STATE OF GEORGIA DEPARTMENT OF PUBLIC HEALTH

STATE OF GEORGIA

DEPARTMENT OF PUBLIC HEALTH

ADMINISTRATIVE ORDER

LONG-TERM CARE FACILITIES REOPENING GUIDANCE

WHEREAS, on March 14, 2020, Governor Brian P. Kemp issued Executive Order 03.14.20.01, declaring a

Public Health State of Emergency in Georgia due to the impact of Novel Coronavirus Disease 2019 (COVID-

19); and

WHEREAS, on March 16, 2020, the Georgia General Assembly concurred with Executive Order 03.14.20.01

by joint resolution; and

WHEREAS, the Public Health State of Emergency has been extended as provided by law; and

WHEREAS, the Centers for Disease Control and Prevention (“CDC”) recommends that all states and

territories implement aggressive measures to slow and contain transmission of COVID-19 in the United

States; and

WHEREAS, the number of cases of COVID-19 in the state of Georgia continues to grow; and

WHEREAS, COVID-19 presents a severe threat to public health in Georgia; and

WHEREAS, COVID-19 is a severe respiratory disease that is transmitted primarily through respiratory

droplets produced when an infected person coughs or sneezes; and

WHEREAS, beginning March 13, 2020, Georgia long-term care facilities began implementing guidance

from the Centers for Medicare and Medicaid Services (“CMS”) that outlined recommended restrictions to

normal operations in an attempt to mitigate the entry and spread of COVID-19; and

WHEREAS, public health mitigation efforts remain critically important, especially in long-term care

settings where residents may be more vulnerable to virus exposure, and the state acknowledges that it is

equally important to consider the quality of life and dignity of the residents who reside in these settings;

and

WHEREAS, using recent guidance from CMS, the state has collaborated with appropriate agencies, long-

term care associations, and other stakeholders on how to responsibly ease restrictions in long-term care

facilities while COVID-19 remains in communities across the state; and

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WHEREAS, I have determined that it is necessary and appropriate to adopt guidance for long-term care

facilities, which for the purposes of this Order includes intermediate care facilities, personal care homes,

and skilled nursing facilities as defined by O.C.G.A. §31-6-2; nursing homes as defined by Ga. Comp. R. &

Regs. r. 111-8-56-.01(a); inpatient hospice as defined by Code Section 31-7-172 and licensed pursuant to

O.C.G.A. §31-7-173; and assisted living communities and all facilities providing assisted living care

pursuant to O.C.G.A. §31-7-12.2.

NOW, THEREFORE, in accordance with O.C.G.A. §§ 31-2A-4, 31-12-4, and Governor Kemp’s Executive

Orders,

IT IS HEREBY ORDERED as follows:

Section 1.0 Recommendations for Progression Through Phases

1. Because staffing levels and access to supplies and testing may vary by facility and because the

pandemic is affecting facilities and communities in different ways, decisions about relaxing

restrictions in a facility should include the following considerations, as recommended by the CMS

in QSO-20-30-NH:

a. Case status in local community: Facilities in communities with high incidence of COVID-19

are at increased risk for introduction of COVID-19 into the facility. Recommendations

based on surveillance data are listed for each phase. These are subject to change as

knowledge evolves.

b. Case status in the facility: Absence of any new facility-onset resident COVID-19 cases, or

any staff cases.

c. Written plans to support reopening: In accordance with Code section 31-7-12.5, the long-

term care facility will maintain and publish for its residents and their representatives or

legal surrogates policies and procedures pertaining to infection control and mitigation

within their facilities and update such policies and procedures annually; and as part of the

facility's disaster preparedness plan required pursuant to subsection (c) of Code Section

31-7-3 and Department of Community Health rules and regulations, include an epidemic

and pandemic plan for influenza and other infectious diseases which conforms to

department and federal CDC standards that contains the following minimum elements:

i. Protocols for surveillance and detection of epidemic and pandemic diseases in

residents and staff;

ii. A communication plan for sharing information with public health authorities,

residents, residents' representatives or their legal surrogates, and staff;

iii. An education and training plan for residents and staff regarding infection control

protocols;

iv. An infection control plan that addresses visitation, cohorting measures, sick leave

and return-to-work policies, and testing and immunization policies; and

v. A surge capacity plan that addresses protocols for contingency staffing and supply

shortages.

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d. A testing plan: Based on recommendations listed in Section 4.0. At minimum, the plan

should consider the following components:

i. Testing of all symptomatic residents and staff, outbreak response testing, and

testing of asymptomatic staff;

ii. Arrangements with commercial laboratories to test residents using tests able to

detect SARS-CoV-2 virus (e.g., polymerase chain reaction (PCR)). Antibody test

results should not be used to diagnose active SARS-CoV-2 infection; and

iii. A procedure for addressing residents or staff that decline or are unable to be

tested (e.g., symptomatic resident refusing testing in a facility with positive

COVID-19 cases should be treated as positive).

e. Adequate staffing: Facility is not under a contingency staffing plan and/or is not receiving

supplemental staffing from the State.

f. Access to adequate Personal Protective Equipment (PPE) for staff: Contingency capacity

strategy is allowable, such as CDC’s guidance on Strategies to Optimize the Supply of PPE

and Equipment (facilities’ crisis capacity PPE strategy would not constitute adequate

access to PPE). All staff wear all appropriate PPE when indicated. Staff wear cloth face

covering if facemask is not indicated, such as administrative staff.

g. Local hospital capacity: Ability for the local hospital to accept transfers from nursing

homes.

Section 2.0 Critical Components of Infection Prevention and Control

1. The following practices are recommended throughout the pandemic. Section 3.0 provides

considerations for identifying the reopening phases and infection control recommendations for

each phase. Infection control questions can be directed to the district health department

(https://dph.georgia.gov/document/document/directory-district-epidemiologists/download) or

[email protected].gov.

a. Implement Universal source control. Implementation and compliance evaluation of

universal source control: Residents and visitors should wear a cloth face covering or

facemask. If a visitor is unable or unwilling to maintain these precautions (such as young

children), consider restricting their ability to enter the facility. All visitors should

maintain social distancing and perform hand washing or sanitizing upon entry to and

frequently during their visit at the facility.

b. Designate a COVID-19 unit.

i. Create a plan for management of COVID-19 positive residents.

ii. Designate a COVID-19 unit or cluster of rooms with dedicated staff for cohorting

and managing care for residents who test positive with COVID-19. This unit also

houses admitted residents with a history of COVID-19 that have not met criteria

for discontinuation for transmission-based precautions. Assign dedicated staff

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to work on the COVID-19 care unit and provide separate facilities and

entrance/exit for these staff. These staff should have separate breakrooms and

bathrooms.

iii. If the predetermined COVID-19 unit may not be feasible based upon the

number of positive residents and the types of rooms available, matching

resident gender for room assignments, or a high census, consider the following:

1. Install temporary physical barriers/screens/curtains that separate

residents by at least 6 feet.

2. Transport COVID-19 residents to a dedicated facility in consultation with

your local health department.

c. Designate an observation unit for admissions/re-admissions. Designate an observation

unit or cluster of rooms to manage new admissions and readmissions with an unknown

COVID- 19 status. The observation unit needs to be separate from the COVID-19 unit.

In the observation unit, residents are monitored for 14 days or until criteria for

discontinuation of transmission-based precautions are met.

d. Manage new resident admission and re-admission placement.

i. Residents with confirmed COVID-19 who have not met criteria for

discontinuation of transmission-based precautions should be placed in the

designated COVID-19 care unit.

ii. Residents who have met criteria for discontinuation of transmission-based

precautions can go to a regular unit unless the resident has persistent COVID-19

symptoms (e.g., persistent cough). Those with persistent symptoms should be

placed in a single room, be restricted to their rooms, and wear a facemask

during care activities until all symptoms are resolved and they meet criteria for

discontinuation of transmission-based precautions.

iii. New admissions and readmissions whose COVID-19 status is unknown should be

placed in the observation unit.

e. Create a plan to respond to widespread testing results.

i. If widespread testing is being conducted in the facility, the facility should not

move residents until test results are available and should be prepared to assess

relocation once results are received.

ii. If a facility decides to relocate residents who have been exposed but test

negative, the following should occur:

1. Residents should be quarantined for 14 days in a private room on

transmission-based precautions. If a private room is not available, leave

the resident in place until a single room is available.

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2. Close daily monitoring for COVID-19 signs and symptoms (i.e., screen 3

times a day)

3. If a resident becomes symptomatic, they should be retested.

f. Manage exposed and symptomatic residents.

i. When a resident develops COVID-19 symptoms, test the resident in their room

and wait for results before moving the resident. If the symptomatic resident has

a roommate, ensure that the roommate is tested and leave the roommate in

place unless the facility has an available single room to which to move them.

ii. If testing indicates a positive resident with a negative roommate, move the

positive resident to the COVID-19 care unit and leave the roommate in the room

by themselves. For the negative resident, quarantine in place for 14 days.

Section 3.0 Considerations to Identify Pandemic Phase and Recommended Mitigation Steps

1. Facilities may use discretion to be more restrictive in certain areas, where deemed appropriate

through internal policies. Additional guidance for assisted living communities is provided in

Section 6.0 and for long-term care facilities with memory care units in Section 7.0.

a. Phase III guidance will serve as the least restricted phase a facility may operate in until

further guidance is issued.

b. Many senior care communities that include assisted living programs attached to skilled

nursing facilities or are a part of a continuing care retirement community or senior living

campus have commonly shared kitchen facilities. In the current public health mitigation

environment, facilities should not routinely share direct care, dietary, or environmental

services staff who may have contact with residents or tenants in other segments of the

senior living operations. If there are identified cases of COVID-19 in other service delivery

areas of the campus, there should be no sharing of staff between those care systems

unless the same criteria and guidance are being followed.

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Phase I

Phase II

Phase III

Phase

Identification

Phase I is designed for

vigilant infection control

during periods of heighted

virus spread in the local

community and potential

for healthcare system

limitations.

Facility may or may not be

in outbreak status.

14-day COVID-19 county

case rate >100/100,000

14-day COVID-19 county

positivity rate >10%

Facility may decide to

initiate Phase II upon

alignment with all of the

following:

• Baseline testing of

residents and

direct care staff has

been conducted

(see Section 4.0)

• 28 days since last

confirmed or

suspected case

resolved.

• No outbreak in the

facility (e.g.,

norovirus,

influenza, C.

difficile, etc.).

• 14-day COVID-19

county case rate

50-99/100,000

AND

• 14-day COVID-19

county positivity

rate <10%

Facilities may decide to

initiate Phase III upon

alignment with all of the

following:

• 28 days since last

COVID-19 confirmed

or suspected case

identified. In

addition, the facility

should not have an

outbreak in the

facility (e.g.

norovirus, influenza,

C. difficile, etc.)

• 14-day COVID-19

county case rate

<50/100,000

AND

• 14-day COVID-19

county positivity rate

<5%

Data Sources

to Identify

Pandemic

Phases

The DPH COVID-19 Status Report web site (https://dph.georgia.gov/covid-19-daily-

status-report) provides the 14-day case rates and the 14-day positivity rates by

county (appear when cursor is over selected county). See also CMS county report:

https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg.

Visitation

Visitation generally

prohibited except for:

• Compassionate care

situations restricted to

end of life or outdoor or

window visitation for

residents with significant

changes in condition

including psychosocial or

medical issues associated

with isolation. Phase I

outdoor or window

visitation must meet all

criteria in Section 5.0.

Addition of outside visits as

the facility can support.

See Section 5.0 for details

on outside visitation.

All residents should have

the ability to have limited

visitation, with a

preference for outside

visitation when possible

(see Section 5.0).

Each facility should

develop a limited

visitation policy which

addresses the following,

at minimum:

• Visitation schedule,

hours, and location.

• Number of visitors and

visits.

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Phase I

Phase II

Phase III

• Compassionate care

visitors are screened

upon entry and additional

precautions are taken

including social distancing

and hand hygiene. All

visitors must wear a cloth

face covering or other

facemask for the duration

of their visit. The facility

must provide a face mask

to the visitor in the event

they do not have one to

ensure universal source

control.

• Guidelines for outdoor

and window visitation are

presented in Section 5.0.

• Facilities should have

policies in place for

virtual visitation,

whenever possible, to

include:

o Access to

communication with

friends, family and

their spiritual

community

o Access to the Long-

Term Care

Ombudsman

• Infection control

practices including

proper hand hygiene,

universal source

control, and overall

facility supervision of

safe practices related to

visitors and social

distancing.

• Use of PPE.

• By appointment only,

or as coordinated by

the nursing facility,

based on their ability to

manage infection

control practices and

proper social

distancing.

• Only in designated

areas to ensure safe

distancing, proper hand

hygiene, universal

source control, and

overall facility

supervision of safe

practices related to

visitors. Note: each

facility must determine

their capacity to

manage limited visits,

based on

considerations, such as,

staff availability to

screen visitors,

availability of supplies

to support universal

source control (e.g.,

face masks), monitoring

for visitor compliance

with safe visitation

practices, and

disinfection of area

between visits.

• Facilities may limit the

number of visitors for

each resident per week

and per occurrence.

Page 8 of 24

Phase I

Phase II

Phase III

• Preference should be

given to outdoor

visitation opportunities

like parking lot visits

with distancing.

• All visitors are screened

upon entry.

• Visitors unable to pass

the screening or comply

with infection control

practices like masks

should refrain from

visiting.

Non-

essential

healthcare

personnel

Restricted entry of non-

essential healthcare

personnel.

Entry of limited non-

essential healthcare

personnel/contractors as

determined necessary by

the facility, with screening

and additional precautions,

including social distancing,

hand hygiene, and cloth

face covering or facemask.

Allow entry of non-

essential healthcare

personnel/contactors as

determined necessary by

the facility, with

screening and additional

precautions, including

social distancing, hand

hygiene, and cloth face

covering or facemask.

Resident

trips outside

the facility

for non-

medically

necessary

reasons

Non-medically necessary

trips should be avoided.

Telemedicine should be

used whenever possible.

Non-medically necessary trips outside the building

should be limited. Trips might be allowed for COVID-19

negative residents or residents that meet

discontinuation of transmission-based precautions and

are asymptomatic. Residents with multiple co-

morbidities and immunodeficiencies (i.e., at increased

risks for severe illness) are not recommended to

participate in non-medically necessary resident trips.

For limited non-medically necessary trips away from

the facility:

• The resident must wear a cloth face covering or

facemask; and

• Transportation staff, at a minimum, must wear a

facemask. Additional PPE may be required.

• Transportation staff should use alcohol-based hand

sanitizer (ABHR) upon entry and exit to the facility.

Residents should use ABHR prior to leaving facility

and upon re-entry.

• Transportation equipment shall be sanitized between

transports

• Resident screening for signs and symptoms three

times a day for 14 days.

Page 9 of 24

Phase I

Phase II

Phase III

Resident

trips outside

the facility

for medically

necessary

reasons

For medically necessary trips away from of the facility:

• The resident must wear a cloth face covering or facemask.

• The facility must share the resident’s COVID-19 status with the transportation

service and entity with whom the resident has the appointment.

• Transportation staff, at a minimum, must wear a facemask. Additional PPE may be

required.

• Transportation staff should use alcohol-based hand sanitizer (ABHR) upon entry and

exit to the facility. Residents should use ABHR prior to leaving facility and upon re-

entry.

• Transportation equipment shall be sanitized between transports.

• Resident screening for signs and symptoms three times a day for 14 days.

Communal

dining

Communal dining limited to residents not exhibiting any signs or symptoms and only

if the facility has completed baseline testing (see Section 4.0) and is without any new

facility onset COVID-19 cases for 14 days.

• Residents may eat in the same room with social distancing (limited number of

people at tables and spaced by at least 6 feet).

• A limited number of individuals in a dining area at one time, not to exceed 50

percent of capacity unless that would be less than 10 people.

• If staff assistance is required, appropriate hand hygiene (ABHR preferred) must

occur between residents as well as use of appropriate PPE.

• All tables, chairs, and dining area to be cleaned and disinfected after each use.

Screening of

Residents

and Staff

• Resident screening each shift for a minimum of 3 times

a day. It should be clearly documented in the facility

policies when shift screenings should occur and how it is

tracked.

• Staff screening and documentation at the beginning of

each shift.

• Daily resident

screening. Screening

process should be

documented in the

facility guidelines.

• Staff screening and

documentation at the

beginning of each shift.

Universal

Source

Control &

Personal

Protective

Equipment

(PPE)

• Universal source control for everyone in the facility. Residents and visitors wear

cloth face covering or facemask, if able to tolerate and wear safely.

• All facility staff and essential healthcare personnel, regardless of their position, who

may interact with residents or enter resident rooms, should wear a

surgical/procedural facemask. Those facility staff, regardless of their position, who

do not provide any care to the residents and who have no interaction with residents

should wear either a cloth face covering or facemask while in the facility.

• All facility staff and essential healthcare personnel wear appropriate PPE when they

are interacting with residents, in accordance with CDC PPE optimization strategies.

• Additional universal source control recommendations can be found throughout this

document (e.g., visitors, essential healthcare personnel).

• New admissions or readmissions from a hospital setting must quarantine for 14

days. (Note: we do not recommend quarantine for residents undergoing

hemodialysis at outpatient clinics or for resident day outpatient visits.)

Page 10 of 24

Phase I

Phase II

Phase III

Group

Activities

Restrict group activities but

some outdoor/doorway

small group activities may

be conducted (for COVID-

19 negative or

asymptomatic residents

only) with social distancing,

hand hygiene, and use of a

cloth face covering or

facemask (e.g., sit in

doorway for group

activity).

• Engagement through

technology is preferred to

minimize opportunity for

exposure.

• Facilities should have

policies in place to

engage virtually, where

possible, in activities that

improve quality of life

(e.g. church service, art

classes, book clubs).

Limit group activities

• Small group activities may

occur with social

distancing, hand hygiene,

and use of a cloth face

covering or facemask and

no more than 10 people.

• Facilities must restrict

activities that encourage

multiple residents to

handle the same object(s)

(e.g., ball toss).

Limit large group

activities

• Expanded group

activities may occur

with hand hygiene and

use of a cloth face

covering or facemask,

and no more than the

number of people

where social distancing

among residents can be

maintained.

• Facilities should restrict

activities that

encourage multiple

residents to handle the

same object(s) (e.g.,

ball toss).

Salons

Entry of beautician or

barber prohibited.

Entry of beautician or

barber generally

prohibited, but facility may

conduct a risk assessment

to determine if it can safely

include these staff at its

facility for COVID-19

negative and asymptomatic

residents. To allow entry of

beautician or barber, see

Phase III requirements.

All applicable rules for

operation of salon

facilities set forth in the

Governor’s Executive

Orders shall be followed.

Additionally, the

following requirements

shall be followed:

• The beautician or

barber must remain in

the salon area and avoid

common areas of the

facility.

• No hand-held dryers.

• Residents must wear a

face mask during their

salon visit.

• The same guidelines

need to be followed for

trimming beard with two

exceptions: (1) facemask

removal only for the time

to trim facial hair and (2)

Page 11 of 24

Phase I

Phase II

Phase III

no other residents in the

salon.

On site gym

or fitness

center

No gym access.

Physical therapy is

addressed under medically

necessary visits (see:

Resident trips outside the

facility for medically

necessary reasons).

Gym access is limited to COVID-19 negative or

asymptomatic residents or residents who meet criteria

for discontinuation for transmission-based precautions.

All applicable rules for operation of gyms and fitness

facilities set forth in the Governor’s Executive Orders

shall be followed. Physical therapy is addressed under

medically necessary visits (see Resident trips outside

the facility for medically necessary reasons).

Testing

• Facility shall report

progress towards

completion of baseline

testing for staff and

residents, as described in

Section 4.0.

• See additional testing

guidance in Section 4.0.

• See guidance for testing

in Section 4.0.

• See guidance for

testing in Section 4.0.

Testing and

Resident

Managemen

See Section 2.0 for further details on setting up a COVID Unit, an Observation Unit,

and Management of Positive and symptomatic residents and their roommates.

Phase

regression

• Not Applicable.

• A facility will continue to

monitor for the presence

of COVID-19 in their

buildings. This will occur

through resident

screenings and staff

screening before each

shift and through the

review of the facility

COVID-19 data, which

includes COVID-19 cases,

availability of PPE,

laboratory testing, and

alcohol-based hand

sanitizer.

• If one or more staff or

resident is confirmed

positive for COVID-19 the

facility will return to

Phase I.

• Once 28 days have

passed with no additional

• A facility will continue

to monitor for the

presence of COVID-19

in their buildings. This

will occur through daily

resident screening and

staff screening before

each shift and through

the review of the

facility COVID-19 data,

which includes COVID-

19 cases, availability of

PPE, laboratory testing,

and alcohol-based hand

sanitizer.

• If one or more staff or

resident is confirmed

positive for COVID-19

the facility will return to

Phase I. Once 28 days

have passed with no

additional residents or

staff testing positive for

Page 12 of 24

Phase I

Phase II

Phase III

residents or staff testing

positive for COVID-19, the

facility has demonstrated

the ability to mitigate the

spread of COVID-19 and

may return to Phase II of

the reopening process.

• The facility also returns to

Phase I when the county

meets Phase I high

transmission criteria.

COVID-19, the facility

has demonstrated the

ability to mitigate the

spread of COVID-19 and

may return to Phase III

of the reopening

process.

• The facility also returns

to Phase I or Phase II

when the data criteria

for Phase III are no

longer met.

References: Facilities should consult these authorities on a regular basis to ensure current understanding of guidance

and recommendations:

• CMS website:

https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-

Emergencies/Current-Emergencies-page

• CDC website: https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/index.html

• GA Department of Public Health Website: https://dph.georgia.gov/

• District health department; see district health department

(https://dph.georgia.gov/document/document/directory-district-epidemiologists/download).

• Georgia Department of Public Health: email hai@dph.ga.gov.

Section 4.0 Testing Requirements and Guidance

1. On May 18, 2020, CMS issued QSO-20-30-NH, Nursing Home Reopening Recommendations for

State and Local Officials. The document provides guidance for State Survey Agencies and other

state officials to determine how nursing facilities may begin to lift restrictions previously

imposed to mitigate the spread of COVID-19. CMS indicates in the above referenced QSO

memorandum that testing will be a critical part of a facility lifting restrictions on operations.

2. On August 25, 2020, CMS has issued interim final rules requirement for testing of residents and

staff (https://www.cms.gov/files/document/covid-ifc-3-8-25-20.pdf

), and on August 26, 2020,

CMS issued QSO-20-38-NH (https://www.cms.gov/files/document/qso-20-38-nh.pdf), which

provides some details on requirements for resident and staff testing. This section will be

updated as more information becomes available.

a. Antigen, PCR and Serology Tests.

i. All nursing homes need to arrange with a commercial laboratory to conduct

nucleic acid (i.e., PCR) testing for SARS-CoV-2. As part of this arrangement,

nursing homes need to have a procedure in place to retain supplies at their

facility or to receive them via overnight shipping. Although antigen testing may

be conducted in many circumstances, nursing homes need to maintain access to

PCR testing for confirmatory testing.

Page 13 of 24

ii. On July 22, 2020, the U.S. Department of Health and Human Services (HHS)

announced the distribution of rapid, antigen point-of-care (POC) testing devices

to some nursing homes, and that nursing homes have the option to purchase

additional instruments and supplies. On August 26, 2020, CMS issued QSO-20-

38-NH (https://www.cms.gov/files/document/qso-20-38-nh.pdf), which

specifies nursing homes with a CLIA waiver (https://www.cms.gov/Regulations-

and-Guidance/Legislation/CLIA/Downloads/HowObtainCertificateofWaiver.pdf)

can meet testing requirements using the POC devices.

iii. While having the benefit of rapid turnaround times, antigen tests generally have

lower sensitivity compared to PCR, and the FDA Emergency Use Authorization

recommends negative antigen tests be considered presumptive.

iv. If antigen testing is available, it can be used for rapid testing of symptomatic

residents and staff, and all negative antigen tests for these individuals must be

followed by collection and shipment of a specimen for PCR testing within 48

hours. Clinicians should use their judgment to determine if a patient has signs

or symptoms compatible with COVID-19

(https://www.cdc.gov/coronavirus/2019-ncov/symptoms-

testing/symptoms.html) and whether the patient should be tested. Most

patients with confirmed COVID-19 have developed fever and/or symptoms of

acute respiratory illness (e.g., cough) but some infected patients may present

with other symptoms (e.g., altered smell or taste) as well. Clinicians are

encouraged to consider testing for other causes of respiratory illness, for

example influenza, in addition to testing for SARS-CoV-2 depending on patient

age, season, or clinical setting; detection of one respiratory pathogen (e.g.,

influenza) does not exclude the potential for co-infection with SARS-CoV-2.

v. Antigen tests may be used to test asymptomatic staff to meet CMS staff serial

testing requirements based on local incidence of COVID-19

(https://www.cdc.gov/coronavirus/2019-ncov/symptoms-

testing/symptoms.html). Facilities should follow CDC test considerations

(https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-antigen-

testing.html) and interpretation guidance

(https://www.cdc.gov/coronavirus/2019-ncov/downloads/hcp/nursing-home-

testing-algorithm-508.pdf).

vi. Antigen tests may be used to test asymptomatic residents and staff as part of a

COVID-19 outbreak response. Facilities should follow CDC test considerations

and interpretation guidance. COVID-19 outbreaks must be reported to the

district health department

, including the use of PCR or antigen testing as part of

the response.

vii. All positive and negative results for PCR and antigen testing of residents and

staff must be reported to the health department. Procedures to report these

data are under development and will be published at a later date.

Page 14 of 24

viii. As of August 2020, CDC is evaluating the performance of commercial antibody

(serology) tests for SARS-CoV-2. At this time, DPH does not recommend

serology testing as the sole basis for diagnosis of COVID-19 in residents or

staff. In certain situations, serologic assays may be used in conjunction with

viral detection tests to support clinical assessment of persons who present late

in their illness.

b. Mandatory Baseline Testing.

i. O.C.G.A. 31-7-12.2 requires all long-term care facilities to complete baseline

testing for all residents and direct care staff no later than September 28, 2020.

Direct care staff includes any employee, facility volunteer, or contract staff who

provide to residents any personal services, including but not limited to,

medication administration or assistance, assistance with ambulation and

transfer, and essential activities of daily living, such as eating, bathing,

grooming, dressing, toileting, or any other limited nursing services.

ii. All long-term care facilities must conduct baseline testing for all residents and

direct-care staff before progressing to Phase II. Baseline testing can identify

asymptomatic and pre-symptomatic residents and healthcare workers so that

informed decisions can guide appropriate steps for containment. Baseline

testing should include testing all staff and residents except individuals

previously testing positive in the past 3 months. As an additional

recommendation, if a staff or nursing home-onset case is identified, testing

should be repeated for all previously negative or untested residents and staff

until no new positives are identified as discussed under Outbreak Response

Testing below.

c. Additional Testing Guidance for Residents and Staff.

i. Immediately test any resident or staff with symptoms.

ii. Asymptomatic residents or staff who have previously tested positive for SARS-

CoV-2 (by PCR or antigen detection methods) and recovered (i.e., have met

criteria for removal from isolation or return to work) do not need retesting for 3

months. Residents and staff who develop new symptoms of COVID-19 should be

retested regardless of previous infection.

iii. Consider testing any staff who had close contact with an individual

and exposure is considered high risk (https://www.cdc.gov/coronavirus/2019-

ncov/hcp/guidance-risk-assesment-hcp.html), either at work or in

the local community that has tested positive for COVID-19. For certain

exposures believed to pose a high risk, CDC recommends that exposed staff be

excluded from work for 14 days following the exposure. When testing is readily

available, performing testing during the 14-day post-exposure period can be

considered to more quickly identify pre-symptomatic staff who could contribute

to SARS-CoV transmission. Facilities that elect to perform post-exposure testing

of staff should be aware that testing only identifies the presence of virus at the

Page 15 of 24

time of the test. It is possible that staff can tested negative because they are in

the early stages in their infection when the sample is collected. In such

situations, repeat testing can be considered.

iv. Staff that decline testing should be treated as having a positive or unknown

COVID-19 status. The facility should make recommendations based on whether

they are in conventional, contingency, or crisis capacity status

(https://www.cdc.gov/coronavirus/2019-ncov/hcp/return-to-work.html

v. Facilities need to follow their respective policies regarding staff testing as a

condition of employment.

d. Outbreak Response Testing.

i. In a long-term care facility, an outbreak is defined as a confirmed COVID-19

nursing home-onset case in one or more residents or one or more confirmed

cases in staff members.

ii. In the event of an outbreak, facilities should conduct testing every week of all

staff and residents except those previously testing positive in the past 90 days.

Testing should be conducted every week until there are no new cases among

staff or nursing-home onset cases among residents for the previous 14 days (at

a minimum testing should be conducted twice). Testing in response to an

outbreak is required by CMS for nursing homes as of August 25, 2020 (see

https://www.cms.gov/files/document/covid-ifc-3-8-25-20.pdf

iii. Once a facility is no longer conducting weekly outbreak response testing, it

should immediately return to testing any residents or staff with symptoms.

iv. The trigger to resume weekly outbreak response testing is the identification of a

nursing home-onset case in a resident or a case in a staff member.

v. Direct care staff and staff directly exposed to residents through job

responsibilities (e.g., environmental services) declining testing should be treated

as having a positive or unknown COVID-19 status. The facility should make

recommendations based on their current status: conventional, contingency,

and crisis capacity (

https://www.cdc.gov/coronavirus/2019-ncov/hcp/return-to-

work.html).

e. Serial Testing of Asymptomatic Nursing Home Staff.

i. On August 26, 2020, CMS issued QSO-20-38-NH

(https://www.cms.gov/files/document/qso-20-38-nh.pdf), Additional Policy and

Regulatory Revisions in Response to the COVID-19 Public Health Emergency

related to Long-Term Care Facility Testing Requirements. The County Positivity

Rate is posted at this CMS web site:

https://data.cms.gov/stories/s/COVID-19-

Nursing-Home-Data/bkwz-xpvg. The following information is excerpted from

QSO-20-38-NH:

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Community COVID-19 Activity

County Positivity Rate in past

week

Minimum Testing Frequency

Low

<5%

Once a month

Medium

5%-10%

Once a week*

High

>10%

Twice a week*

*This frequency presumes availability of Point of Care Testing on-site at the nursing home or testing by a

laboratory where turnaround is <48 hours. If the 48-hour turnaround time cannot be met due to community

testing shortages, limited access or inability of laboratories to process tests within 48 hours, the facility should

document its efforts to obtain quick turnaround test results with the identified laboratories and contact with local

or state health departments.

ii. The facility should begin testing all staff at the frequency prescribed in the

Routine Testing table based on the county positivity rate reported in the past

week. Facilities should monitor their county positivity rate every other week

(e.g., first and third Monday of every month) and adjust the frequency of

performing staff testing according to the table above.

iii. If the county positivity rate increases to a higher level of activity, the facility

should begin testing staff at the frequency shown in the table above as soon as

the criteria for the higher activity are met.

iv. If the county positivity rate decreases to a lower level of activity, the facility

should continue testing staff at the higher frequency level until the county

positivity rate has remained at the lower activity level for at least two weeks

before reducing testing frequency. See QSO-20-38-NH

(https://www.cms.gov/files/document/qso-20-38-nh.pdf) for more details.

f. Test Result Reporting.

i. All long-term care facilities should report resident and staff cases (including

baseline testing) to their district health department

and all data required to the

State COVID Long-Term Care Facility Database. Nursing homes also need to

report all mandated data required to NHSN; see Section 8.0 for conferring rights

to the State of Georgia.

ii. Pursuant to O.C.G.A. 31-7-12.5, facilities must also notify residents and their

representatives or legal surrogates by 5:00 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.

iii. All on-site antigen testing conducted by long-term care facilities must be

reported to DPH within 24 hours of test completion for all testing completed for

each individual tested. CMS reporting requirements can be found here

(https://www.hhs.gov/sites/default/files/covid-19-laboratory-data-reporting-

guidance.pdf). DPH will issue state reporting requirements in the future.

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Section 5.0 Guidance for Time Outdoors, Window Visits, and Outdoor Visits

1. This section provides guidelines for allowing residents to have time outdoors, outdoor visits, and

window visits. This guidance also includes recommendations for safe transport of residents to

participate in these activities. Georgia long-term care facilities should follow these guidelines if

the facility chooses to offer outdoor and visitation guidance for its residents.

2. Safely Transporting Residents to Have Time Outdoors, Window Visits, and for Outdoor Visits.

a. Staff should wear face mask and eye covering (face shield or googles) and any other

appropriate PPE

b. Resident should wear a face covering (cloth is acceptable) or face mask if tolerated.

c. Resident treatments should be performed in the resident’s room (except in emergency

situations).

d. Prior to departing room, the resident should void/have incontinence care provided and

put on clean clothes/gown. The resident should use soap/water for hand hygiene after

using the bathroom.

e. If resident utilizes a dedicated wheelchair/assistive devices, staff should use multiple

appropriate disinfectant wipes to wipe down all parts of the chair/device (e.g., handles,

arm rest, seat back, seat, and wheels—clean areas from cleanest to dirtiest) following

the disinfectants instructions for use (dwell/contact/kill time) and prior to resident

being placed in wheelchair and/or prior to exiting their room, and again upon exiting the

common areas, dining room, therapy gym, etc.

f. Prior to departing room, ensure that the resident has performed hand hygiene with

alcohol-based hand rub or washed hands with soap and water (if hands are visibly

soiled) and donned clean clothes. Teach the resident how to properly perform hand

hygiene with alcohol-based hand rub and soap/water. Validate comprehension by

return demonstration by staff.

g. Staff should perform hand hygiene before and after resident contact (after leaving

resident in visitation area and prior to retrieving resident) as well as other hand hygiene

indications.

h. Upon re-entry to the facility, staff and residents should perform hand hygiene.

3. Allowing Residents to Have Time Outdoors.

a. Resident time outdoors is not recommended during widespread outbreaks. During

more contained outbreaks, the facility needs to assess staff ability to safely provide this

service.

b. Current COVID-19 positive residents, residents with COVID-19 signs or symptoms, and

residents in quarantine in the Observation Unit are not eligible for time outdoors.

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i. Assess the size of the outside space. Determine how many residents/staff can

safely go out at once while adhering to social distancing. Assess the necessity

for social distancing of residents (i.e., roommates, spouses, siblings).

ii. Consider marking areas to support maintaining social distancing in designated

outdoor space.

iii. Staff must accompany residents outside. While residents are outside, at least

one staff member should be present.

iv. Residents who are suspected or confirmed of having COVID-19 should not go

outside.

v. Determine the route to travel to get outside. The route should not go through

the COVID-19 Unit or Observation Unit.

vi. Prior to leaving their room, the resident should don a mask and perform hand

hygiene. If the resident cannot tolerate wearing a mask, they must adhere to

social distancing.

vii. Follow the safe transport procedures to allow residents to have time outdoors,

socially distanced.

viii. When erecting open tents or other structures outdoors to support outdoor

visitation, ensure that such structures allow for natural ventilation and do not

require mechanical ventilation, such as an air conditioner or fan.

4. Window Visits.

a. Window visits in the residents’ room may be feasible during outbreaks. Window visits

requiring moving the resident from their room should not occur during outbreaks.

b. Current COVID-19 positive residents, residents with COVID-19 signs or symptoms, and

residents in quarantine in the Observation Unit are not eligible for window visits that

require moving the resident from their room. These residents can participate in window

visits in their room.

i. Determine if it is appropriate for your facility have window visits:

1. Consider if your residents have access to ground-floor windows and

staffing to support window visits.

2. If not all residents have access to ground-floor windows, evaluate if the

facility has an area with windows to which it can safety transport

residents.

ii. Issue a communication to your families regarding your plans for window visits.

1. Explain that with residents with dementia may not understand the rules

of this type of visit and may become confused or frustrated. Residents

may also become confused or scared if someone walks up to their

window.

Page 19 of 24

2. Families need to plan for a window visit and notify the facility to make

sure the resident is prepared to greet them and has access to a phone.

3. For residents without window access, families will need to make

appointments.

iii. For residents with windows in their rooms:

1. If the resident’s window will be open, the resident should stay three

feet from the window and wear a face mask. Family members at the

window outside the building, should sit 3 feet away from the window

and wear a cloth facemask.

2. Visitors need to practice social distancing during the visit and stay in

family group or sit 6 feet apart from other family group/visitors.

3. Staff should monitor window visits and provide support, such as

providing a telephone for communication if needed.

iv. For residents without windows in their rooms:

1. Evaluate if your facility has a ground-floor common area with windows

that can accommodate socially distanced residents inside and distanced

visitors outside.

2. Request that families make appointments in advance for window visits

in common areas and have at least one staff monitor window visits.

3. Limit the number of residents and visitors to ensure residents and

visitors are socially distanced and visits are not to extend beyond 1

hour.

4. Disinfect all surfaces in the visitation area, including chairs and tables.

5. Outdoor Visits.

a. Outdoor visitation is only recommended for facilities that meet all criteria for Phase 2 or

Phase 3 (see Section 3.0).

b. Facility-related recommendations

i. Establish a schedule for visitation hours, and should work with prospective

visitors individually.

ii. Ensure adequate staff must be present to allow for helping transport residents

and to assist with cleaning and disinfecting any visitation areas as necessary.

iii. Ensure that staff maintain visual observation but provide as much distance as

necessary to allow for privacy of the visit conversation.

iv. Have a system to ensure visitors are screened for signs and symptoms of COVID-

19 at a screening location designated outside the building.

Page 20 of 24

v. Have a system to ensure residents and visitors always wear a mask or other face

covering , as described below.

vi. Designate outdoor visitation spaces to be accessible to visitors without walking

through the facility.

vii. Ensure outdoor visitation spaces support social distancing of at least 6 feet

between the visitor and resident.

viii. Provide alcohol-based hand rub to persons visiting residents and provide

signage or verbal reminders of correct use.

ix. Establish additional guidelines as needed to ensure the safety of visitations and

their facility operations. These guidelines must be reasonable and must consider

the individual needs of residents.

x. Consider weather conditions when permitting outdoor visitation. Visits may be

prohibited or cancelled if weather conditions pose a potential safety risk.

xi. Ensure that open tents or other structures outdoors to support outdoor

visitation allow for natural ventilation and do not require mechanical

ventilation, such as an air conditioner or fan.

c. Resident-related recommendations

i. Residents who have had COVID-19 must no longer require transmission-based

precautions as outlined by the CDC and DPH guidelines in order to participate in

outdoor visitation.

ii. Residents must wear a mask, or other face covering, as tolerated.

d. Visitor-related recommendations

i. Wear a mask, or other face covering, during the entire visit unless medically

contraindicated.

ii. Use alcohol-based hand sanitizer upon entering and exiting the visitation area.

iii. Participate in active screening for signs and symptoms of COVID-19 and attest to

COVID19 status if known. This should be done at a designated location outside

the building.

iv. Walk around rather than through the facility to get to the outdoor visitation

area.

v. Sign in and provide contact information.

vi. Not engage in holding hands, hugging, kissing, or other physical contact during

family visits to reduce risk of exposure

vii. Control visitors under age 12 years who accompany them and ensure they

comply with social distancing requirements.

viii. Control pets who accompany them

ix. Maintain 6 feet social distance.

x. Stay in designated visitation locations.

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Section 6.0 Considerations for Assisted Living Communities

1. In contrast to nursing homes, assisted living communities may have small units or apartments that

residents may occupy by themselves. Residents may function more independently and may need

some assistance with activities of daily living, like dressing and bathing. Family members and

friends may come to visit residents and to also take them on visits outside the facility. Most of the

guidelines provided in this document apply to assisted living communities, and the following

modifications are provided.

2. The visitation guidelines listed above apply to assisted living community residents. During

Phases 1 and 2, assisted living community residents should also not leave the facility. The

facility may designate leave policies for its residents under Phase III and will educate its

residents on appropriate infection control measures, such as social distancing, hand hygiene,

and wearing a cloth face covering or facemask.

3. Because residents may be in single rooms, cohorting of roommates may not apply. Residents

that are symptomatic or confirmed with COVID-19 can be isolated in their rooms. Place contact

precaution and CDC COVID-19 PPE signs (

https://www.cdc.gov/coronavirus/2019-

ncov/downloads/COVID-19_PPE_illustrations-p.pdf) on the resident’s door and provide PPE for

staff use before entering the residents room.

4. Moving confirmed positive COVID-19 residents in an assisted living community takes planning

and consideration. Assisted living residents have a full apartment of furniture and personal

affects. We do not recommend moving residents, except as a last resort. Staff moving items for

either positive or suspect COVID-19 residents must wear full PPE for a COVID-19 patient while in

the resident’s room.

5. The facility must ensure that a suspect or confirmed COVID-19 resident has appropriate access

to medical care.

6. The facility must ensure that residents in the assisted living community have COVID-19

screenings as outlined in this document.

7. Before progressing beyond Phase I, ensure facility is not under a contingency staffing plan.

8. Any cluster of illness should be reported immediately to your district health department

and

COVID-19 is included on the DPH Notifiable Disease List

(https://dph.georgia.gov/epidemiology/disease-reporting).

9. A resident with COVID-19 might be able to remain in the facility if the resident:

a. Is able to perform their own activities of daily living or a consultant personnel (e.g.,

home health agency) can provide the level of care needed with access to all

recommended PPE and training on proper selection and use

Page 22 of 24

b. Can isolate in their room for the duration of their illness;

c. Can have meals delivered;

d. Can be regularly checked on by staff (e.g., checking in by phone during each shift (if

resident has a phone) or visits by home health agency and assisted living community

staff who wear all recommended PPE); and

e. Is able to request assistance if needed.

10. All long-term care facilities should report their baseline and ongoing testing numbers for

residents and staff to their district health department

and to the State COVID Long-Term Care

Facility Database. Assisted living communities also have the option to report data to the

National Healthcare Safety Network (NHSN) Long-term Care Facility (LTCF) COVID-19 module

(

https://www.cdc.gov/nhsn/ltc/covid19/index.html) weekly.

11. Additional recommendations for assisted living can be found here:

https://www.cdc.gov/coronavirus/2019-ncov/hcp/assisted-living.html

Section 7.0 Considerations for Memory Care Units

1. Memory care units are dedicated wings or units that provide specialized care for individuals with

cognitive impairment, such as Alzheimer's disease or other dementia. In Georgia, these units are

found in nursing homes, assisted living communities, and personal care homes. Implementing

infection prevention strategies in memory care units is especially challenging, as residents can be

mobile and may not be able to follow recommended infection prevention practices, such as social

distancing, washing their hands, avoiding touching their face, and wearing a cloth face covering

or surgical mask for source control.

2. In addition to the guidance provided in this document, the following is provided:

a. Dedicate personnel to work only on memory care units when possible and try to keep

staffing consistent. Limit personnel on the unit to only those essential for care.

b. Continue to provide structured activities, which may need to occur in the resident’s

room or be scheduled at staggered times throughout the day to maintain social

distancing.

c. Provide safe ways for residents to continue to be active, such as personnel walking with

individual residents around the unit or outside.

d. Frequently clean often-touched surfaces in the memory care unit, especially in hallways

and common areas where residents and staff spend a lot of time.

e. Continue to ensure access to necessary medical care, and to emergency services if

needed and if in alignment with resident goals of care.

f. Increase the frequency of hand hygiene for staff and residents.

3. When a resident on a memory care unit is suspected or confirmed to have COVID-19, consider

the following:

Page 23 of 24

a. Given that memory care residents may be ambulatory and often cannot follow infection

prevention recommendations, consider that all residents and unit staff may have been

exposed.

b. Interactions with memory care residents can be unpredictable, so include eye

protection (face shield or googles) for all staff on the memory care unit. Eye protection

is in addition to other PPE recommendations.

c. Before moving a positive resident to a COVID-19 unit, consider if the COVID-19 unit staff

can manage a memory care resident.

4. Additional guidance can be found here:

https://www.cdc.gov/coronavirus/2019-

ncov/hcp/memory-care.html

Section 8.0 Reporting to the National Healthcare Safety Network (NHSN)

1. The CMS requirement for nursing homes to report data to the NHSN LTCF COVID-19 module

became effective on May 8, 2020 when CMS published their interim final rule with comment

(https://www.govinfo.gov/content/pkg/FR-2020-05-08/pdf/2020-09608.pdf

). CMS memo QSO-

20-29-NH (https://www.cms.gov/files/document/qso-20-29-nh.pdf) provides additional

information for nursing homes to meet COVID-19 reporting requirements including details

about a grace period prior to enforcement.

2. CMS is only collecting nursing home (i.e., skilled nursing facility and/or nursing facility) data.

Nursing homes are to confer rights (share data) in NHSN to the Georgia Department of Public

Health group prior to entering Phase I. Instructions for conferring rights can be found here

3. Assisted living communities and personal care homes larger than 25 beds may submit data to

NHSN and confer rights to the State of Georgia if they wish, but they are not required to do so.

4. More details regarding the NHSN LTC Module are found at

https://www.cdc.gov/nhsn/ltc/covid19/index.html.

This Administrative Order shall take effect at _5_:30__ a.m./p.m. on September _15__, 2020, and unless

amended, terminated, or otherwise superseded, shall remain in effect until the conclusion of the Public

Health State of Emergency initially declared by Executive Order 03.14.20..

SO ORDERED, this _15_ day of September 2020.

____________________________________

Kathleen E. Toomey, M.D., M.P.H.

Commissioner

State Health Officer

Page 24 of 24

Attachment:

Georgia Department of Public Health Isolation Protocol

Georgia Department of Public Health Quarantine Protocol