all times for source control while in the facility. A higher level of personal protective equipment will be used when indicated.
  • Adhere to the requirement of home isolation, limiting close contact with others to the greatest degree possible, except while scheduled to work.
  • Stop working, notify their supervisor, and return home if they develop even mild symptoms at any time.

Facilities are asked to notify the Division of Quality Assurance, Bureau of Nursing Home Resident Care regional office and the local public health department (LHD) of their decision by using Nursing Home Notification of Intent to Use Asymptomatic, COVID Positive Staff, F-02734 (Word). Staffing shortages should be re-evaluated regularly to determine whether exceptions to isolation remain necessary for resident safety.

  1. If the facility’s Medical Director submitted a notification form to use staff exposed to SARS-C0V-2 before completing the 14-day quarantine to the LHD, attach a copy of the notification form to the Nursing Home Notification of Intent to Use Asymptomatic, COVID Positive Staff, F-02734 (Word) and submit to the Division of Quality Assurance, Bureau of Nursing Home Resident Care regional office.

The facility should take the following precautions:

  • Asymptomatic COVID-19 positive staff should only be allowed to work on the COVID-19 unit. There needs to be a separate entrance and break area for these staff. To prevent transmission between staff, only asymptomatic COVID-19 positive staff should be working on this wing once it is allowed, and they should not leave the unit for any reason.
  • The facility should have enough of the proper personal protective equipment (PPE) to prevent transmission of the virus, including respirators or facemasks, gowns, gloves, and eye protection (face shields or goggles).
  • All recommended COVID-19 PPE, including the use of a fit-tested N95 or higher-level respirator without an exhalation valve (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown, must be worn by asymptomatic COVID-19 positive staff at all times in the building. 
  • Strict symptom monitoring (prior to and during their shift) of these staff needs to be implemented. If they develop even mild symptoms currently 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.
  • Staff returning to work should be educated that this exception applies to their role in the facility. They should continue to isolate outside of work as previously indicated upon diagnosis. 
  1. Facility representatives should check in regularly with their LHD to assess current staffing levels to determine when allowing asymptomatic COVID positive staff to return to work prior to completion of isolation should be discontinued.

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.

  • Nursing homes should use separate staffing teams for COVID-19 positive residents, to the best of their abilities.
  • To the extent possible, nursing homes 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.

Facility leadership should work with state and local authorities to identify and designate facilities or units within a facility dedicated to residents with known or suspected COVID-19, ensuring that they are separate from COVID-19 negative residents.

  • COVID-19 positive facilities and units/wings must be capable of maintaining strict infection control practices and testing protocols, according to current regulations and emergency guidance.
  • When possible, facilities should use consistent assignments or have separate staffing teams for COVID-19 positives and those who are negative.
  • Capacity in dedicated facilities and units/wings may also include the ability to manage higher intensity residents, including ventilator management.
  • State health departments, hospitals, health systems, and advocates should work together to ensure coordination among facilities to identify and support designation of facilities or parts of facilities and ensure PPE and other supplies.
  • Facilities should, to the fullest extent possible, inform residents and their families of limited access to and ability to leave and re-enter the facility. Information should also be shared about requirements and procedures for placement in alternative facilities for COVID-19 positive or unknown status.

Testing Criteria

Testing Staff and Residents
The State of Wisconsin Testing Framework, P-02709 (PDF) describes the state’s containment strategy, known as “Box it in” 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.

Individuals who live and work in high-risk congregate living facilities are most at risk for spreading infection and developing complications from COVID-19. During May/June 2020 Wisconsin provided the opportunity to conduct baseline testing to every nursing home and Intermediate Care Facility for Individuals with Intellectual Disability (ICFs/IID) resident and staff member at no cost.  

Initial Baseline Testing
Many nursing homes and Intermediate Care Facilities for ICFs/IIDs completed a Point Prevalence Survey (PPS) (baseline testing) of all residents and staff for SARS-CoV-2 using molecular assay testing. Baseline testing establishes the prevalence of infection in a population and is used to appropriately isolate/cohort positive residents, restrict positive staff from work, and inform contact investigations so people who have been in close contact with infected cases receive quarantine instructions.  Initial baseline testing should include testing of all residents and all staff, including both direct care staff and support staff.

Who Should NOT be Tested for SARS Cov-2

  • Newly admitted patients/residents known to have COVID-19 and placed into Transmission-Based Precautions (TBP). 
  • Newly admitted patients/residents placed in quarantine for 14 days, unless they develop symptoms. 
  • Asymptomatic residents and staff who have recovered from SARS-CoV-2 infection in the past 3 months.

CMS Testing Requirements 
See Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements and Revised COVID19 Focused Survey Tool, QSO-20-38-NH (PDF) or testing regulations, guidance, and information regarding reporting, documentation of testing and surveying for compliance. Facilities can meet the CMS testing requirements in 42 CFR § 483.80 (h) (F886) by using rapid point-of-care (POC) antigen diagnostic testing devices provided by the Department of Health and Human Services (HHS) or through an arrangement with an offsite laboratory. Facilities without the ability to conduct COVID-19 POC testing should have arrangements with a laboratory to conduct tests to meet these requirements. 

Considerations for Use of COVID-19 Antigen Testing in Nursing Homes

  • Antigen tests are available with rapid turn-around-time critical to the identification of COVID-19 infection and rapid implementation of infection prevention and control strategies. 
  • These tests can augment other testing efforts, especially in settings where reverse transcription polymerase chain reaction (RT-PCR) testing capacity is limited or testing results are delayed (e.g., >48 hours).
  • In general, these POC antigen tests have a lower sensitivity, but similar specificity, for detecting COVID-19 compared to RT-PCR tests. 

Interpreting Antigen Testing
The CDC developed a process to help interpret antigen test results in nursing homes. Follow-up testing is recommended to confirm diagnosis depending on symptoms and exposure. 

  • Symptomatic or close contact (including outbreaks) individuals have a higher likelihood for disease. So when the result is negative, perform confirmatory RT-PCR testing to rule out absence of infection.
  • Asymptomatic or low exposure individuals have a lower likelihood for disease. So when the result is positive, perform confirmatory RT-PCR testing to confirm presence of infection.

Implement a Plan for Follow-up Testing
Testing only provides information for a given point in time. Residents and staff with negative test results can become infected in the future. Following initial baseline testing, nursing homes and ICFs/IID should implement a plan for follow-up testing as a way to continue to identify infections early and stop transmission. A facility’s plan for follow-up testing should be based on the results of initial baseline testing, the level of COVID-19 transmission in the community and the following guidance. The plan should include a procedure for addressing residents or staff who decline or are unable to be tested.

Testing Priorities – Symptomatic Testing, Outbreak Testing and Routine Testing
Regardless of the frequency of testing being performed, or the facility’s COVID-19 status, the facility should continue to screen all staff (each shift), each resident (daily), and actively screen ALL persons entering the facility to include but not limited to employees, vendors, volunteers, and visitors, for signs and symptoms of COVID-19.

Symptomatic Testing 

  • As soon as possible, facilities should test any resident or staff member who develops symptoms of COVID-19. The CDC’s website lists symptoms of COVID-19
  • Exclude positive staff from work and use symptom-based, time-based, or test-based return to work strategies.
  • Immediately implement transmission-based precautions (TBP) in accordance with CDC guidance for any resident who develops signs, symptoms, or tests positive for SARS-CoV-2. This includes the use of the CDC COVID-19 PPE for Healthcare Personnel (PDF)
    • Gown
    • Gloves
    • Mask (respirator if involved in aerosol generating procedure)
    • Eye protection (face shield/goggles)
  • Contact and collaborate with the local public health department to identify all people who were in close contact with confirmed cases within the facility and in the community.

Outbreak Testing

  • To enhance surveillance and quickly identify residents who may be infected with COVID-19, long-term care facilities who meet the definition of an outbreak as defined in Prevention and Control of Acute Respiratory Illness Outbreaks in Long-Term Care Facilities, BCD 2020-27 (PDF), should immediately notify their local public health department to confirm the outbreak. (A resident admitted to the facility with COVID-19 does not constitute an outbreak.)
  • If the outbreak is confirmed, then the facility may order outbreak testing via the state testing portal. Facilities should follow the guidance of their state partnered lab for the collection and submission of samples.  
  • Test all residents and staff upon identification of a single new case of COVID-19 in any resident or staff.  
  • Retest all residents and staff that tested negative every 3-7 days until testing identifies no new cases of COVID-19 among residents or staff for a period of 14 days since the most recent positive result.
  • Repeat testing for residents or staff who previously tested positive for COVID-19 is not recommended. 

Routine Testing 

Process to Obtain Testing Supplies and Lab Support 
Wisconsin has contracted with several labs to support both routine staff testing and outbreak testing. Submit all orders for both routine and outbreak testing via the state testing portal.

If you have questions regarding your lab testing partnership please notify testing team at: WICOVIDTest@Wisconsin.gov

If you have testing questions, please email WICOVIDTest@Wisconsin.gov

Updates are shared weekly on the Nursing Home Provider webinars. The recordings and presentations for those meetings can be accessed in the Resources section of this page. 

Staff/Resident Testing Consent Forms

Resources

Visitors to Facilities

CMS Memo QSO-20-39 Nursing Home Visitation (PDF) has new guidance and expectations on how nursing homes can safely facilitate in-person visitation to address the psychosocial needs of residents. As stated in CMS Memo QSO-20-39 Nursing Home Visitation (PDF), if a facility has had no COVID-19 cases in the last 14 days and its county positivity rate is low or medium, a nursing home must facilitate in-person visitation consistent with the regulations, and the Core Principles of COVID-19 Infection Prevention. Failure to facilitate visitation, without adequate reason related to clinical necessity or resident safety, would constitute a potential violation of 42 CFR 483.10(f)(4), and the facility would be subject to citation and enforcement actions. 

There may be circumstances when a nursing home is not able to provide in-person visitation due to the COVID-19 county positivity rate, the facility’s COVID-19 status, a resident’s COVID-19 status, visitor symptoms, lack of adherence to proper infection control practices, or other relevant factor related to the COVID-19 Public Health Emergency. When a facility is not able to provide in-person visitation based on the reasons above, the following guidance is recommended.

DHS Guidance

People who live in nursing homes and the staff who work there are at a high risk of contracting COVID-19. Their safety and well-being continues to be a top priority for DHS. When a resident or staff member tests positive for COVID-19, the potential for rapid spread can be extremely high and life-threatening, and asymptomatic individuals who are COVID-positive can spread the virus. In order to minimize spread, we ask that facilities remain vigilant about minimizing the numbers of people entering their buildings from the community. When a nursing home is not able to provide in-person visitation consistent with CMS Memo QSO-20-39 Nursing Home Visitation (PDF), the following guidance is recommended.

  • 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 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.
  • Decisions about compassionate care visits should be made on a case-by-case basis, and should include careful screening of the visitor (including clergy, bereavement counselors, etc.) for fever and/or respiratory symptoms and known exposure to someone with COVID-19.
  • In compassionate care situations, visitors will be limited to a specific room only. If possible, facilities could create dedicated visiting areas (for example, “clean rooms”) near the entrance to the facility where residents can meet with visitors in a well-ventilated sanitized environment, if possible. Facilities should disinfect rooms after each resident-visitor meeting.
  • For individuals allowed in the facility provide instruction on hand hygiene, the importance of limiting surfaces touched, and the proper use of PPE according to current facility policy.
  • If individuals have symptoms of COVID-19 such as a fever, or are unable to demonstrate proper use of infection control techniques, they should be restricted from entry (even in end-of-life situations).
  • Facilities should 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 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.

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
  • Use of online and smartphone video technology (e.g. Zoom, Skype, Face Time)
  • Encourage families to send 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.

Benefits and Potential Uses of Telehealth

  • Telehealth services can facilitate public health mitigation strategies during this pandemic by increasing social distancing. These services can be a safer option for staff and patients by reducing potential infectious exposures. They can reduce the strain on healthcare systems by minimizing the surge of patient demand on facilities and reduce the use of PPE by healthcare providers.
  • Maintaining continuity of care to the extent possible can avoid additional negative consequences from delayed preventive, chronic, or routine care. Remote access to healthcare services may increase participation for those who are medically or socially vulnerable or who do not have ready access to providers. Remote access can also help preserve the patient-provider relationship at times when an in-person visit is not practical or feasible.
  • 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

Note: Nursing Home Reopening Recommendation for State and Local Officials Memo, QSO-20-30-NH (PDF) provides a phased approach to gradually reopening Wisconsin nursing homes. The recommendations cover criteria for implementation and visitation and service considerations. DHS will release additional guidance on these issues in the near future.

Resources

DHS Resources

Webinars
CDC Resources
CMS Resources
  • Memo, QSO-20-25-NH: Supplemental information for transferring or discharging residents between facilities for the purpose of cohorting residents based on COVID-19 status (i.e., positive, negative, unknown/under observation).
  • Memo, QSO-20-23-ICF/IID & PRTF: Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IIDs) and Psychiatric Residential Treatment Facilities (PRTFs)
  • Memo, QSO-20-14-NH: Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in nursing homes (Revised)
  • Memo, QSO-20-17: ALL Guidance for use of Certain Industrial Respirators by Health Care Personnel
  • Recordings and transcripts of CMS-hosted calls with a clinicians, hospitals, other facilities, and states in an effort to keep stakeholders updated on COVID-19 efforts.
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 for Residents

    Last Revised: October 29, 2020