Citadel Healthcare COVID-19 Testing and Response Plan

Policy, Purpose, and Background

It shall be the policy of the Facility to guard against the introduction and spread of SARS-CoV-2 within its community of residents and staff.  The Facility uses available and current guidance from the Centers for Disease Control and Prevention (CDC), Center for Medicare and Medicaid Services (CMS), the Illinois Department of Public Health (IDPH), and Local Health Department (LHD) officials to instruct the development and implementation of policies and procedures that comprise its strategy to prevent, respond to, and mitigate the presence of SARS-CoV-2.  This policy will provide the administrative framework for the development and implementation of specific subordinate policies, procedures, and protocols for the prevention, monitoring, testing, and responding to any incidence of SARS-CoV-2 within the Facility.

The Facility’s global response strategies are articulated in part in the Testing and Response Plan and are also included in the Infection Control Policy (ICP) and other related policies. The Facility’s Testing and Response Plan is intended to be fluid and responsive to local conditions related to SARS-CoV-2 infection in the Facility and the surrounding region as defined in the Restore Illinois Public Health Plan to Safely Reopen Illinois.

1. Facility Information & Situation Awareness

The Facility will monitor specified characteristics of the local SARS-CoV-2 situation as defined in the Restore Illinois Public Health Plan to Safely Reopen Illinois as well as relevant local, state, and federal information in order to inform infection prevention and control actions, resource planning, and coordination of appropriate responses as changes occur.

1. Name of the Facility: _Citade
2. Facility Address
3. County-Restore Illinois Region
4. Individual preparing Facility Testing & Response Plan: The Facility’s Testing & Response Plan was prepared by:Administrator
5. Date of initial Facility Testing & Response Plan: The Facility’s initial Testing & Response Plan was prepared on 06-05-20
6. The Facility will review and update its Facility Testing and Response Plan on a periodic basis to ensure it is up to date with current CDC, IDPH, CMS, and LDH guidelines.
7. Communication – The Facility communicates its testing plans and results to the LHD, residents, families, legally authorized representatives, and Healthcare Personnel (HCP).
8. SARS-CoV-2 Local Incidence: The Facility’s Infection Preventionist or designee monitors local SARS-CoV-2 incidence and regional designation in IDPH’s Restore Illinois Reopening plan and reports this information to the Administrator and Director of Nursing Services to inform infection prevention activities.
9. Local Health Department (LHD) Contact: The Facility’s Infection Preventionist/designee or Administrator will maintain regular communication with its Local Health Department contact. Communication is documented in the Facility’s COVID-19 Facility Response Log.
10. IDPH Regional Infection Control Consultant: The Facility’s Infection Preventionist/designee or Administrator will maintain regular communication with its IDPH Regional Infection Control Consultant Communication is documented in the Facility’s COVID-19 Facility Response Log.
11. CDC Social Vulnerability Index for County: CDC’s SVI uses U.S. Census data to determine the social vulnerability of every census tract. Census tracts are subdivisions of counties for which the Census collects statistical data. The SVI ranks each tract on 15 social factors, including poverty, lack of vehicle access, and crowded housing, and groups them into four related themes. As noted by IPDH, the CDC SVI may influence IDPH in determining testing assistance To aid IDPH, the Facility notes that the CDC SVI.

1. Infection Control Capacity: The Testing and Response Plan is part of the Facility’s overarching Infection Control Policy.
   1. Infection Preventionist or designee: The Testing and Response Plan is executed under the guidance of the Facility’s Infection Preventionist or designee.
   2. The Testing and Response Plan is executed by the necessary Healthcare Personnel (HCP) with appropriate training and experience. The Facility ensures that training includes: COVID-19 (e.g., symptoms, how it is transmitted); Hand hygiene (how to use alcohol-based hand rub (ABHR) and properly wash hands with soap and water); Donning and doffing of personal protective equipment (PPE) including Gloves, Face protection (goggles or face shield), Face mask (surgical or procedure mask), N95 respirator (if applicable), and Gowns (disposable, reusable, or alternative sources of protection). It also includes cleaning and disinfection and Specimen collection procedure. Training includes return demonstration competencies for PPE donning and doffing.
   3. The Testing and Response Plan is executed by the Facility’s additional HCP.
   4. Appropriate Personal Protective Equipment (PPE) is a critical component of the Facility’s Infection Control Policy. PPE is necessary to both protect staff and reduce transmission within the Facility.. Constraints on PPE resulting in changes to the Testing and Response Plan are documented in the COVID-19 Facility Response Log or similar document.
   5. Infection Prevention & Control interventions – The Facility has policies addressing the following:
      1. Visitor restrictions – The Facility restricts visitation to essential individuals. All visitors are informed of risk and instructed on proper PPE use prior to entering any unit. Appropriate signage is posted.
      2. Cessation of communal dining and large group activities – The Facility discontinued communal dining and large group congregate activities such as bingo, beauty shop, church, etc. and provided alternatives that maintains social distancing such as arranging in room dining.
      3. Universal source control – The Facility implements universal source control for residents, HCP, and any persons entering the building including compassionate care.
      4. Social distancing – The Facility implements social distancing maintaining 6 feet between individuals except during direct care activities.
      5. Residents leaving the facility – Residents are asked to wear a face mask when leaving the building for appointments. Their COVID-19 status is shared with transportation services and whomever the resident has the appointment. Note: In the event any resident asked to wear a mask is unable to do so due to a medical condition, a physician order is used to document this information in the medical chart. The Facility works to explore alternative measures to keep the resident and others safe.
      6. Cleaning and disinfection – The Facility has policies addressing cleaning and disinfection surfaces including product selection based on EAP-approved disinfectants against COVID-19.
      7. Facility design – The Facility designates appropriate space for cohorting and managing care for residents with COVID-19 and for cohorting and managing new/ readmissions with unknown COVID-19 status. It may transfer recovered COVID-19 residents to a transitional or observational area for 14 days before admitting directly back to the regular unit or may transfer back to the regular unit if unable to designate a transitional or observational area.

• Testing Capacity and Protocol
  1. Medical Director or Ordering Physician for Testing: The Facility’s health care provider responsible for ordering SARS-CoV-2 tests for the Facility’s residents and HCP .
  2. Method for Obtaining Consent: The Facility ensures informed consent is obtained by testing staff prior to collecting specimens from residents and HCP. Testing staff informs residents or their legally authorized representatives and HCP of their right to authorize or refuse testing, how the test will be conducted, that the test will be performed by a 3^rd party laboratory, how result information will be handled, the potential need for isolation to prevent the spread of infection and that there is the potential for false positive or negative test results. Additionally, if positive, the Facility notes that testing does not replace treatment by their medical provider, and they have the responsibility to obtain appropriate medical treatment.
     1. Signed consents are retained in the appropriate resident medical record or staff member employee health record. In the event where it is not possible to obtain a signed consent at the time of specimen collection, a verbal informed consent will be obtained prior to testing and documented in the resident’s chart.
     2. The Facility acknowledges that residents or their legally authorized representatives have a legal right to refuse testing. The Facility uses targeted education and motivational interviewing techniques to inform residents of the risks and benefits, including community benefits, of testing. If the resident refusal persists, the Facility takes the following measures to protect other residents from risk of exposure to a resident with undetermined SARS-CoV-2 status:
     3. The Facility acknowledges that healthcare personnel have a legal right to refuse testing and have [either – alerted staff that testing is a condition for continued employment – or – have adopted the following measures to protect residents from risk of exposure to a staff member with undetermined SARS-CoV-2 status:
  3. Method for Funding Testing: The Facility will properly bill claims for reimbursement to the resident’s and HCP’s insurer or the appropriate uninsured testing program, ensuring that it will not collect any co-pays for tests conducted.
  4. Contracted/Engaged Lab: The Facility’s Administrator has contracted or engaged Simple Laboratory to provide SARS-CoV-2 clinical testing services according to the volume and frequency identified in the Testing and Response Plan.  Simple Laboratory reports they have or do not have  current capacity to meet the Facility’s testing needs as of date. The Facility’s Infection Preventionist or designee monitors the Laboratory’s capacity and result turn-around time on a regular basis. The Facility promptly responds to any delays in turn-around times or evidence of decreased capacity by identifying additional laboratory partners and contacting IDPH to receive assistance in identifying laboratories with available capacity. The Facility’s Administrator will then pursue an appropriate arrangement for testing and billing.
  5. Viral Testing Type and Specimen Source – The Facility determined that it will utilize the following type of Emergency Use Authorization or Food and Drug Administration approved viral test. The test used should be able to detect SARS-CoV-2 virus (e.g., polymerase chain reaction (PCR)) with greater than 95% sensitivity, greater than 90% specificity, with results obtained rapidly (e.g. within 48 hours) and the specimen source g., nasopharyngeal, anterior nares, or oropharyngeal, appropriate to the viral tests available.
  6. Test Kit Supply (Current and Pipeline): The Facility calculates the total number of test kits necessary to have in inventory and on order to complete testing according to the periodicity schedule as determined by the current testing requirements and documents this information in the Facility’s COVID-19 Response Log or other document, taking into consideration the following:
     1. Current inventory of test kits
     2. Lab result turnaround time in days with the acknowledgement that if this takes longer than 1 week, testing frequency may be modified to correlate
     3. Current SARS-CoV-2 test kit order-to-delivery time in weeks
     4. On-site inventory needed
  7. Process for Specimen Collection and Transportation: The Facility’s Infection Preventionist or designee oversees the process for specimen collection and transportation to the laboratory ensuring that the instructions provided with the test kits and laboratory protocols are followed to prevent contamination or altered specimen that can interfere with diagnosis.
  8. Staff Designated to Conduct Testing: The specimen collection process is conducted by the Facility’s trained Nurses.
  9. Training of Personnel for Testing: The Facility’s Infection Preventionist or designee is responsible to assure testers receive training for safe and correct testing of residents and HCP and the safety of those professionals who will be administering the tests. Training includes identification of who should be tested, appropriate locations for specimen collection, informed consent including explanation of the procedure to the individual, standard precautions, appropriate use and removal of PPE, contents of diagnostic test kit, proper individual and specimen identification, procedure for nasal and throat swabs, guidelines for storing specimens for shipment, and appropriate documentation.
  10. Test Result Communication, Documentation and Reporting Protocol – The Facility’s Infection Preventionist or designee oversees the process for receiving and acting on results of testing to identify asymptomatic cases, confirm infection in symptomatic cases, evaluate quality indicators, follow-up on infection control programs, and to support decision-making. Once results are obtained, Nurses are responsible to record the result and date in the resident’s medical record or HCP’s employee health record, communicate the result to the individual or legally authorized representative on a timely basis, and ensure the appropriate government entities are informed via designated processes including National Healthcare Safety Network (NHSN) COVID-19 Module for LTCF weekly and IDPH or LHD daily or as directed.
      1. The Facility maintains documentation or line listing of aggregated testing results for both residents and HCP, including such fields as: test type conducted, date of tests, date of results, results, unit of residence or of staff assignment, and any barrier preventing testing.
      2. The Facility informs residents/legally authorized representatives, HCP, and families of the number of cases in the facility by 5 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other as follows:. Communications are recorded by date and type in the Facility’s central document. Recommend COVID-19 Facility Response Log or similar document.
      3. All identified SARS-CoV-2 tests, results, and documentation are maintained under strict compliance with HIPAA requirements.

1. Testing Periodicity regardless of Outbreak status:
   100. Resident Symptom Screening and Testing: Consistent with the Facility Infection Control Policy and IDPH guidance, all residents are screened for symptoms consistent with SARS-CoV-2 infection and temperature, heart rate, respirations and pulse oximetry once per shift and blood pressure once daily in accordance with IDPH guidance. SARS-CoV-2-like illness is described by IDPH as new onset of subjective or measured (≥100.4^oF or 38.0^oC) fever OR cough OR shortness of breath OR sore throat that cannot be attributed to an underlying or previously recognized condition. The Clinical Supervisor (or appropriate facility staff) is immediately notified of any resident who screens positive for symptoms or change in vital signs and appropriate infection control measures are initiated according to Facility IC Policy or other policy regarding clinically ill residents.  Resident receives immediate SARS-CoV-2 testing via testing process as described in Section III. Residents with symptoms or change in vital signs are tested regardless of previous SARS-CoV-2 testing status.
   101. Staff Symptom Screening and Testing:  Consistent with the Facility’s Infection Control policies, and IDPH guidance, all HCP (including non-staff visiting HCP, vendors, volunteers, and visitors) are screened for temperature and symptoms of SARS-CoV-2 in accordance with IDPH guidance prior to shift and at mid-shift. HCPs who have fever or symptoms receive SARS-CoV-2 testing as described in Section III and are excluded from work pending results of the test. HCPs who test positive for SARS-CoV-2 are excluded from work until they meet return to work criteria as defined in current IDPH guidance. Visiting HCPs who screen positive for symptoms or fever while onsite at the Facility are immediately removed from the Facility and must either be tested according to procedures outlined in Section III for staff HCP or provide documentation of negative testing or clinical statement from a qualified professional that fever and/or symptoms can be reliably ascribed to another condition prior to resuming visiting work.
   102. Testing for readmission after hospitalization for COVID: Whenever possible the Facility requests hospitals to verify negative SARS-CoV-2 status through testing prior to discharge back to the Facility. When testing is not available, the Facility employs a symptom-based strategy to determine length of infection control precautions. Residents with verified SARS-CoV-2 infection are excluded from Point Prevalence Surveys and baseline surveys in the future.
   103. Testing for readmission after hospitalization or other prolonged or multiple encounters outside of the Facility for non-COVID related condition: In consultation with the resident’s healthcare providers and LHD, the Facility may periodically test asymptomatic residents who are at elevated risk for transmission of SARS-CoV-2 based on their exposure outside of the Facility. This includes residents who are hospitalized with a non-COVID condition or residents with frequent visits outside of the Facility such as residents undergoing dialysis, cancer treatments, and other services. Conditions impacting testing frequency are documented in the COVID-19 Facility Response Log or other document. When the rate of community transmission is high as defined by the facility region in Phase 1 or 2 of the Restore Illinois Plan, these residents will be tested weekly.
   104. Residents with known exposure to COVID-19: Asymptomatic residents with known exposure to COVID-positive case while outside the facility will be tested within 3-7 days after exposure.

1. Periodic testing of HCP: Consistent with CMS Guidance QSO-20-30-NH, the Facility performs weekly testing of all previously negative HCP staff and visiting HCP staff who enter the building more than three times each week until the Facility is advised by IDPH, IDPH Regional Infection Control Consultants, or LHD officials that the community has completed Phase 3 of Reopening nursing homes and Opening Up America Again and weekly testing of HCP is no longer indicated. The Facility will consider testing more frequently than weekly when the Facility has been advised by IDPH or LHD to pursue more frequent testing based on local transmission.
2. Baseline Testing: The Facility has completed baseline testing of all residents and staff. The Facility will complete baseline testing of all residents and staff.The testing dates and clearance dates are documented in the COVID-19 Facility Response Log or other document.
3. Follow-up to baseline testing: The Facility completed weekly testing of all previously negative residents until all residents were tested negative for 14 days. The Facility plans to continue weekly testing of all previously negative residents until all residents test negative for 14 days after the baselines testing.
4. Periodic re-testing of Residents: Consistent with Emergency Rule TITLE 77: PUBLIC HEALTH CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER c: LONG-TERM CARE FACILITIES PART 300 SKILLED NURSING AND INTERMEDIATE CARE FACILITIES CODE as promulgated on 5-28-2020, the Facility establishes a testing plan for conditions when the facility has no identified cases in the last 28 days. The Facility Testing Plan is based on the regional phases defined in the Restore Illinois Plan to Safely Reopen. (
   1. If the facility region is in Restore Illinois phases 1 or 2, the Facility testing will include: Asymptomatic roommates of symptomatic or COVID-positive residents will be tested.
   2. One or more units of the facility will be tested weekly so that the entire facility is tested is tested monthly.

If the facility region is in phases 3, 4, or 5, the Facility testing will include:

1. One or more units of the facility will be tested periodically so that the entire facility is tested every two months.

At any time, if testing results in two or more cases being identified, the facility will resume testing conditions as indicated in the Outbreak conditions. The regional Restore Illinois phase and testing periodicity are documented in the COVID-19 Facility Response Log or other document.

1. Testing for Outbreak Conditions: IDPH has defined an Outbreak as one laboratory confirmed case in either resident or HCP and one additional presumed case by COVID-19- like symptoms or confirmed case by laboratory testing. Cases considered in an Outbreak definition must presumably originate in the facility and not be the result of residents with positive status being newly admitted to the facility. Testing periodicity for Outbreak Conditions is in addition to testing conducted during non-outbreak conditions.
   1. Point Prevalence Survey: During an Outbreak, as soon as possible (ideally within 7 days) based on testing constraints and mitigation strategies described in Section VI, the Facility completes a facility-wide Point Prevalence Survey testing all residents and staff. All Testing for the Point Prevalence Survey is completed within 24 hours except when constraints as described in Section VI impact testing schedules. Execution of a Point Prevalence Survey is documented in the COVID-19 Facility Response Log or similar document.
   2. Reportage: Any new Outbreak is reported to the LHD. The Facility, LDH and IDPH Regional Infection Control Consultant (RICC) will arrange testing for residents and HCP using the Testing and Response Plan.
   3. Continued surveillance of residents and HCPs during an Outbreak: The Facility will increase temperature, heart rate, respirations, pulse oximetry and symptom monitoring of symptomatic residents to every four hours. The Facility continues to perform weekly testing of all previously negative HCP, visiting HCP who enter the building more than three times each week, and residents until all tests are negative for 14 days, unless advised to perform testing at another frequency by IDPH or LDH. Any resident identified to be positive for COVID-19 (symptomatic or asymptomatic) will be placed on droplet/contact precautions and moved to the COVID-19 designated area. Execution of weekly surveillance after a Point Prevalence Survey is documented in the COVID-19 Facility Response Log or similar document.

1. Testing for readmission after hospitalization or other prolonged or multiple encounters outside of the Facility for non-COVID related condition: During Outbreak Conditions and consistent with CDC guidance, the Facility will test asymptomatic residents who are at elevated risk for transmission of SARS-CoV-2 based on their exposure outside of the Facility weekly. This includes residents with frequent visits outside of the Facility such as residents undergoing dialysis, cancer treatments, and other services.

1. Testing Constraints, Mitigation Strategies, and Prioritization

1. Testing Constraints and Mitigation Strategies: The Facility may encounter a variety of constraints that impair the ability to execute the periodicity of testing as described in Sections IV and V. The constraints and mitigation strategies are listed in Table 1 below.

Table 1:

All testing constraints, mitigation strategies, and impact on periodicity of testing schedules will be documented in the COVID-19 Facility Response Log or other document.

1. Prioritization Strategies: At all times, the Facility strives to accomplish testing according to CDC, CMS, IDPH, and LHD guidance and best practices and uses every available means to mitigate constraints and deploy appropriate infection control policies. When the Facility is unable to accomplish testing according to the periodicity described in Sections IV and V, testing will be prioritized according to the following criteria:
   1. HCP testing prioritization criteria:
      1. HCP who work in other facilities that may also be experiencing an outbreak
      2. HCP with frequent resident contact
      3. Visiting HCP who visit at higher frequency than others
   2. Resident testing prioritization criteria:
      1. Roommates or close contacts of resident who has tested positive
      2. Residents who leave the facility frequently (e.g. residents receiving dialysis)
      3. Residents on units where HCP who have tested positive have been recently working
      4. Units or wings where residents have recently tested positive
      5. Residents with co-morbidities that increase their risk of morbidity from SARS-CoV-2 infection

• Appendix A: Acronyms

CDC: Centers for Disease Control and Prevention

CMS:  Centers for Medicare and Medicaid Services

IDPH:  Illinois Department of Public Health

HCP:  Healthcare Personnel

LHD:  Local Health Department

Sample COVID-19 Facility Response Log