








key: cord-272995-yvj2pqh1
authors: Bergman, Christian; Stall, Nathan M.; Haimowitz, Daniel; Aronson, Louise; Lynn, Joanne; Steinberg, Karl; Wasserman, Michael
title: Recommendations for Welcoming Back Nursing Home Visitors during the COVID-19 Pandemic: Results of a Delphi Panel
date: 2020-10-07
journal: J Am Med Dir Assoc
DOI: 10.1016/j.jamda.2020.09.036
sha: 
doc_id: 272995
cord_uid: yvj2pqh1

Objectives Nursing homes became epicenters of COVID-19 in the spring of 2020. Due to the substantial case fatality rates within congregate settings, federal agencies recommended restrictions to family visits. Six months into the COVID-19 pandemic, these largely remain in place. The objective of this study was to generate consensus guidance statements focusing on essential family caregivers and visitors. Design A modified two-step Delphi process was used to generate consensus statements. Setting and Participants The Delphi panel consisted of 21 US and Canadian post-acute and long-term care experts in clinical medicine, administration, and patient care advocacy. Methods State and federal reopening statements were collected in June 2020 and the panel voted on these using a three-point Likert scale with consensus defined as ≥80% of panel members voting “Agree.” The consensus statements then informed development of the visitor guidance statements. Results The Delphi process yielded 77 consensus statements. Regarding visitor guidance, the panel made five strong recommendations: 1) maintain strong infection prevention and control precautions, 2) facilitate indoor and outdoor visits, 3) allow limited physical contact with appropriate precautions, 4) assess individual residents' care preferences and level of risk tolerance, and 5) dedicate an essential caregiver and extend the definition of compassionate care visits to include care that promotes psychosocial wellbeing of residents. Conclusions and Implications The COVID-19 pandemic has seen substantial regulatory changes without strong consideration of the impact on residents. In the absence of timely and rigorous research, the involvement of clinicians and patient care advocates is important to help create the balance between individual resident preferences and the health of the collective. The results of this evidence-based Delphi process will help guide policy decisions as well as inform future research.

Visitor Guidance for America's Nursing Homes regarding the abrogation of self-determination and clinical concerns that ongoing restrictions 24 have begun to outweigh any potential benefits. 15, 20-22 25 CMS released phased reopening guidelines on May 18, 2020, instructing nursing homes 26 to reopen only when the facility had no new COVID-19 cases for a 28 day period and no 27 shortages in PPE, staffing, or testing capacity. 23, 24 Three months after release of these guidelines, 28 many facilities are still far from meeting these criteria. 11 Residents, families, clinicians, and 29

advocates are calling for a more immediately actionable, sustainable, balanced, nuanced, and 30 resident-centered approach to reopening nursing homes that respects residents' rights to 31 autonomy, informed risk taking, access to essential family caregivers, and other face-to-face 32 interactions. A group of experts convened to develop a set of evidence-informed guidance 33 statements to welcome back visitors and essential family caregivers to America's nursing homes. In round one, participants voted on the statements, using a three-point Likert scale 74 ("Agree," "Neutral," or "Disagree") with an option to offer "Absent" due to a lack of perceived 75 expertise. Consensus was defined as ≥80% of participants voting "Agree" (green statements). 76

We grouped non-consensus statements into ≤50% (red statements) and 51-79% (yellow 77 statements) for purposes of facilitating discussion after each round. The whole panel discussed 78 statements not reaching consensus in a videoconference, starting with statements that had the 79 highest degree of uncertainty (red statements). In preparation for round two of voting, 80 participants also suggested additional statements for consideration. Following the second round 81 of voting, a final videoconference discussion collected comments on the non-consensus 82 statements to help inform the final document. We report the final count of consensus and non-83 consensus statements. Descriptive statistics and tables illuminated differences in responses 84 among the expert panel. 85 86

Although the present reopening statements cover a wide range of topics, we focused on the 88 statements specific to visitors in order to communicate immediately actionable recommendations 89 to policymakers. Those statements reaching consensus shaped our visitor guidance document. 90

We edited the final guidance statements for clarity, aiming to capture the consensus of the Delphi aspects of the following topics (see Table 1 ): testing of asymptomatic staff and residents, 111 surveillance testing, visitor guidance, immunity from prior COVID-19 infection and associated 112 risk of infecting others. The panel generally agreed on the need for testing of asymptomatic staff 113 (79%); but the panel discussion reflected the importance of understanding community prevalence 114 as a key factor in deciding to test asymptomatic individuals. While the panel mostly agreed 115 J o u r n a l P r e -p r o o f Visitor Guidance for America's Nursing Homes (68%) that residents should be allowed to opt out of testing for sole purposes of surveillance, 116 fewer agreed that testing of asymptomatic residents should not be done (53%). Most members 117 agreed that an asymptomatic resident who has recovered from the disease need not be tested 118 within 8 weeks from the onset of symptoms (74%) but fewer agreed to extend that to 90 days 119 (58%) or to never test again (11%). This general uncertainty about the time was again reflected 120 when the panel commented on whether an asymptomatic COVID-19 resident who has recovered 121 could be contagious 8 weeks after recovery (65% agreement that they are not contagious), or 122 after 90 days (53% agreement that they are not contagious). A minority of the panel members 123 (35%) agreed that a recovered COVID-19 who remains asymptomatic is not contagious. 124

The Delphi process reached consensus on 12 of 14 statements related to visitors. These 127 statements were then merged and expanded into guidance statements (see Table 2 guidance that begins to balance the well-being and self-determination of residents and their 141 families with the very real public health concern of preventing nursing home outbreaks. 142

Our panel was able to review 119 guideline statements and develop consensus around 77 143 general statements to help inform a set of suggested visitor guidance statements. The panel 144 strongly agreed on some preconditions that would be essential prior to welcoming back visitors, 145 such as universal masking for staff, sufficient disinfecting supplies, PPE, and written plans 146 around isolation, cohorting, screening, testing, and outbreak investigations. Furthermore, our 147 panel had wide consensus on testing of symptomatic residents and staff, the importance of 148 contact tracing, and barring communal and group activities for symptomatic residents. A key 149 finding reinforced by the panel was the future need to assess individual residents' care 150 preferences and level of risk tolerance, something that has been missing in many of the existing 151 reopening guidelines, in part due to cohorting challenges. This was envisioned by the panel as 152 allowing some residents to participate in a risk-accepting group that could be cohorted together 153 for increased social interactions and dining. 154

However, as illustrated in Table 1 J o u r n a l P r e -p r o o f agreed that limited physical contact between visitors and residents should be allowed with 185 meticulous hand hygiene before and after resident contact, and the use of masks, gowns and 186 gloves. A lack of visitor access to PPE should not preclude a visit, so nursing homes must be 187 able to provide masks, gloves and gowns when required. 188

The panel had less accord, however, regarding infection prevention strategies during a 189 visit encounter. For example, universal masking for staff was supported but the group did not 190 reach consensus on which type of mask (e.g. surgical vs. cloth) or whether all visitors had to 191 wear a mask all of the time during a visit. Similarly, it was agreed that physical distancing be 192 required in public, common spaces such as the lobby, hallways, or nursing stations, but perhaps 193 not applicable during a visit encounter with an asymptomatic resident. 194

Regarding visitor guidance logistics, the panel strongly recommended the use of an 195 electronic process to schedule visits and a sign-in log with contact information to aid in potential 196 contact tracing. Additionally, the panel recommended allowing the designation of one or two 197 essential family caregivers by the resident or surrogate decision maker. The essential family 198 caregiver(s) and the surrogate decision maker would have priority to visit the resident. These 199 visitors, for example, might provide complex care, such as assistance with feeding or support for 200 responsive behaviors commonly encountered in residents with dementia. All visitors and 201 essential family caregivers must be provided entry during serious illness, including at the end-of-202 life, irrespective of COVID-19 status of the resident, provided that the visitor dons appropriate 203

Lastly, regarding visitor guidance and risk tolerance, the panel acknowledged that 205 essential family caregivers may wish to visit a resident who may be contagious such as 1) a 206 symptomatic resident with a positive COVID-19 test, 2) a symptomatic resident with an 207 J o u r n a l P r e -p r o o f unknown or pending COVID-19 test, or 3) an asymptomatic resident who has tested positive for 208 COVID-19. After discussion, the authors recommend three steps be followed. First, a shared 209 informed consent discussion between essential caregivers and nursing leadership that would Regarding immunity and cohorting, our panel agreed (83%) that cohorting asymptomatic 216 residents who have all recovered for COVID-19 can be safely done and that a resident who has 217 recovered from COVID-19, remains asymptomatic, and is at least 3 weeks post onset of 218 symptoms is likely not infectious (88% consensus). Regarding the role of antibody testing, a 219 modest majority agreed (69%) that antibody testing could be a surrogate marker of individual 220 immunity; but all agreed that a positive immunity test does not currently inform clinical practice 221 and instead one has to rely upon recovery from prior infection. It should be noted that the Delphi 222 process occurred before the CDC guidance that recovered COVID-19 residents do not require re-223 testing or precautions for 90 days had been released 27 . 224

The areas of congruence leading to the suggested visitor guidance statements stem from 225 thoughtful resident-centered debates among a panel of Delphi experts. The fact that there are 226 many areas with substantial variation certainly arises from the state of the science but might also 227 be a result of the interaction of certain statements with each other, difficulties with precise 228 wording or statements, or the persistent inability of guidelines to accommodate the wealth of 229 variations in clinical situations. One limitation of this study was that a rapid two-step modified 230 J o u r n a l P r e -p r o o f Delphi process may not have allowed enough time for the panel to develop consensus around 231 some of the challenging language or the more controversial topics, but the panel felt the urgency 232 to produce high-quality guidance statements promptly. 233

The use of a modified Delphi process to standardize the process, provide iterative 234 feedback, and consensus-gathering strengthens the findings of this study. The Delphi process 235 itself limits bias but could be influenced by how panelists were selected 29 . There was some 236 degree of self-selection in the organization of this panel as the group shared a common concern 237 regarding the health and wellbeing of the vulnerable older adults living in nursing homes during 238 the COVID-19 pandemic. Additionally, the panel had substantial diversity but did not include all 239 important stakeholders, such as nurse leaders, direct care workers, or residents. Nevertheless, the 240 panelists were chosen for their expertise in the field of geriatrics and long-term care medicine, 241

and have all been listed in the acknowledgement section. 242 243

The objective of this study was to develop a set of visitor guidance statements that could 245 be used to welcome back visitors and essential family caregivers to US nursing homes. Even 246 after a structured Delphi process, experts in nursing home care still had substantial discord on 247 important elements. However, through rigorous and evidence-informed discussions, a concise 248 and practical set of guidance statements was developed (Table 2) 

In order for a nursing home to proceed with phased reopening, there should be no new NH-onset cases for 28 days.

14 (74) 1 4

Testing a proportion of randomly selected asymptomatic HCP (staff) who have not previously tested positive should be done for surveillance efforts. The frequency and sample size of staff should be guided by size of the nursing home and level of local community spread.

In facilities without any positive COVID-19 cases, test 100% of asymptomatic HCP (staff) who have previously not tested positive weekly for 4 weeks; if no new positives may test 25% of asymptomatic HCP (staff) every 7 days such that 100% of the nursing home staff are tested each month.

10 (53) 3 6

Testing a proportion of randomly selected asymptomatic residents who have not previously tested positive should not be done for surveillance efforts. Instead, residents who are asymptomatic should only be tested during outbreak investigations of close contacts of a known COVID-19 positive resident or staff member.

Residents who are asymptomatic should be allowed to opt out of testing for sole purposes of surveillance. This statement would not be applicable for contact tracing with a known exposure to a COVID-19 resident or staff member.

An asymptomatic resident who has previously tested positive for COVID-19 and recovered does not need to be 14 (74) 2 3

tested again within an 8 week window of prior onset of symptoms.

An asymptomatic resident who has previously tested positive for COVID-19 and recovered does not need to be tested again within a 90 day window of prior onset of symptoms.

An asymptomatic resident who has previously tested positive for COVID-19 and recovered does not need to be tested again.

A new or returning asymptomatic nursing home resident without a prior diagnosis of COVID-19 and who has remained under isolation in a private room for 14 days since admission tests positive during nursing home testing of asymptomatic residents. Not during an outbreak investigation and there has been no exposure to a COVID-19 positive resident or staff. In this situation, re-test the resident only. If subsequently negative and no further suspicion of COVID-19 in the building, this scenario would not warrant nursing home-wide testing or phase regression.

14 (74) 1 4

A negative COVID-19 test is not a requirement prior to visiting a nursing home. 14 (70) 1 5

Visitors who wish to visit a nursing home resident who is actively symptomatic but for whom COVID-19 testing is pending or unknown should have an informed consent discussion with nursing leadership, demonstrate appropriate donning/doffing of PPE and agree to wear appropriate PPE during the visit.

Allow entry of all essential and non-essential healthcare personnel, contractors, and vendors with appropriate screening, physical distancing, hand hygiene, and face coverings. They would be subject to the same testing and surveillance requirements as the rest of the HCP (staff) cohort. Visitors including non-employed caregivers and surrogate-decision makers would be subject to the visitor The nursing home should consider a designated care giver (or dedicated support person, surrogate decision-maker) an essential member of the healthcare team who would not be subject to visitor guidelines if resources (PPE, training, monitoring) are available at the time and the person is directly engaged in compassionate care to alleviate a residents psycho-social stress as a result of isolation.

15 (79) 0 4

A resident who engages in a visit with family or friends beyond the nursing home grounds, remains outside, and the visit does not involve close contact with COVID+ individuals or symptomatic individuals would not be subject to isolation upon re-entry to the nursing home.

After a resident returns from an outside trip beyond the nursing home grounds and prior to the resident resuming activities within a shared space, the resident should be bathed according to accepted practice with soap and have the clothes they were wearing laundered in a standard fashion.

Immunity A currently asymptomatic individual who has recovered from COVID-19 and is post 8 weeks from onset of symptoms is not considered infectious and should not be tested. If tested and the test returns positive, as long as the resident remains asymptomatic, it would not be considered a re-infection and the resident is not contagious.

A currently asymptomatic individual who has recovered from COVID-19 and is post 90 days from onset of symptoms is not considered infectious and should not be tested. If tested and the test returns positive, as long as the resident remains asymptomatic, it would not be considered a re-infection and the resident is not contagious.

A currently asymptomatic individual who has recovered from COVID-19 is not considered infectious and should not be tested. If tested and the test returns positive, as long as the resident remains asymptomatic, it would not be considered a re-infection and the resident is not contagious.

Antibody testing can be a surrogate marker of individual immunity but does not currently inform clinical practice; recovery from prior infection does.

Color scheme represents level of consensus among panel. Yellow represents statements in which 51-79% of members voted "Agree" and red represents statements in which <50% of members voted "Agree."

J o u r n a l P r e -p r o o f 

All staff, residents, and visitors engage in basic hand hygiene and physical distancing in public, shared spaces.

All staff wear a medical-grade mask while in the nursing home.

All residents and visitors wear a face covering when in shared, public spaces. If a resident or visitor does not own a face covering, one must be provided by the nursing home.

The facility has sufficient disinfecting supplies (hand sanitizers, soap, detergent, etc.) and adequate personal protective equipment (gloves, gowns, masks, face shields/goggles).

A written isolation and cohorting plan is in place.

A written screening and testing plan with adequate capacity for implementation is in place.

A written contact tracing and outbreak investigation plan is in place.

All persons entering the nursing home (staff, visitors, volunteers, and vendors) undergo the same entrance screening process, including a temperature check and answering an exposure and symptom questionnaire by a trained entrance screener.

Visitors that do not comply with the screening procedure are not allowed to enter.

Visitors and volunteers can sign up to visit a resident for a defined time period using an electronic process.

The nursing home maintains a sign-in log that includes contact information (name, phone number, email address) of visitors and volunteers to help with contact tracing in the event of an exposure.

A nursing home may need to limit the number of indoor visitors to no more than 2 visitors at one time to allow physical distancing between visitor groups.

Visit frequency and the number of visitors a nursing home is able to accommodate would depend on the physical space, availability to visit outdoors, and PPE availability.

Visitors must be guided to the designated visit area to limit interactions with patient-care areas, staff, or other residents.

Gloves and a gown with associated hand hygiene are required if visitors wish to engage in limited physical contact with a resident, such as hugging, hand holding, or direct resident care such as assistance with meals. The nursing home must provide gloves and gowns for this purpose.

The nursing home should designate areas for indoor and outdoor visits. Ideally the visits would occur outside, conditions permitting.

Indoor areas should be accessible without walking through a resident care area, must be disinfected between scheduled visits, and should be large enough to facilitate physical distancing between visit groups.

A nursing home should allow each resident or surrogate decision maker to choose essential family caregivers who, along with the surrogate decision maker, would have priority to frequently visit a resident, e.g. to provide complex care, aid in feeding, or redirect and reassure those residents living with dementia who have responsive behaviors.

Visiting a resident with or without symptoms who has a positive, unknown, or pending COVID-19 test result requires the following steps: 1. The visitor must participate in an informed consent discussion with leadership regarding the risks of potential exposure to COVID-19 and whether they outweigh the benefits of a visit. Additionally, visitors should be counseled to understand the COVID-19 test status and encouraged to wait for a pending test result to return prior to a scheduled visit. 2. The nursing home must provide education and training so that the visitor can demonstrate appropriate donning/doffing of PPE, including a mask, gowns, gloves, and possibly a face shield. 3. The visitor must agree to wear the recommended PPE during the visit and follow all infection prevention and control procedures within the nursing home.

The nursing home should make every attempt possible to work with visitors of residents who are seriously ill, receiving care focused on comfort, and approaching end-of-life. Specifically, facilities may waive the visitor limits, offer extended hours, and offer an in-person room visit to help facilitate the psycho-social well-being of the resident and family members.

J o u r n a l P r e -p r o o f  Social distancing, hand washing, and disinfection practices need to continue in directpatient care areas.  Residents, visitors, and volunteers wear cloth face coverings or a facemask when in a shared-space.

 All persons entering the facility (including staff, visitors, volunteers, and vendors) should undergo screening to include: temperature check, exposure questionnaire, and symptom questionnaire.  Entry screening is performed by a screener who has received training in basic infection control, appropriate education on questionnaires and hands-on practice with thermometer.  All persons attempting to enter the facility who have either recorded a temperature >99.5 F or report having taken a medication to treat fever (anti-pyretic such as acetaminophen) should not be permitted to enter.  All residents should undergo a daily symptom screening and have temperature monitored.

 Symptomatic Residents/Staff o Test all symptomatic residents and staff but allow individual residents autonomy with an appropriate plan on how to isolate and cohort a resident who is symptomatic but does not wish to be tested. o A symptomatic staff member who does not wish to be tested would be excluded from work until they meet the return to work criteria of a presumed positive individual. o Treat a symptomatic resident who does not wish to be tested as a presumed positive. Isolate and cohort accordingly. o  Asymptomatic Residents/Staff o All residents, staff should have undergone baseline testing as part of Phase 1 and Phase 2. o Have a plan for ongoing surveillance testing of asymptomatic staff and residents.

 Testing a proportion of randomly selected asymptomatic HCP (staff) who have not previously tested positive should be done for surveillance efforts. The frequency and sample size of staff should be guided by size of facility and level of local community spread. -79% agreement  In facilities without any positive COVID-19 cases, test 100% of asymptomatic HCP (staff) who have previously not tested positive weekly for 4 weeks; if no new positives may test 25% of asymptomatic HCP (staff) every 7 days such that 100% of facility staff are tested each month. 53% agreement  Testing a proportion of randomly selected asymptomatic resident who have not previously tested positive should not be done for surveillance efforts. Instead, residents who are asymptomatic should only be tested during outbreak investigations of close contacts of a known COVID-19 positive resident or staff member. 53% agreement  Residents who are asymptomatic should be allowed to opt out of testing for sole purposes of surveillance. This statement would not be applicable for contact tracing with a known exposure to a COVID-19 patient or staff member. -68% agreement o Triggers to increase testing:

 A trigger to increase testing of asymptomatic individuals would be based on response to an outbreak investigation and contact tracing results.  One COVID-19 + case in staff or residents should trigger the execution of a comprehensive plan addressing contact tracing, isolation/cohorting, and testing within 24 hours of positive test result.

 During an outbreak investigation, there should be a low threshold to extend testing of all staff and residents to entire units, floors, buildings if the situation deems it necessary.  Asymptomatic residents and staff who have previously tested positive would not be subject to repeat testing.  Once one NH-onset case (case definition from CDC) has been identified within a facility, facilities should resume testing of asymptomatic HCP (staff) who have not previously tested positive o The facility should make every effort possible to secure a collection method that is least invasive and uncomfortable if testing residents and staff with a low pretest probability of COVID-19 disease (asymptomatic without known exposure), such as saliva testing or nasal/oral swabs instead of a nasopharyngeal swab. o Asymptomatic COVID-19 recovered resident  An asymptomatic resident who has previously tested positive for COVID-19 and recovered does not need to be tested again within an 8 week window of prior onset of symptoms. 74% agreement  An asymptomatic resident who has previously tested positive for COVID-19 and recovered does not need to be tested again within a 90 day window of prior onset of symptoms. 58% agreement  An asymptomatic resident who has previously tested positive for COVID-19 and recovered does not need to be tested again. 11% agreement

 A process should be identified for how facilities will actively track staff/ resident and visitor interactions to help facilitate appropriate contact tracing in the event of an outbreak investigation.  In the event of a PUI or COVID-19 positive staff or resident, a list of individuals with possible exposures should be able to be generated for the prior 3 days (preferably 5 days) within 24 hours.

 Facilities should be aware and document individual resident and/or surrogate decisionmakers' care preferences regarding testing, cohorting, and isolation. It may be possible to cohort a certain group of individuals (ie recovered COVID-19 positive patients who are asymptomatic) as long as the risks for other residents is not substantially increased.  New admissions should be placed in a dedicated area of the facility where appropriate isolation and contact precautions are maintained.  There should be a written cohorting and isolation plan for the facility. Group Activities  Do not allow symptomatic residents with an unknown COVID-19 status to participate in group activities in which proper infection control practices cannot be maintained.  Make every effort possible to maintain social distancing, practice hand hygiene, and wear a mask during group activities.  Try to facilitate indoor group activities in a well-ventilated space that allows for appropriate social distancing.  Make an effort to offer residents the ability to join a risk-accepting group that could be cohorted together for activities, provided that the facility can manage them separately.

Non-medically Necessary Trips Outside Facility  Residents must adhere to face coverings, hand hygiene, and social distancing during trips outside of the facility.  Isolation o A resident who engages in a supervised outside visit with family or friends within the nursing home grounds, remains outside, and the visit does not involve close contact with COVID+ individuals or symptomatic individuals would not be subject to isolation upon re-entry to the facility. o A resident that makes a trip outside the facility and is exposed to a COVID+ individual, symptomatic individual or otherwise fails the screening questionnaire upon re-entry to the building would be subject to 14 days of isolation. o A resident who engages in a visit with family or friends beyond the nursing home grounds, remains outside, and the visit does not involve close contact with COVID+ individuals or symptomatic individuals would not be subject to isolation upon re-entry to the facility. 17% agreement  Infection Control o After a resident returns from an outside trip beyond the nursing facility grounds and prior to the resident resuming activities within a shared space, the resident should practice hand hygiene and have their wheelchair and belongings disinfected. o After a resident returns from an outside trip beyond the nursing facility grounds and prior to the resident resuming activities within a shared space, the resident should be bathed according to accepted practice with soap and have the clothes they were wearing laundered in a standard fashion. 47% agreement  Leave of absence o The facility should have a discussion regarding risks/benefits with every resident and family who requests a leave of absence with a bed hold. This would include a discussion on hand hygiene, social distancing, and mask covering as well as subsequent isolation upon return to the facility if deemed necessary at the time of the visit based on level of community spread.

 Phase regression and facility wide restrictions should not be imposed after one isolated COVID-19 case. Rather, a prompt outbreak investigation should occur with further results triggering appropriate restrictions.  Response to positive resident o Once one nursing home resident tests positive for COVID-19, an outbreak investigation should include baseline testing of close contacts (to include roommate, neighboring rooms, and staff)

o Once one NH-onset case (case definition from CDC) has been identified within a facility, facilities should resume testing of asymptomatic HCP (staff) who have not previously tested positive. o During an outbreak investigation of a single case it is determined that there is 1 NH-onset case on an isolated wing with isolated staff. This scenario would warrant testing of the entire wing staff and residents but not warrant facility wide testing or phase regression. o A new SNF admission who has remained under isolation in a private room becomes symptomatic within 14 days of admission and tests positive. In this situation, I would re-test and extend testing to close contacts. If no further positive cases, this situation would not warrant facility wide testing or phase regression. o A new or returning asymptomatic nursing home resident without a prior diagnosis of COVID-19 and who has remained under isolation in a private room for 14 days since admission tests positive during facility testing of asymptomatic residents. Not during an outbreak investigation and there has been no exposure to a COVID-19 positive patient or staff. In this situation, I would re-test the resident only. If subsequently negative and no further suspicion of COVID-19 in the building, this scenario would not warrant facility-wide testing or phase regression. 74% agreement  Response to positive HCP o An asymptomatic HCP tests positive on routine surveillance testing and is appropriately following work-restrictions. This scenario should prompt an outbreak investigation of close contacts but should not automatically warrant a phase regression as long as the outbreak investigation does not identify new cases among staff or residents who have not previously tested positive. o A symptomatic HCP tests positive. This would warrant testing of close contacts (staff and residents) of the immediate patient care area. o Once one nursing home staff member tests positive for COVID-19, an outbreak investigation should include baseline testing of close contacts (to include roomate, neighboring rooms, and staff)  Phase Regression o During an outbreak investigation, it is determined that there is >2 NHonset cases in a building within a short time period (<14 days). There is concern for wide spread disease in the building. This scenario would warrant testing of the entire facility and phase regression with subsequent restrictions on visitors, communal dining, and group activities.

Immunity  A patient who has recovered from COVID-19 disease and is 3 weeks post onset of symptoms is likely not infectious to another individual as long as they have not developed new symptoms.  A cohort of asymptomatic individuals who have all recovered from COVID-19 can safely be cohorted together.  Antibody testing can be a surrogate marker of individual immunity but does not currently inform clinical practice; recovery from prior infection does. 69% agreement  COVID-19 recovered individual o A currently asymptomatic individual who has recovered from COVID-19 and is post 8 weeks from onset of symptoms is not considered infectious and should not be tested. If tested and the test returns positive, as long as the resident remains asymptomatic, it would not be considered a re-infection and the patient is not contagious. 65% agreement o A currently asymptomatic individual who has recovered from COVID-19 and is post 90 days from onset of symptoms is not considered infectious and should not be tested. If tested and the test returns positive, as long as the resident remains asymptomatic, it would not be considered a re-infection and the patient is not contagious. 53% agreement o A currently asymptomatic individual who has recovered from COVID-19 is not considered infectious and should not be tested. If tested and the test returns positive, as long as the resident remains asymptomatic, it would not be considered a re-infection and the patient is not contagious. 35% agreement

 Hairdressers, beauticians, hospice staff and other staff members who work within a nursing home should be included in the CDC definition of Healthcare Personnel (HCP) and follow the same guidelines regarding screening and testing.  Hairdressers and stylists should be considered direct patient care staff and be subject to the same screening and work restrictions as other healthcare facility staff.  Patients that are unable to adhere to social distancing or face coverings should be allowed to visit with family in a private isolated area as long as visitors were full PPE.  Dialysis patients who leave the facility regularly for hemodialysis will remain under appropriate isolation and contact precautions and not mix with COVID-, asymptomatic individuals.

J o u r n a l P r e -p r o o f 

Definitions I agree with the following modification of the formal CDC definition of Healthcare personnel (HCP). "HCP include, but are not limited to, emergency medical service personnel, nurses, nursing assistants, physicians, technicians, therapists, phlebotomists, pharmacists, feeding assistants, students and trainees, contractual HCP not employed by the healthcare facility, and persons not directly involved in patient care but who could be exposed to infectious agents that can be transmitted in the healthcare setting (e.g., clerical, dietary, environmental services, laundry, security, beauticians and hairdressers, engineering and facilities management, administrative, billing, and volunteer personnel)". (Added Beauticians to CDC definition of HCP)

Nursing Homes Are Ground Zero for COVID-19

COVID-19 Nursing Home Data

COVID-19 in Nursing Homes: Calming the Perfect Storm

Coronavirus Disease 2019 in Geriatrics and Long-Term Care: The ABCDs of COVID-19

Presymptomatic SARS-CoV-2 Infections and Transmission in a Skilled Nursing Facility

Asymptomatic SARS-CoV-2 infection in Belgian long-term care facilities

Presymptomatic Transmission of SARS-CoV-2 Amongst Residents and Staff at a Skilled Nursing Facility: Results of Real-Time PCR and Serologic Testing

Epidemiology of Covid-19 in a Long-Term Care Facility in King County, Washington

CMS Announces New Measures to Protect Nursing Home Residents from COVID-19

Centers for Disease Control and Prevention. Preparing for COVID-19 in Nursing Homes

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Continued bans on nursing home visitors are unhealthy and unethical. The Washington Post

Amid the COVID-19 Pandemic, Meaningful Communication between Family Caregivers and Residents of Long-Term Care Facilities is Imperative

Families Caring for an Aging America

Essential Family Caregivers in Long-Term Care During the COVID-19 Pandemic

Detrimental effects of confinement and isolation on the cognitive and psychological health of people living with dementia during COVID-19: emerging evidence. LTCcovid, International Long-Term Care Policy Network: Care Policy and Evaluation Centre (CPEC)

Finding the Right Balance: An Evidence-Informed Guidance Document to Support the Re-Opening of Canadian Nursing Homes to Family Caregivers and Visitors during the COVID-19 Pandemic

We gratefully acknowledge the time and dedication of our Delphi panel experts and other experts who have participated in this process, provided guidance, or critically appraised our manuscript. Their names are listed below in alphabetical order. None received compensation, financial or otherwise, for their contributions.

J o u r n a l P r e -p r o o f

The facility should make every effort possible to secure a collection method that is least invasive and uncomfortbale if testing residents and staff with a low pretest probability of COVID-19 disease (asymptomatic without known exposure), such as saliva testing or nasal/oral swabs instead of a nasopharyngeal swab. Immunity Q86 A currently asymptomatic individual who has recovered from COVID-19 and is post 8 weeks from onset of symptoms is not considered infectious and should not be tested. If tested and the test returns positive, as long as the resident remains asymptomatic, it would not be considered a re-infection and the patient is not contagious.

Immunity A currently asymptomatic individual who has recovered from COVID-19 and is post 90 days from onset of symptoms is not considered infectious and should not be tested. If tested and the test returns positive, as long as the resident remains asymptomatic, it would not be considered a re-infection and the patient is not contagious. 9 1 7 17 53% Immunity A currently asymptomatic individual who has recovered from COVID-19 is not considered infectious and should not be tested. If tested and the test returns positive, as long as the resident remains asymptomatic, it would not be considered a re-infection and the patient is not contagious. Immunity Q85 Antibody testing can be a surrogate marker of individual immunity but does not currently inform clinical practice; recovery from prior infection does. 

